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CHAPTER XII THE THORAX
  
 
 
 
 
 
 
 
 
 
 
 
CHAPTER XII
 
 
THE THORAX
 
 
 
 
  
 
Thoracic Wall.  
 
Thoracic Wall.  
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CHAPTER XIII  
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==CHAPTER XIII DEVELOPMENT OF VASCULAR SYSTEMS==
 
 
DEVELOPMENT OF VASCULAR SYSTEMS  
 
  
  

Revision as of 22:58, 29 June 2020

CHAPTER XII THE THORAX


Thoracic Wall.

Muscles—Intercostal Muscles.—The classic description of t muscles gives them as two in number in each space, external internal, arranged as thin sheets of obliquely-disposed muscular hi with a large admixture of tendinous fibres.

External Intercostal Muscles— Origin .—The lower border of upper rib bounding an intercostal space.

Insertion .—The outer margin of the upper border of the lower

Nerve-supply .—The intercostal nerve of the corresponding spat



Interosseous Part of Internal Intercostal Muscle

Fig. 577. —Diagram of the Intercostal Muscles and Intercostal Arte:

A small portion of the external intercostal muscle has been divided and

reflected.

The fibres of each muscle are directed downwards and forwc and in this respect coincide with those of the obliquus exte abdominis. The muscles, as a rule, extend as far forwards as junction of the ribs with their cartilages, but sometimes they short of this point, especially in the upper spaces. From the p where the fibres cease the upper six muscles are continued inw to the side of the sternum by a thin delicate membrane, called anterior intercostal membrane. This occupies the spaces between true costal cartilages. Posteriorly the muscles extend as far as tubercles of the ribs.


994




THE THORAX


995


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[nternal Intercostal Muscles.— Origin. —The upper margin of the al groove of the upper rib.

Insertion. —The inner margin of the upper border of the lower rib. Serve-supply. —The intercostal nerve of the corresponding space, rhe fibres of each muscle are directed downwards and backwards, and lis respect coincide with those of the obliquus internus abdominis, upper six muscles extend as far inwards as the side of the sternum, the lower two are continuous anteriorly with the obliquus internus )minis. Posteriorly the muscles extend as far back as the angles le ribs. In this situation each is replaced by a delicate membrane id the posterior intercostal membrane , which lines the adjacent ion of the external intercostal muscle, and ds behind with the superior costo-transverse nent. The internal intercostal muscles are ired internally by the parietal pleura.

4 ction of the Intercostal Muscles. —This subhas given rise to much discussion and irence of opinion. Three views are entered: (i) According to Haller, the external internal intercostal muscles both act as ators of the ribs, and are therefore muscles ispiration. Inasmuch as the fibres of the muscles decussate, they must, according to view, act on the principle of the parallelon of forces. The common nerve-supply of Fig. 578. —Diagram of two muscles tends to favour this view. Section across an According to Hamberger, the external inter- ntercostal pace.

al muscles are elevators of the ribs, and El, I, external and in 'efore muscles of inspiration; whilst the inLal intercostal muscles are depressors of

ribs, and therefore muscles of expiration.

According to Hutchinson, the external inter:al muscles and the interchondral portions of internal intercostal muscles act as elevators the ribs, and are therefore muscles of ination; whilst the interosseous portions of the internal intercostal scles act as depressors of the ribs, and are therefore muscles of iration.

When a rib is elevated, its lower border is at the same time

rted.


ternal intercostal muscles ; INT, intercost, intimus, or intracostal. Pleura represented by interrupted line. Lateral cutaneous nerve shown between El and I.


Subcostal Muscles.—Deep to the internal intercostal muscles the lains of a third sheet of muscular fibres can often be demonstrated, i sheet is best developed dorsally and in connection with the lower ces. The direction of the fibres is similar to that taken by the cs of the internal intercostal, but unlike these last the fibres, tead of passing between adjacent ribs, pass between ribs some ces apart. The fibres constitute the subcostal muscles, which are the same plane as the sterno-costalis and the costal fibres of the






A MANUAL OF ANATOMY


996

diaphragm, and represent in the thoracic wall the transversus mus of the abdominal wall.

For the levatores costarum muscles, see Index.

It is customary, in modern descriptions of the intercostal muscu ture, to speak of three layers of muscles in this situation. 1 additional fibres are referred to as intercostales intimi: they w described and figured many years ago by Henle, and are usually tal to be partly detached fibres of the internal intercostals. Their fib have the same direction as those of the internal intercostals, from wh they are separated by the intercostal vessels and nerves (Fig. 57 They form a very thin layer, aponeurotic in some places, and tra lucent, better developed in the lower part of the thoracic wall, a more particularly in the middle portions of the spaces.

They are frequently considered to be parts of the same sh as the sterno-costalis (triangularis sterni) and subcostal fibi but this does not seem to be at all certain. If this view is tak the three kinds of muscle are grouped together as the transver thoracis, implying their general continuity with the sheet of abdominal transversus.

Intercostal Nerves.—These are eleven in number on each side, a are the anterior primary divisions of the upper eleven thoracic spi nerves. The anterior primary division of the twelfth thoracic spi nerve is not an intercostal nerve, but lies along the lower border the twelfth rib, and is known as the subcostal nerve (‘ last doi nerve ’).

The lower five intercostal nerves ultimately leave the intercom spaces, and pass into the anterior abdominal wall.

Upper Six Intercostal Nerves .—Each of these nerves, as it ent the back part of an intercostal space, lies between the posterior ini costal membrane and the parietal pleura. About the level of the an of the rib it pierces the posterior intercostal membrane, and pas forwards in the costal groove of the upper rib, lying between intercostal muscles. It continues its forward course in this posit in company with the intercostal artery and intercostal vein, the or of these from above downwards being intercostal vein, intercom artery, and intercostal nerve. The nerve is concealed by the ov lapping lower border of the upper rib.

At (or just beyond) the angles of the ribs between which it is pass the intercostal nerve gives off a collateral branch and, a little furt on, its lateral cutaneous branch. The collateral branch runs forw; along the upper surface of the rib below the space, supplying muscles and terminating either in them or by forming a connect loop with the main nerve some distance from the sternum. The late cutaneous branch pierces the internal intercostal muscle to run forw: between this and the external muscle: it pierces this to reach the surfa the actual site of the perforation varying, of course, according to level of the nerve. The main intercostal nerves themselves run


THE THORAX


997


reen the intercostales interni and intimi after they have given off branches described.

laving arrived at the anterior extremity of the osseous rib, each r e, still internal to the internal intercostal muscle, passes inwards ts deep surface, lying at first upon the parietal pleura, and sublently upon the sterno-costalis muscle, crossing in its course the rnal mammary vessels. On reaching the side of the sternum it es straight forwards, to become an anterior cutaneous nerve, cing in succession the following structures: the interchondral ion of the internal intercostal muscle; the anterior intercostal ibrane; the pectoralis major muscle; and the deep fascia.

Branches.—These are muscular, lateral cutaneous, and anterior ineous.

rhe muscular branches supply the following muscles: the levatores arum, serratus posterior superior, subcostal muscles, intercostal


internal mammary artery; AOR, aorta; RA, anterior primary ramus of thoracic spinal nerve; COLL, collateral branch; LC, lateral cutaneous branch; P, anterior terminal perforating, passing in front of internal mammary.

scles, the sterno-costalis, the serratus posterior inferior, and the scles of the anterior abdominal wall.

The lateral cutaneous nerves arise just beyond the costal angles, 1 run as described above. They pierce the external intercostal scles, and make their appearance under fibrous arches connecting

costal slips of origin of the serratus anterior. The first intercostal

ve, as a rule, gives off no lateral cutaneous branch, and that of the ond is known as the intercosto-brachial nerve.

The anterior cutaneous nerves are the terminal branches of the upper intercostals, that of the first being sometimes absent. For their

criptions, see Index.

Intercostal Arteries.—These vessels are arranged in two sets derior and anterior.

Posterior Series.—The intercostal arteries of the first two spaces ! derived from the superior intercostal artery (see Index). The







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A MANUAL OF ANATOMY


intercostal arteries of the lower nine spaces are branches of the < scending thoracic aorta, and are called the posterior intercostal arten Each at first lies between the posterior intercostal membrane and 1 parietal pleura. About the level of the angle of the rib it pierces i posterior intercostal membrane, and gives off its collateral intercos branch, which inclines downwards. These two arteries now p; forwards between the two intercostal muscles, the main poster intercostal lying in the costal groove of the upper rib, where it 1 the intercostal vein above it and the intercostal nerve below it, a the collateral intercostal lying along the upper border of the lov rib. These two vessels, in the case of the upper nine spaces, termin; by anastomosing with the anterior intercostal arteries, which are t in number in each of these spaces, and will be presently describi These anastomoses take place a little in front of the mid-point betwe the vertebral column and the side of the sternum.

Branches.—These are posterior, collateral intercostal, and late cutaneous.

The posterior branch passes backwards to the muscles and inte^ ment of the back, giving off in its course a spinal branch, which ent< the vertebral canal through the intervertebral foramen.

The collateral intercostal branch, as stated, arises about the le^ of the angle of the rib, and inclines downwards to the upper border the lower rib, along which it passes between the intercostal muscles.

The lateral cutaneous branch accompanies the corresponding latei cutaneous nerve.

The posterior intercostal and collateral intercostal arteries gi branches to the intercostal muscles and ribs. Those of the thii fourth, and fifth spaces, at least, furnish branches to the mamma gland and pectoral muscles, anastomosing with the thoracic brand of the acromio-thoracic artery from the first part of the axillary, a with the lateral thoracic from the second part of that vessel. T first posterior intercostal artery, as it enters the third intercostal spa< gives off a branch which ascends to the back part of the second int< costal space, and anastomoses with the branch of the superior intercos artery to that space.

Anterior Series. — The internal mammary artery furnishes t' anterior intercostal arteries to each of the upper six intercostal spac and the musculo-phrenic branch of the internal mammary furnisl two anterior intercostal arteries to each of the seventh, eighth, a ninth intercostal spaces. The arteries of the upper six spaces lie first upon the sterno-costalis muscle, and then upon the parietal pleu being under cover of the internal intercostal muscle. Afterwards the anterior intercostal arteries pass between the external and inter] intercostal muscles. In each space they anastomose with the poster intercostal and collateral intercostal arteries, and also with the c responding intercostal arteries of the upper two spaces.

Branches.—These are distributed to the intercostal muscles, ri mammary gland, and pectoral muscles. %


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THE THORAX


999


The lower two intercostal spaces are not furnished with anterior srcostal arteries. The posterior intercostal arteries of these spaces, sr leaving them, enter the abdominal wall, and pass forwards ween the internal oblique and transversalis muscles to the rectus lominis, in which they anastomose with the superior epigastric 1 inferior epigastric arteries.

Intercostal Veins.—These veins accompany the corresponding


enes.

The posterior intercostal vein passes backwards in the costal iove of the upper rib in company with the posterior intercostal ery, above which it lies. In the region of the angle of the rib it is ned by the collateral intercostal vein , which accompanies the corremding artery. Close to the vertebral column the posterior intercostal n receives a large posterior branch, which returns blood from the iscles and skin of the back, the vertebral venous plexus, and the -tebral canal. The mode of termination of the posterior intercostal ns differs on the two sides, and will be described in connection

h the dissection of the posterior wall of the thorax.

The anterior intercostal veins accompany the anterior intercostal cries. Those of the upper six intercostal spaces pass to the internal immary, and those of the succeeding three spaces pass to the musculo

renic veins.

Intercostal Lymphatics.—The lymphatic vessels of the intercostal ices pass partly to the posterior intercostal glands, which lie at the ck parts of the intercostal ices, and partly to the anter intercostal or sternal glands, rich lie along the course of 3 internal mammary artery.

Internal Mammary Artery.— ris vessel arises from the lower .e of the first part of the bclavian artery, and passes wnwards, forwards, and inirds behind the inner part of 3 clavicle and the first costal F IG - 580. To show the Interrelations

of the Right Internal Mammary Artery and Phrenic Nerve, and their Relations to Subclavian and Innominate Veins (Interrupted Lines) and to Pleura.


AP, anterior margin of pleura (PL). The mediastinal surface is stippled.


rtilage. It then descends verbally behind the succeeding stal cartilages as low as the

th intercostal space, where it
minates by dividing into two

anches—namely, the superior igastric and the musculorenic. The artery lies about ■§ inch from the margin of the sternum.

Cervical Relations— Anterior. —The clavicular portion of the sternoistoid muscle, and the internal jugular and subclavian veins. The aenic nerve crosses it superficially from without inwards. Posterior. The dome of the pleura.


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A MANUAL OF ANATOMY


Thoracic Relations — Anterior. —The pectoralis major; upper costal cartilages; anterior intercostal membrane; internal intercos muscles; and upper six intercostal nerves. Posterior. —The plei above, and subsequently the sterno-costalis muscle. Lateral .—1 artery has a vena comes on either side of it. The anterior intercos or sternal glands lie along the course of the vessel.

Branches. —The artery gives off no branches in the neck. In i thoracic part of its course it furnishes the following branches:


Pericardiaco-phrenic.

Mediastinal.

Pericardial.

Sternal.


Anterior intercostal. Perforating. Musculo-phrenic. Superior epigastric.


The pericardiaco-phrenic artery , long and slender, arises high up, a accompanies the phrenic nerve to the diaphragm. It gives twigs the pericardium and pleura, and in the diaphragm it anastomoses w the phrenic branch of the abdominal aorta and with the muscr phrenic branch of the internal mammary. The mediastinal branc are distributed to the contents of the mediastinum—namely, remains of the thymus body, mediastinal glands, and areolar tiss The pericardial branches supply the front part of the pericardium. 1 sternal branches are distributed to the sternum and the sterno-cost; muscle. The anterior intercostal arteries . are two in number to each the upper six intercostal spaces. For their description, see Ind The perforating branches are six in number, one arising opposite e£ of the upper six intercostal spaces. Each vessel pierces the inter intercostal muscle, anterior intercostal membrane, and pectoralis maj It then gives a few twigs to the front of the sternum, and turns o wards to supply the skin of the pectoral region. The second, thi fourth, and fifth perforating branches give offsets to the inner port; of the mammary gland.

The musculo-phrenic artery is one of the terminal branches of 1 internal mammary. It arises from that vessel in the sixth intercos space, and passes obliquely downwards and outwards behind 1 seventh, eighth, and ninth costal cartilages. About the level of 1 tenth rib it perforates the diaphragm, and terminates in the late wall of the abdomen, where it anastomoses with the ascending brar of the deep circumflex iliac artery. It gives off anterior intercos and muscular branches. The anterior intercostal arteries are two number to each of the seventh, eighth, and ninth intercostal spac in which they are disposed in a manner similar to the anterior intercos branches of the internal mammary. The muscular branches c distributed to the diaphragm and lateral wall of the abdomen, the diaphragm they anastomose with the phrenic branch of t abdominal aorta and the pericardiaco-phrenic branch of the interi mammary.

The superior epigastric artery is the other terminal branch of i internal mammary, of which it is the continuation. It descer


THE THORAX


IOOI


nd the seventh costal cartilage, and passes through the areolar val between the sternal and costal portions of the diaphragm. In manner it enters the sheath of the rectus abdominis, lying at first nd the muscle, but afterwards entering it. In the muscle it tomoses with the inferior epigastric artery, which is a branch of external iliac.

'he branches of the superior epigastric artery will be found deed on p. 731.

'he internal mammary veins (venee comites) are two in number, lie one on each side of the artery. They are formed respectively


Sterno-hyoid Muscle Sterno-thyroid Muscle.


Subclavian Artery (First Part)


Internal Mammary Artery


,. m Anterior Intercostal Arteries


Sternal Glands


V

__ Rectus Superior

Abdominis Abdominis Epigastric j

Artery Musculo-phrenic Artery

Fig. 581. —Dissection of the Anterior Wall of the Thorax

(Posterior View).


he union of the venae comites of the musculo-phrenic and superior astric arteries. In their course they receive tributaries correspondto the branches of the artery. About the level of the first rcostal space the outer vein crosses over the artery and joins the r vein to form a single vessel, which opens into the corresponding 'inmate vein. The internal mammary veins are provided with ns at intervals.

►ternal or Internal Mammary Lymphatic Glands. —These glands } a chain along the internal mammary vessels. They are usually ined, however, to the first three spaces, there being one, or it may









1002


A MANUAL OF ANATOMY


be two, in each of these spaces. They usually lie in front of the inter mammary vessels.

They receive their afferent vessels from (i) the inner third of mammary gland, (2) the anterior half of the costal pleura, (3) anterior halves of the external and internal intercostal muse (4) the lymphatics which accompany the superior epigastric arte and (5) the anterior group of superior diaphragmatic glands. T 1 efferent vessels pass to the thoracic duct , or to the right lymphatic d\ according to the side on which the glands lio. Frequently one more of these vessels drain to the supraclavicular group of gland? fact which explains the infection (which sometimes occurs) of th glands in malignant disease of certain abdominal viscera.

Sterno-costalis (Triangularis Sterni) — Origin. —(1) The deep surf; of the xiphoid process and body of the sternum close to the late border, and extending as high as the level of the third costal cartila and (2) the deep surfaces of the lower two or three true costal cartila at their sternal ends.

Insertion. —The deep surfaces and lower borders of the co? cartilages from the sixth to the second. The insertion takes pi by separate slips, and one or two of the upper slips may be partk attached to the rib itself.

Nerve-supply. —The intercostal nerves of the adjacent spaces.

The lowest fibres of the muscle are horizontal; the succeeding fit pass obliquely upwards and outwards; and the upper fibres are aim vertical.

Action. —To depress the anterior extremities of the ribs, and take part in expiration. It fixes the anterior part of the chest w and so assists the actions of the muscles, particularly those of pectoral group, attached to that region.

The muscle forms a thin musculo-tendinous sheet, which is situa on the deep surfaces of the costal cartilages and side of the sterni and is serially continuous with the transversalis abdominis mus< It supports the internal mammary vessels, sternal glands, and cert of the intercostal nerves, whilst its deep surface rests upon the park pleura.

Thoracic Cavity.

Contents and their General Position. —The thoracic cavity is chk occupied by the lungs and heart. The lungs are situated one in e; half of the cavity, and each lung is provided with a serous membra called the pleura. The heart lies obliquely between the lungs, project more to the left of the sternum than to the right, and is enclosed wit a fibro-serous sac, called the pericardium. Each lung is free to exp; except at the hilum, which is situated on its inner surface. Throi this hilum the bronchus, pulmonary artery, and pulmonary v( pass, along with other structures, and the pedicle so formed is ca the root of the lung. The upper part, or apex, of the lung rises i the root of the neck, where it is covered by the cupola of the plei




THE THORAX


1003


in turn being covered by the suprapleural membrane. The lower , or base, of the lung rests upon the corresponding half of the hragm, the heart lying upon the central tendon of that muscle, rhe two pleural sacs fill the spaces enclosed by the ribs of their sides, but an interval exists between them; this is the mediastinum s. 582 and 583). Nearly all the contents of the thorax (other than lungs and pleurae) lie in the iastinal space, which, as will be ., is arbitrarily divided for conience and description, rhe pulmonary artery springs a the base of the right ventricle

he heart, and the aorta from

base of the left ventricle. The innominate vein courses along upper aspect of the arch of the

a in front of the origins of the

)minate, left common carotid, left subclavian arteries, and

es with the right innominate

1 behind the sternal end of the

right costal cartilage to form

superior vena cava. This latter sel opens into the posteroerior angle of the right atrium he heart, and, just before piercthe pericardium, receives the a azygos which arches forwards r the right bronchus. The inor vena cava, having entered thorax through the foramen for a cava in the central tendon the diaphragm, almost lmmetely opens into the postero:rior angle of the right atrium of heart.

The phrenic nerve on each side cends in front of the root of lung, and is intimately related the pericardium, especially on left side. The small anterior monary plexus of nerves lies in

it of the root of each lung. The vagus nerve on each side descends ind the root of the lung, and forms in that part of its course the ch larger posterior pulmonary plexus. The following important ves descend in front of the arch of the aorta: the left phrenic, the vagus, the superior cervical cardiac branch of the left sympathetic, !■ the lower cervical cardiac branch of the left vagus. The left


LEADING TO A COSTOPHRENIC SUL cus of Pleura (Dotted Line).

TH is placed in the mediastinum between the pleural sacs.


d











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A MANUAL OF ANATOMY


superior intercostal vein lies in front of the back part of the a arch, usually intervening between the phrenic in front and the v behind. The superficial cardiac plexus of nerves lies within concavity of the arch of the aorta, and the deep cardiac plexus behind the arch and in front of the trachea close to its bifurcc into the two bronchi. The left recurrent laryngeal nerve p; backwards under the arch, and then ascends behind it. Withir


F 1G - 583-—Diagrams showing, in the First Figure, how the Mediasti IS SIMPLY THE INTERVAL BETWEEN THE TWO PLEURAL SACS, A DEFINI WHICH HOLDS EVEN WHEN, AS IN THE SECOND FIGURE, IT IS MUCH TENDED BY PERICARDIUM, ETC.

The lower figure shows how the space between the pleural sacs can be div into a superior (S) mediastinum and an ‘ inferior ’; this term, howeve not commonly used, the lower space being subdivided, by the subver planes of the front and back walls of the pericardium, into a posterior (J middle (M), and a rather doubtful anterior space.

concavity of the aortic arch the trunk of the pulmonary artery bn up into its right and left divisions, and the ligamentum arterioi extends from the root of the left pulmonary artery to the back ] of the concavity of the aortic arch immediately beyond the origii the left subclavian artery; the recurrent laryngeal nerve winds ro its left side prior to passing upwards behind the arch of the ao The gangliated trunk of the sympathetic lies very deeply, and desce











THE THORAX


1005


the heads of the ribs close behind the parietal pleura, and the or three splanchnic nerves lie obliquely on the sides of the bodies ie lower thoracic vertebrae.

'he oesophagus lies in contact with the front of the vertebral mi, and the trachea is anterior to it. The descending thoracic a lies very deeply, being situated at first on the left side of the T>ral column, but subsequently in front of it. The thoracic duct ads on its right side, and the vena azygos ascends on the right of the thoracic duct, both structures being under cover of the )hagus. The superior and inferior venae hemiazygos, upper and

r, as well as the two transverse azygos veins, upper and lower, fiosely related to the vertebral column.

'he thoracic cavity contains the following sets of lymphatic glands : anterior mediastinal or anterior group of superior diaphragmatic ds in front of the pericardium; the superior mediastinal above pericardium, along the arch of the aorta and innominate veins; posterior mediastinal behind the pericardium; the posterior rcostal in the back parts of the intercostal spaces; and the bronchial tie interval between the diverging bronchi, and also at the root ach lung. In early life a portion of the thymus body, which is l of large size, lies behind the upper part of the sternum, whence fiends into the lower part of the neck.

fleurse. —The pleurae are the two serous sacs which invest the

s, and line the adjacent parietes. Each forms a closed sac, which uite distinct from its fellow. Like other serous membranes, the ra consists of two portions—parietal and visceral—which, however, continuous with one another.

rhe parietal pleura lines the parietes, and is divisible into five ions—namely, costal, diaphragmatic, pericardial, cervical, and iastinal. The costal pleur alines the inner surfaces of the ribs and rnal intercostal muscles. The diaphragmatic pleura covers the er surface of one half of the diaphragm. The pericardial pleura 1 intimate contact with the pericardium, the phrenic nerve and •mpanying vessels alone intervening. The cervical pleura forms t is known as the cupola (dome ), and rises into the neck for about ch above the clavicle, being a little higher on the right side than file left, on account of the projection formed by the liver. The iastinal pleura of each side bounds the mediastinum. rhe viscera pleural closely invests the lung, and is known as the nonary pleura. It is intimately connected with the lung substance, extends into the fissure, or fissures, which map out the lung into s. Below the root of each lung it forms a fold, called the pulmonary went, which descends to the diaphragm; medianly the fold is icted in front on to the pericardium, and behind on to the cesogus..

Continuity and Reflections of the Pleura —(1) In the Transverse action .—Commencing at the deep surface of the sternum, the etal pleura of each side passes backwards to the pericardium, the


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A MANUAL OF ANATOMY


two being in contact except for a little inferiorly. They form lateral boundaries of the space which is called the anterior mediastin When they reach the pericardium the two pleurae separate, each keep to its own side of that sac, and so forming the pericardial plei which bounds laterally the space known as the middle mediastin Each pleura in this manner reaches the anterior aspect of the i of the corresponding lung, where it becomes the visceral pleura. 1 covers the front of the root of the lung, and then invests the en organ, dipping into its fissure or fissures, as the case may be, and gi\ a covering to the posterior aspect of the root. On leaving the b of the root of each lung, the two pleurae pass backwards slightly c the pericardium, trachea, and oesophagus, and over the descenc thoracic aorta, to the lateral aspects of the bodies of the thor; vertebrae. These portions form the lateral boundaries of the sp which is called the posterior mediastinum. From the vertebral coir each pleura passes outwards over the gangliated trunk of the s^


Fig. 584. —Schemes to show Pleural Conditions above, through,

BELOW THE ROOT OF LUNG (L).

P, parietal pleura; V, visceral pleura.

pathetic, and then lines the inner surfaces of the ribs, as well as internal intercostal muscles. In this manner it reaches the d surface of the sternum.

From the foregoing description it will be evident that the plei in passing from the deep surface of the sternum to the vertebral colui meets with, and is reflected over, the lung and its root. At the If of the manubrium sterni the pleura passes uninterruptedly backwa to the vertebral column. That of the right side passes over the 1 of the superior vena cava, innominate artery, right innominate v and trachea; whilst that of the left side passes over the side of left common carotid and left subclavian arteries, (esophagus, ; thoracic duct. The two pleurae, as they pass backwards at this le form the lateral boundaries of the space which is called the supe\ mediastinum.

Below the level of the root of the lung the antero-posterior reflect of the pleura is complicated by a triangular fold, called the pulmon ligament. This fold consists of two layers of pleura in close appositi


THE THORAX


1007

h are continuous superiorly with the anterior and posterior pleural
stments of the root of the lung. It extends, on the one hand,

veen the lower border of the root of the lung and the diaphragm i vhich latter it is attached, and, on the other hand, between the cardium and the inner surface of the lung below the level of the

. In the last-named situation its two layers separate to encase

lung at that level. Its lower border is free and concave.

[2) In the Vertical Direction.—Superiorly the parietal pleura of 1 side rises in the form of a cupola into the root of the neck for about ch above the clavicle, where it is covered by suprapleural membrane sons fascia). This fascia is derived from the scalene group of teles, and is attached, on the one hand, to the medial border of the rib, and, on the other, to the front of the transverse process of the


STERNUM


Fig. 585.—Diagram showing the Reflections of the Pleurae

(Transverse Section).

Hith cervical vertebra. The subclavian artery and innominate 1 are intimately related to the cupola of the pleura internally and eriorly, the artery being the higher of the two. Immediately in it of the artery the phrenic and vagus nerves and the internal umary vessels lie in contact with the pleura. Inf eriorly the ietal pleura of each side is reflected from the thoracic wall on to upper surface of the corresponding portion of the diaphragm, ch it covers where the base of the lung rests upon it. The intering portion of the diaphragm (central tendon) is covered by the )us portion of the pericardium. Medially the diaphragmatic pleura omes continuous with the mediastinal pleura.

Lines of Reflection of the Pleurae — Sternal Reflection.- —Behind the ■lubrium sterni the right and left pleurae are separated from each er by an interspace which represents the superior mediastinum .








ioo8


A MANUAL OF ANATOMY


At the level of the junction of the manubrium and body of the steri they meet each other, and descend behind the body of the bon close contact and inclining slightly to the left of the median line, the level of the lower border of the fourth costal cartilage the pleura parts company with the right, and passes outwards downwards close to the left border of the sternum, and in intin


Fig. 586. —Surface Markings on Front of Thorax.

Thick black lines mark pleura; dotted lines within these show lungs and ' fissures; fine lines heart and main vessels and lower edge of liver medi interrupted line shows transpyloric plane.

relation with the pericardium. There is, however, a small triang area of that sac which is uncovered by the pleura, and lies in di relation to the anterior thoracic wall. The left pleura continues downward course as far as the inner surface of the sixth costal cartil lying not far from the left border of the sternum. At this leve again passes outwards and downwards, to be reflected on to diaphragm. The right pleura pursues an undeviating course downw;


















THE THORAX


1009


nd the sternum as far as the junction of the body and xiphoid ess. At this level it leaves the bone, and passes obliquely outwards, iwards, and backwards over the inner surface of the seventh costal lage, from which it is reflected on to the diaphragm.

'osto-diaphragmatic Reflection .—The level of this reflection may be idered, in the first place, as it affects certain definite vertical lines, he left sternal line it takes place at the level of the sixth costal


Fig. 587. —Surface Markings on Back of Thorax.

ira, thick line; lungs and fissures, dotted lines within these; uppermost level of diaphragm and liver on right side, interrupted line, hirst, sixth, and twelfth thoracic spines marked. Roots of lungs indicated.

tilage, and in the right sternal line at the level of the seventh costal tilage. In the left mammary line it takes place at the level of the ith costal cartilage, where it joins the osseous part of the rib, and the right side at a similar level. In the left mid-axillary line it es place on a level with the lower border of the tenth rib, this being lowest point to which the pleura descends. In the right midllary line it takes place on a level with the upper border of the tenth , or, it may be, the lower border. Posteriorly, in the scapular line










IOIO


A MANUAL OF ANATOMY


(inferior angle of the scapula) on each side it takes place at the k of the lower border of the twelfth rib. From this point inwards the vertebral column the line of pleural reflection is a little below adjacent border of the twelfth rib, and is very nearly midway betw the vertebral end of that rib and the first lumbar transverse proces

From the foregoing description it will be evident that the pie descends lowest in the mid-axillary line, and that posteriorly, d to the vertebral column, it actually descends below the level of lower border of the twelfth rib. The direction of the line of cos diaphragmatic reflection, from before backwards, is at first obliqr downwards and outwards until the level of the tenth rib is reach The line then passes backwards and upwards to the vertebral colui The costo-diaphragmatic pleural line is on a distinctly lower le than the margin of the base of the lung, but it is a little above the ] of the costal attachment of the diaphragm. The portion of diaphragm below the line is therefore in direct contact with the thoiz wall and adjacent internal intercostal muscles, without the intervent of the pleura, and the costo-diaphragmatic reflection is connected these structures by a fascial expansion.

The free surfaces of the parietal and visceral pleurae are in hea in close contact. They are polished, and moistened by a slight amoi of serous fluid, so that they glide smoothly upon each other. In ca of pleurisy, however, certain changes take place. The free surfa become roughened by the deposit of lymph, and the movement of lung is accompanied by the sound known as pleuritic fricti Adhesions are also frequently formed, and a serous exudation tai place into the pleural sac, which tends to compress the lung injurious the condition being known as pleurisy with effusion. In cases serous exudation the cavity of the pleura, which is a shut sac, is clea demonstrable, but in health no such cavity exists, the parietal a visceral pleurae being at all times in intimate contact with each oth The attached surfaces of the parietal and visceral pleurae are rougher by fibrous processes, by means of which they are connected to 1 parts which they cover.

The costal pleura is the thickest, and can readily be stripped fr< the inner surfaces of the ribs and internal intercostal muscles. Tb is a fairly thick layer of subserous areolar tissue on its attached surfa The diaphragmatic and pericardial pleurae are thinner than the cos pleura, and are more adherent to the subjacent structures. 1 diaphragmatic pleura follows closely the upper surface of the diaphraj in its antero-posterior curvature, with the result that though in 1 mammary line it is attached anteriorly to the eighth costal cartila it ascends when traced backwards to the level of the fifth costal cartik prior to turning downwards to the level of the twelfth rib. 1 pulmonary pleura is the thinnest and most adherent. Beneath there is a layer of subserous areolar tissue containing much elas tissue, and this is in continuity with the areolar tissue which perva( the lung.



THE THORAX


ioii


ifferences between the Two Pleural Sacs. —The right pleural sac rises higher

he root of the neck, and is shorter and wider than the left. These differences

ue partly to the projection formed by the liver on the right side, and partly 3 greater inclination of the heart to the left of the sternum than to the right.

Ilood-supply. —The parietal pleura receives its arteries from the rior and posterior intercostals, and from the various branches of internal mammary. The visceral pleura receives its blood from bronchial arteries.

'he veins pursue courses corresponding to the arteries, ferve-supply. —The nerves are derived from the sympathetic, nic, vagus, and intercostal nerves.

lymphatics—Visceral or Pulmonary Pleura. —The lymphatic vessels lis part of the pleura open into the superficial lymphatics of the s. Parietal Pleura. —The lymphatics of the costal pleura open the lymphatics of the internal intercostal muscles , which terminate ) the sternal or internal mammary glands, and (2) the intercostal ds. The lymphatics of the diaphragmatic pleura open into the )hatics of the diaphragm. The lymphatics of the mediastinal pleura into (1) the anterior mediastinal glands, and (2) the posterior iastinal glands.

'here are some costal pleural areas, however, which have particular lages. The ‘ apical ’ or cervical pleura, including that part below niddle of the first rib, drains into glands in the bottom of the neck, nd the lower end of the jugular, or it may be into the subclavian k; occasionally it seems to have some drainage into the uppermost of the axillary glands. Just below this area, and extending 1 to about the fourth rib, is a second region which, beside the lary drainage into posterior intercostal and internal mammary ds, usually has some drainage through the thoracic wall into the ary glands, accompanying the lateral intercostal nerves and vessels, drainage into axillary glands may even (but unusually) extend down r as the sixth rib.

iructure. —The pleura is a typical serous membrane like the serous portion le pericardium, the peritoneum, and the tunica vaginalis. Such mem*s are called serous because their free surfaces are moistened by a small tity of serous fluid. Briefly stated, the pleura consists of a homogeneous, sctive-tissue basement membrane, containing elastic tissue, and lined endothelium.

evelopment. —The pleura is developed from the walls of the coelom, or -cavity, which is the cleft in the mesoderm separating the splanchnopleure >omatopleure (see p. 78).

'he Mediastinum. —The mediastinum is formed by the approxion of the two pleural sacs in the region of the median anteroerior line of the thorax. The interval between the two sacs is d the mediastinal space , and its boundaries are as follows: in front, sternum; behind, the bodies of the thoracic vertebra; and on either the corresponding pleural sac. The mediastinal space contains dures so numerous as to necessitate its subdivision into four parts perior, anterior, middle, and posterior.


1012


A MANUAL OF ANATOMY


Fig. 588. —Mediastinal Contents exposed by pulling back the Ante

Parts of the Pleural Sacs.

Smaller mediastinal vessels are not shown.

and laterally, the mediastinal pleura of each side as it extends from deep surface of the manubrium sterni to the vertebral column.

Contents.—These are as follows: (1) the arch of the aorta; (2) innominate artery, and the thoracic portions of the left common car and left subclavian arteries; (3) the right and left innominate ve and the upper half, or extra-pericardial portion, of the superior \ cava; (4) the phrenic, vagus, left recurrent laryngeal, and can nerves; (5) the trachea, oesophagus, and thoracic duct; (6) the supe mediastinal glands; and (7) the remains of the thymus.

In studying the topographical anatomy of the thorax it wT


The superior mediastinum is situated above the pericardium, its boundaries are as follows: in front, the deep surface of the manub: sterni, with the origins of the sterno-hyoid and sterno-thyroid mus behind, the bodies of the upper four thoracic vertebrse and the I portions of the longus cervicis muscles; above, an imaginary \ corresponding to the superior aperture of the thorax; below imaginary plane passing from the lower border of the manub: sterni to the lower border of the body of *the fourth thoracic verte


Inf. Thyroid vein L. Innominate V. Thymus

Bulmonary A.




THE THORAX


1013


d convenient to use as a landmark the manubrio-sternal joint,

h is often sufficiently superficial to be apparent as a transverse

3 known as the sternal angle (angle of Louis). The angle is in the 3 horizontal plane as the disc between the bodies of the fourth and thoracic vertebrae, and therefore indicates the level of the imaginary e separating the superior from the other divisions of the mediasti. The angle marks the level at which the ascending aorta ends and descending aorta begins: the superior limit of the pericardium-and


L. Vagus N.

L. Phrenic N.

Sup. Intercostal Vein


Recurrent Laryngeal N. going to turn round Lig.


L. Appendix Infundibulum


R. Vagus


Cardiac Nerves

R. Phrenic N. Sup. V. Cav.

Ascending Aorta


Fig. 589. —Main Mediastinal Structures seen from the Front

(Heart exposed).


he left side of the heart. At this same level the two pleural sacs meet ront, the trachea bifurcates, the vena azygos enters the superior a. cava, the left recurrent laryngeal nerve winds round the ligaitum arteriosum, the thoracic duct crosses the middle line, and the phagus reaches the middle line.

the anterior mediastinum is situated behind the body of the num, and its boundaries are as follows: in front, the deep surface he body of the sternum, and the left sterno-costalis muscle; behind, pericardium; and laterally, the mediastinal pleura of each side as








ioi 4


A MANUAL OF ANATOMY


it extends from the deep surface of the body of the sternum to lateral aspects of the pericardium. Its direction is downwards an the left. At its upper part there is no interspace, because the pleural sacs come into contact behind the first piece of the bod] the sternum. Below this level, however, the left pleural sac dive: from its fellow, so as to leave an interspace. *

Contents.— These are the anterior mediastinal glands, s< lymphatic vessels, the anterior mediastinal branches of the inte mammary artery, and areolar tissue.


Parietal Pleura


Internal Mammary Vessels


Pleural Interval


Pulmonary Pleura


Left

Oblique

Fissure


Left Vagus Nerve


Right

Oblique

Fissure


Nerve


Vena Azygos

Fig. 59 °* Transverse Section of the Thorax through the Sec Sternal Segment in Front and the Body of the Ninth Thor \ ERTEBRA BEHIND, SHOWING THE REFLECTIONS OF THE PLEURAE AND

Position of the Viscera.


S. Sternum

A.M. Anterior Mediastinum A. A. Ascending Aorta P.A. Pulmonary Artery R.A.A. Right Appendix R.A. Right Atrium M.M. Middle Mediastinum L.A. Left Atrium


P.M. Posterior Mediastinum O. (Esophagus

D.A. Descending Thoracic Aorta T.V. Thoracic Vertebra M. Middle Lobe of Right Lung R.U. Right Upper Lobe R.L. Right Lower Lobe L.U. Left Upper Lobe L.L. Left Lower Lobe


Anterior Mediastinal Glands. —These glands are situated within areolar tissue of the lower part of the anterior mediastinum, between lower part of the body of the sternum and the front of the pericardii u re f e * ve ^eir a ff went vessels from (i) the antero-median port

ot the diaphragm, corresponding to the xiphoid process of the sternii (2) the supero-anterior surface of the liver on either side of the falcifc ligament (3) the anterior part of the pericardium; (4) the antei P 3 , 1 ^ Pr . e mec hastinal pleura. Their efferent vessels ascend and oj into the internal mammary and superior mediastinal glands.









THE THORAX


1015


he middle mediastinum lies behind the anterior and below the rior mediastinum, and is the widest part of the interpleural space, ontents. —These are as follows: (1) the heart, enclosed in the ardium; (2) the ascending aorta; (3) the pulmonary trunk; ie lower half or intrapericardial portion of the superior vena cava ; he phrenic nerves and the pericardiaco-phrenic vessels; (6) the cation of the trachea; and (7) the roots of the lungs, he posterior mediastinum is situated behind the pericardium, and v the posterior part of the superior mediastinum, with which r it is continuous. Its boundaries are as follows: in front , the ardium, and below this the posterior part of the diaphragm;


Pericardium and CEsoph.


Aorta

Sympathetic Chain


Subclavian A.


CEsoph. and Thoracic D. Sup. Intercostal V.


Vagus N. Phrenic N.


591. —Structures in Posterior Mediastinum, seen from the Left.


id, the bodies of the thoracic vertebrae below the level of the lower ier of the body of the fourth; and laterally, the mediastinal pleura ich side as it extends from the back of the root of the lung to side of the vertebral column.

Contents. —These are as follows: (1) the descending thoracic aorta;

he oesophagus, and the two vagus nerves; (3) the thoracic duct;

he vena azygos; (5) the superior and inferior venae hemiazygos, with corresponding transverse azygos veins; (6) the greater splanchnic r es, right and left; and (7) the posterior mediastinal glands.

Phrenic Nerve. —The nerve arises chiefly from the anterior primary sion of the fourth cervical nerve. It usually receives a small root









ioi6


A MANUAL OF ANATOMY


from the anterior primary division of the third cervical, and, a rule, an additional root from that of the fifth cervical. Hat descended on the superficial surface of the scalenus anterior mu: to the root of the neck, it crosses the internal mammary artery su] ficially from without inwards. It then enters the thorax and desce in front of the root of the lung in close contact with the side of pericardium, and under cover of the mediastinal pleura. Ha\ reached the diaphragm, the nerve divides into several branches, wl pierce that muscle, to be distributed to its abdominal surface, terminal branches of each nerve are connected in the diaphragm v filaments of the corresponding phrenic plexus of the sympathe which is an offshoot from the coeliac plexus. At the place of junct

of the two sets of fibres on right side there is a small gangli called the phrenic ganglion. the thorax the phrenic ne occupies the superior and mid mediastinal spaces. The n phrenic nerve lies in success on the outer side of the ri innominate vein and superior v< cava, and then descends in fr< of the root of the right lu Certain filaments from this ne not infrequently reach the un surface of the diaphragm passing through the vena ca aperture. The left phrenic ne: descends in the interval betw< the left common carotid £ left subclavian arteries, where crosses the vagus nerve fr without inwards. It then pas behind the left innominate vc and crosses over the arch of aorta separated from the vagus by the left superior intercostal ve after which it descends in front of the root of the left lung. E; nerve is accompanied by the pericardiaco-phrenic artery, which i branch of the internal mammary artery.

Branches.— The nerve of each side furnishes twigs to the p< cardium, the mediastinal pleura, the inferior vena cava, peritonei liver, and suprarenal glands; its principal branches are, howet distributed to the diaphragm.

Differences between the Two Phrenic Nerves. —(i) The right nerve is shoi, than the left, because the right half of the diaphragm, having the bulk of liver below it, is higher than the left half. (2) The right nerve is straighter til the left, because the heart, enclosed in the pericardium, projects less to the ri side than to the left. (3) The right nerve occupies a deeper position in the upl part of the thorax than the left. " }


Fig. 592. —Structures in Posterior Mediastinum, seen from the Right.

PH.N., phrenic nerve.





THE THORAX


1017


Pericardium.—The pericardium is the fibro-serous sac which loosely ounds the heart in the middle mediastinum. It is somewhat cal, being wide below, where it is in contact with the diaphragm, narrow above, where it surrounds the great vessels connected 1 the base of the heart. On each side it is intimately related to mediastinal pleura, and is embraced by the anterior portions of inner surfaces of the lungs. The phrenic nerve on each side descends ery close contact with it. In front of it are the body of the sternum the sternal ends of the corresponding costal cartilages. Its anterior ace is to a greater or less extent encroached upon by the adjacent


Fig. 593. —The Heart (Anterior View) and Pericardium. The anterior part of the pericardium has been removed.


•tions of the anterior margins of the lungs and by the two pleurae, ere is, however, a small portion of this surface which is immediately ited to the sternum below the level of the lower border of the fourth

costal cartilage at its sternal end. Posteriorly, the pericardium
in front of the posterior mediastinum, and the oesophagus is here

ited to it opposite the posterior aspect of the left auricle of the heart. The pericardium consists of two portions—an external or fibrous, I an internal or serous. The fibrous pericardium is strong and dense, eriorly it is attached to the middle lobe of the central tendon of ! diaphragm, and slightly to its muscular part, more particularly









ioi8 A MANUAL OF ANATOMY

on the left side. Superiorly it ensheathes the great vessels connec with the base of the heart, with the single exception of the infei vena cava.

The fibrous layer is attached to the sternum by two fibrous ban which are known as the superior and inferior sterno-pericara ligaments of Luschka, the former being attached to the deep surf; of the manubrium, and the latter to the deep surface of the xiph process.

The serous pericardium is a typical serous membrane, and consi of two layers, parietal and visceral, which together form a closed sa

The parietal portion lii the inner surface of 1 fibrous part, to which it closely adherent, and a intimately covers the up] surface of the central tend of the diaphragm.

The visceral portu known as the epicardiu closely invests the heart, a! also the great vessels at base more or less complete The continuity between t parietal and serous portic is established inferiorly alo the inferior vena ca^ Superiorly the continuity established along the gre vessels at the base of t heart about ij inches abo it. In this situation t serous portion forms an c terial sheath which enclos within it the ascending aor and pulmonary trunk 1 about ij inches, this bei the only complete shea formed by the serous portic Behind this sheath, with its contents, and in front of the atrial port! of the heart, there is a passage, called the transverse sinus of t pericardium, which leads from the right to the left side of the sero sac. The serous portion is also related to the superior vena cava ai the pulmonary veins, but it only covers them in front and at t sides.

The serous portion of the pericardium forms a triangular fo, called the ligament of the left vena cava (vestigial fold of Marshal

which is situated between the left pulmonary artery and the upper 1< pulmonary vein. Its base is directed towards the left, and its surfac


Fig. 594. —Scheme of Disposition of Arterial (A) and Venous Mesocardia (V) on Posterior Wall of Pericardium.

The dotted arrow lies in transverse sinus.







THE THORAX


1019


anterior and posterior. Between its two delicate layers there is nail fibrous cord, a vestige of the left duct of Cuvier; this, like the apericardial part of the superior vena cava on the right side,

es down in front of the pulmonary vessels.

The free surfaces of the parietal and visceral layers of the serous don are smooth, polished, and lubricated by serous fluid to allow of movement on the part of the heart. In the course of pericarditis y become at first dry, and then roughened by deposits of lymph, s giving rise to the pericarditic friction sound, and, it may be, to esions. They may also become separated from each other by an sion into the pericardial sac.

Blood-supply.—The fibrous portion of the pericardium and the ietal layer of the serous portion receive their arteries from (1) the icardial and pericardiaco-phrenic branches of the internal mammary, (2) the descending thoracic aorta. The visceral layer of the >us portion receives arterial twigs from the coronary arteries of the rt.

The veins pass to the internal mammary, pericardiaco-phrenic, and gos veins.

Nerve-supply.—The phrenic, vagus, and sympathetic nerves. Lymphatics.—These pass to the anterior, superior, and posterior liastinal glands.

Structure. —The fibrous portion of the pericardium is composed of fibrous lie, and is very dense, but not very extensible. The serous portion consists a homogeneous, connective-tissue basement membrane containing some tic fibres, and lined with endothelium. The parietal layer is much thicker n the visceral; the latter is intimately connected with the cardiac muscular ue, except along the grooves, which are occupied by adipose tissue and 3 d vessels.

Development. —The serous portion of the pericardium is developed from walls of the coelom, or body-cavity, which is the cleft in the mesoderm arating the splanchnopleure and somatopleure.

The fibrous walls have various origins; the antero-lateral parts come from deep layers of the body-wall, split off by the extension of the pleural cavities, l the lower or diaphragmatic part is derived from the septum transversum.

} cavity is at first continuous with the pleural sacs, but the openings, which dorsal and medial to the ducts of Cuvier, are closed by the end of the first nth.

The Thymus.—This is present in the foetus and young child, a.nd ms a very conspicuous object in the dissection of a child during J first year or two of life. It attains its greatest size at puberty, er which, as a rule, it slowly atrophies, although traces of it are to found even in advanced age. The atrophic process which it under-S is, however, extremely variable. In its fully-developed condition is situated partly in the thorax and partly in the neck. In the mer situation it occupies the superior and anterior mediastinal ices, extending as low as about the level of the fourth costal cartilages, d lying in front of the great bloodvessels and upper part of the perirdium, the upper part of the sternum being in front of it. In the ck it extends as high as the lower part of the thyroid gland, being


1020


A MANUAL OF ANATOMY


under cover of the sterno-hyoid and sterno-thyroid muscles. In situation it embraces the front and sides of the trachea, complel concealing it from view, and encroaches upon the carotid sheath

either side. Its length is ab


Two Follicles


Trabecula


Medulla


Cortex


Fig. 595. —Transverse Section of a Lobule of the Thymus Gland of a Kitten.


The concentric corpuscles of Hassall are shown in the medulla.


2w inches, and its breadth, wt


is greatest inferiorly, is about inches. Its colour is pinkish is soft in consistence; and surface shows indications of lo lation. It consists of two as} metrical lateral lobes, each of wh is pyramidal. In some cases left lobe is the larger, and other cases the right. These lo are in close contact, but are s quite distinct. Sometimes a th lobe is present, occupying an termediate position between other two.

Blood-supply.—The arteries chiefly derived from the inter mammary, inferior thyroid, s superior thyroid.

The veins open into the rij and left innominate and thyr veins.

Nerve-supply.—The nerves ; derived from the sympathetic a vagus.


Structure. —Each lobe has a capsule of fibrous tissue, from which traben pass into the interior. These trabeculae map out each lobe into large and sn lobules. Each lobule consists of an outer cortical and an inner medull portion. The cortex is composed of lymphoid tissue, the lymphoid elem predominating over the retiform, and it is surrounded by a capillary r work of bloodvessels which contains many lymph corpuscles. The lymph tissue of the cortex is incompletely subdivided into nodules by means trabeculae.

The medulla is more transparent than the cortex, the retiform element the lymphoid tissue is more conspicuous, and the lymph corpuscles are \ numerous. In addition, the medulla contains small groups of cells, more less concentrically arranged, which are known as the concentric corpuscles Hassall. According to one view, these cells are remains of the diverticula fr which the thymus body is developed; but another view is that they are conceri with the formation of bloodvessels and connective tissue.

Development. —The thymus body is developed in two lateral parts from entodermic epithelium of the pharyngeal portion of the primitive gut. 1 epithelium of the third visceral cleft on either side becomes evaginated early the second month, and gives rise to dorsal and ventral diverticula. The vent diverticulum, which forms the thymic growth, has a thick epithelial wall, bu small lumen, and grows in a downward direction. Its distal end, which ] ventral to the pericardium, forms a solid enlargement, and the proximal d loses its connection with the third visceral cleft. The enlarged distal end grj




THE THORAX


1021


umerous solid epithelial buds, which are invested with mesoderm. This ing gradually extends to the proximal part of the diverticulum. The solid and cords of each side ramify freely, and give rise to the corresponding lobe e thymus. The original diverticulum thus assumes a lobulated appearance, resembles a racemose gland. The buds or acini, however, are solid, and not w, as in racemose or acinous glands. The acini are separated by connective s and bloodvessels, which are developed from the surrounding mesoderm, phoid tissue is also developed from the mesoderm around the acini, and tissue forms the greater part of the adult thymus. The epithelial elements ch lobe are subordinate to the lymphoid tissue, and are ultimately represented le concentric corpuscles of Hassall.

jungs.—The lungs are two in number—right and left. They are lgy in consistence, float in water, and are readily compressed, m pressed between the fingers crepitation is elicited, this being to the displacement of air. When the lung is incised, similar litation is heard, and a muco-serous fluid, mixed with air, exudes, y possess considerable elasticity, their colour is that of a dark slate, they are usually mottled, this being due to carbonaceous matter, larly life, however, the colour is rose-pink.

rhe lungs occupy the greater part of the thoracic cavity. Normally / are at all times in close contact with the thoracic walls, the pleurae rvening. Unless adhesions have formed during life between the

eral and parietal pleurae, the surface of each lung is quite free

spt in two situations—namely, at the root, which occupies a limited i of the inner surface, and at the attachment of the pulmonary ment. Each lung is conical, the base being directed downwards. >resents for consideration an apex, a base, two surfaces, and two iers.

The apex is blunt, and rises out of the thoracic cavity into the t of the neck for about inches. It is here covered by the cupola he pleura, and a little below its highest point it presents a groove its medial and anterior aspects. In the case of the right lung > groove is produced by the innominate and right subclavian arteries, l in the case of the left lung by the subclavian artery of that side, ow this groove there is another groove, produced on either side by innominate and subclavian veins.

The base is extensive, semilunar in outline, and concave in adaptai to the upper arched surface of the diaphragm, upon which it ts, with the intervention of the pleura. The base of the right g is related to the right lobe of the liver, and that of the left lung [he left lobe of the liver, the stomach, and the spleen, the diaphragm srvening in each case. The margin of the base is thin and sharp, 1 it extends into the costo-diaphragmatic recess, reaching lowest lind, but nowhere as low as the line of the costo-diaphragmatic ection of the pleura.

The costal surface is extensive and convex, and in health it is sely applied to the inner surfaces of the ribs and of the internal ercostal and subcostal muscles.

The medial surface is of much more limited extent than the outer


1022


A MANUAL OF ANATOMY


Fig. 596.—Mediastinal Aspect of Right Lung.


part (DA) of the aortic groove, vertically placed and produced 1 the descending thoracic aorta. Anterior to the lower part of tf groove the left lung is related to the oesophagus, but less intimate than the right lung. The inner surface of the right lung presen above the level of the hilum grooves for the following structures: tl vena azygos (AZ), the superior vena cava (SVC) and right innomina vein, the innominate artery, the trachea (T) and oesophagus. Tl inner surface of the left lung presents above the level of the hilu grooves for the following: the arch of the aorta (A), the left subclavb


(Figs. 596 and 597 )- The greater part of it is concave (P) in adaptat to the heart, enclosed in the pericardium, the concavity being grea in the case of the left lung on account of the projection of the he to the left side. About the junction of the anterior two-thirds c posterior third this surface presents a vertical fissure, called the hilt at which the root of the lung is situated. The medial surface of right lung, behind the hilum, is related ((E) to the oesophagus, and corresponding portion of the inner surface of the left lung prese


CE

p

ivc

A R




THE THORAX


1023


jry (S), the left innominate vein, the oesophagus and thoracic

t ((E) The borders are anterior and posterior. The anterior border is 1 and short, and overlaps the pericardium, more so during inspiral than expiration, but leaving an area of the pericardium uncovered, wn as the area of precordial dulness. The anterior border of right lung keeps behind the sternum as low as the sixth right

al cartilage. The corresponding border of the left lung, beyond

lower border of the fourth left costal cartilage, presents a deep


Fig. 597. —Mediastinal Aspect of Left Lung.


laped notch, called the cardiac notch , for the reception of the al portion of the heart enclosed in the pericardium. The posterior ier is elongated, thick, and round, and occupies the groove by side of the vertebral column.

Each lung is divided into two lobes, upper and lower, by an exten> oblique, and deep fissure, which penetrates to the hilum. So ) is this fissure that, unless adhesions have formed, the lung appears onsist of two halves. The fissure commences on the inner surface,

■ the posterior border, about 3 inches below the apex. It then



1024


A MANUAL OF ANATOMY


turns round the posterior border, and passes obliquely downwa and forwards over the outer surface to the basal margin. In case of the right lung the fissure joins the basal margin some li distance from the lower end of the anterior border; but in the c of the left lung the fissure joins the basal margin distinctly fart forwards. A good ready guide to this fissure is the lower bordei the pectoralis major muscle, as it forms the anterior fold of the axi The upper lobe is comparatively small, and includes the ap about the upper 3 inches of the posterior border, the anterior bon and in the case of the left lung practically all that can be ausculta anteriorly. The lower lobe is of large size, and lies behind and be the oblique fissure. It includes the base, the posterior border exc


Fig. 598.—Diagram showing the Heart and Lungs in -Situ.

1. Tricuspid Orifice 2. Pulmonary Orifice 3. Mitral Orifice

4. Aortic Orifice x> Region of Latham’s Circle

the upper 3 inches, and practically all that can be ausculta posteriorly.

By means of the oblique fissure each lung, as stated, is divided ii two lobes. In the case of the left lung the division proceeds no fartf In the case of the right lung, however, there is an additional fissr which extends from near the mid-point of the chief fissure at 1 posterior border horizontally forwards over the outer surface to anterior border. This additional fissure cuts off from the upper 1 ( a triangular or wedge-shaped portion, which is called the middle lo

A fourth or even a fifth lobe may be present on the right side. Tb accessory lobes are usually found in the region of the hilum or of the infeij vena cava. If in the former position, the accessory lobe appears to be due t ! lateral displacement of the vena azygos, which in these cases lies in the obit fissure; if in the latter position, the accessory lobe represents the azygos lob( many animals.






THE THORAX


1025


)ifferences between the Two Lungs.—(1) The right lung has two res and three lobes, whilst the left lung has only one fissure and two 3. (2) The anterior border of the right lung is uninterrupted whilst

of the left lung presents interiorly the cardiac notch. (3) The right rger and heavier than the left, the weight of the right being about unces and that of the left about 18 ounces. (4) The right lung orter than the left, this being due to the fact that the liver causes right half of the diaphragm to rise higher than the left half, rhe right lung is broader than the left, because the heart projects e to the left side than to the right.

Vertical Extent of the Lungs.—In the mammary line the right lung ends as low as the sixth rib; in the mid-axillary line as low as the


Groove for Subclavian Artery. Groove for Innominate V in


Upper Lobe .


B


Groove for Subclavian Artery , Groove for Innominate Vein


Upper Lobe


Lower Lobe Oblique Fissure


Cardiac N otch i

Obliaue Fissure


Lower Lobe


Fig. 599. —The Lungs (Anterior View), A, the right lung; B, the left lung.


ith rib; and in the scapular line (inferior angle of the scapula) as as the tenth rib. The lower limits of the left lung exceed those he right by about the depth of a rib. It should be borne in mind, /ever, that owing to respiratory changes the vertical extent of the gs is extremely variable.

Root of the Lung.—The root is situated at the hilum on the inner face. Its chief constituents are as follows: (1) the bronchus or tube; (2) the pulmonary artery, which conveys venous blood to lung; and (3) the two pulmonary veins, which convey the arterial oxygenated blood from the lung to the left atrium of the heart, addition to these constituents there are (a) the bronchial arteries and ns, (b) the pulmonary lymphatic vessels, (c) the pulmonary nerves, 1 (d) the bronchial lymphatic glands. All these constituents are

65






1026


A MANUAL OF ANATOMY


connected by areolar tissue, and the entire root is invested by t pleura.


Right Bronchus


Right Pulmonary^ Artery


Right

Pulmonary

Veins


Left Pulmonary Artery


Left Bronchus


Left Pulmonary Veins


Fig. 600.—The Roots of the Lungs (Anterior View).


Relations. —The following relations are common to both root in front, the phrenic nerve, with the pericardiaco-phrenic artery ai


Fig. 6oi.—Mediastinal Views of Roots of Lungs, to show Relations of Bronchi, Arteries, and Veins.


the anterior pulmonary plex of nerves; behind, the vag nerve and the posterior pi monary plexus of nerves; ai below, the pulmonary ligament

Special Relations—Right Ro — Anterior. —The superior vei cava and the upper part of tl right atrium of the heart. S perior. —The vena azygos as arches forwards over the rig bronchus and right vagus open into the superior vena cav Posterior. — The vena azygc Left Root — Superior. —The ar of the aorta. Posterior. —T. descending thoracic aorta.

Relative Position of the Chi


Constituents. —The relation fn

before backwards is the same on each side, and is as follows: (i) t upper of the two pulmonary veins; (2) the pulmonary artery; ai









THE THORAX


1027


the bronchus. The relation from above downwards differs on the sides. On the right side a division of the bronchus, known as eparterial bronchus, occupies the highest position at the hilum, reas on the left side a branch of the pulmonary artery is usually highest structure. The inferior angle of the somewhat pearled hilum is occupied by the lowest tributary of the pulmonary is.

rhe larger portion of the right bronchus and the whole of the left ichus are hyp arterial.

Itructure of the Lungs. —The trachea divides into two bronchi, right and left, structure of which is similar to that of the trachea. The right bronchus, at it | inch from its origin, gives off superiorly a branch, called the eparterial


Fig. 602. _Scheme of a Pulmonary Lobule (after I.. Testut’s

‘ Anatomie Humaine ’).

ichus, for the upper lobe of the right lung, and beyond this point, where it 3w hyparterial, it divides into two branches, one for the middle and the other the lower lobe. The left bronchus is entirely hyparterial, and divides into branches, one for the upper and the other for the lower lobe of the left lung, structure of these primary divisions of the bronchi is similar to that of the ichi themselves. Within each lung these primary divisions undergo subsions to a certain extent dichotomously, but the ramifications are chiefly due ranches being given off laterally, and these never anastomose. The ramificas of the air-tubes within the lungs are called the inter pulmonary hvorichi , and r ultimate subdivisions within the lobules are known as the bronchioles. h bronchiole transmits air to and from a group of infundibula.

Each lobular bronchial tube, after entering a lobule, divides into as many nchioles as there are groups of infundibula. Each bronchiole, on approaching luster of, say, two or three infundibula, presents a dilatation, called the ibule, and from this vestibule reception chambers, known as the atria, proceed he infundibula.





1028


A MANUAL OF ANATOMY


An infundibulum is an irregular, funnel-shaped passage closed at one e; and having its walls and closed extremity beset with pulmonary alveoli, wh also beset, though more sparsely, the walls of the atria.

The interpulmonary bronchi are destitute of membranous walls posterioi and are cylindrical. This is due to the fact that their irregular plates of cartik are disposed round the circumference of the wall. The muscular fibres «  arranged in complete rings round the bronchi, and the elastic tissue for: longitudinal bundles. The mucous membrane is freely provided with racemi mucous glands, and is covered with stratified ciliated columnar epitheliu When the branches of the bronchi, by division, have attained a diameter of abc 2 1 - inch, the cartilaginous plates disappear, and the walls consist of a fibro-elas membrane and circularly-disposed muscular fibres, with a thin mucous coat des tute of mucous glands, and covered with simple ciliated columnar epithelium, th< being here and there patches of squamous, non-ciliated cells. The walls of f vestibule, atria, and alveoli are very thin, and consist of areolar, elastic, a muscular tissues, the elastic element being specially developed at the marg; of the orifices of the cells. This elastic tissue enables the alveoli to recoil at distension. The interior of the vestibule, atria, and alveoli is lined with a sin

layer of squamous, non-ciliated epitheliu which is of extreme delicacy in the alvec Upon the outer walls of the cells there e dense networks of capillary bloodvesse which also pervade the septa between t cells, these septa being formed by infoldir of the contiguous cell-walls. Each septu contains only one capillary layer. T venous blood is thus brought into the me intimate relation with the air, all that sep< ates the two being the very thin walls the cells and the very delicate walls of t capillary bloodvessels. Moreover, there bei only one capillary layer in each intercellu] septum, the blood in the septal capillaries exposed to the air on each side.

Bloodvessels of the Lungs. —Tv

sets of arteries are associated wi each lung—namely, pulmonary ai bronchial, the former having to ( with the respiratory function of the organ, and the latter with nutrition of its component tissues. The pulmonary arteries are tv in number, right and left. They result from the bifurcation of tl pulmonary trunk, and convey venous blood to the lungs. Each arte ramifies freely within the lung, its branches closely accompanying t bronchial tubes, but never anastomosing with one another. Ultimate! they terminate in dense capillary networks which lie upon the wails the alveoli, and also in the septa between adjacent cells. The arteri are somewhat more capacious than the veins.

The pulmonary veins commence as radicles in the capillary ne works already referred to, and they pass to the root of each lun where they give rise to two pulmonary veins, which proceed to tl left atrium of the heart and convey to it arterial or oxygenated bloo The pulmonary veins and their tributaries are destitute of valve Unlike the branches of the pulmonary artery, the tributaries of tl pulmonary veins freely anastomose. Within the lung the arteri)


Fig. 603. —Section of Lung (injected).









THE THORAX


1029


ally lie above and behind the corresponding interpulmonary nchi, the veins below and in front. It is to be noted that the nonary arteries carry venous blood, whilst the pulmonary veins •y arterial blood.

The bronchial arteries convey arterial blood to the lungs for the rition of their component tissues. They will be described in aection with the descending thoracic aorta, with which they are )ciated.

The bronchial veins return their blood chiefly into the vena azygos superior vena hemiazygos respectively. They are not so large he corresponding arteries, since some of the blood conveyed by the nchial arteries is returned by the pulmonary veins.

Lymphatics. —The lymphatic vessels of each lung are arranged wo sets— superficial and deep. At the hilum these two sets open > the interbronchial glands. The superficial set receives the lymtics of the visceral or pulmonary pleura.

Nerves. —These are derived from the anterior and posterior pullary plexuses, which are formed by the vagi nerves, aided by iches from the sympathetic. The nerves penetrate as far as alveoli, upon the walls of which they are regarded as terminating arborizations. The anterior and posterior pulmonary plexuses be found described on p. 1044.

Development of the Respiratory Apparatus.

rhe respiratory apparatus consists of the larynx, trachea, and lungs. The est indication of it is a median longitudinal groove, appearing in the third c on the inner aspect of the ventral wall of the oesophageal part of the foreThis groove is called the laryngo-tracheal groove, and it produces an evaginn of the ventral wall of the oesophagus. It consists of entoderm derived 1 that of the fore-gut, and it is covered by splanchnic 'mesoderm. This groove lually deepens, and gives off the two lung-buds from its caudal end; these then carried caudally by elongation of the recess to form a trachea. The ngo-tracheal tube consists of (1) entoderm derived from that of the fore-gut, (2) mesoderm, which invests it.

rhe condition of matters now is that there are two tubes, dorsal or pharyngophageal, and ventral or laryngo-tracheal, which communicate freely cephalad. Larynx. —The larynx is developed from the cephalic or proximal part of the nonary diverticulum, with coincident modification of the pharyngeal floor

the Larynx).

rrachea. —The trachea is developed from the caudal or distal part of the ngo-tracheal tube, the cartilaginous rings, connective tissue, and muscular ie of the trachea being developed from the mesodermic investment of the litive tube and becoming evident after the middle of the second month. Lungs. —The simple lung-buds of early stages (Fig. 604) are hollow club-shaped >dermal extensions from the caudal end of the laryngo-tracheal tube, which v into the small rounded mesodermal masses already prepared for them; e project into the upper end of the pericardio-peritoneal channels, rhe buds are asymmetrical, and grow rapidly. Various stages of this growth, 0 the middle of the second month, are given in the figure, also the outward earance of a lung a little older than this, in which the early lobulation is seen, enlarging lung, with its surrounding pleura, gains room for its growth by thing the body-wall and extending (p. 78) in this, splitting it cranially, bally, and to a smaller extent caudally. The entoderm of each lung-bud and


A MANUAL OF ANATOMY


1030

of its various ramifications furnishes all the epithelial elements, bronchial ; alveolar, of the corresponding lung. The mesoderm of the bud and of its vari ramifications gives rise to the bloodvessels, connectiye and muscular tissues,; cartilages of the bronchial tubes, as well as to the visceral pleura. The pedi

of the lung-buds give rise to the bronchi. The right lung-bud gives off ti processes or vesicles, and the left lung-bud gives off two processes, and in manner the three-lobed condition of the adult right lung and the two-lo condition of the adult left lung are indicated.

Each of these processes gives rise by budding to secondary processes, : these in turn give rise successively to other processes. This budding goes very freely, and the ramifications constitute the pulmonary lobes. All the b


Fig. 604.— Entodermal Lung-Buds of Embryos of 5-7 and 8 mm.

Below, at a smaller magnification, the same from embryos of fifth and si: weeks. Also outer aspect of right lung (18 mm.)

or processes, which carry along with them an investment of mesoderm, give 1 to the ramifying system of interpulmonary bronchi. The terminal ramificati* form the bronchioles and infundibula. The air-cells or pulmonary alveoli ;

formed as hollow sessile buds or evaginations of the walls of the infundibula, w the cavities of which they communicate freely.

As stated, the epithelial cells of the lung-buds and of all their ramificatic as well as the epithelial cells of the pulmonary diverticulum, are developed fr the entoderm of the fore-gut.

The eparterial bronchus is often said to be an additional bronchial outgrow The condition, however, is due in all probability to the enlargement of a si si diary arterial anastomosis; an ordinary epibronchial pulmonary artery deveL and enlarges in the second month, comparable with that on the left side, but wa



THE THORAX


i°3 T


lisappears in the latter part of this month, leaving the hypobronchial artery rry on the supply to the lung.

jungs of the Foetus. —The lungs prior to birth, having been imious to air, feel solid, like liver, and at once sink if placed in a el containing water.

luperior Mediastinal or Cardiac Glands. —These glands, which are Lerous and important, are situated in the superior mediastinum, g the upper aspect of the arch of the aorta, in front of the lower of the trachea, and along the right and left innominate veins, rhey receive their afferent vessels from (i) the anterior mediastinal ds, (2) the upper part of the pericardium, (3) the heart, (4) the hea, (5) the oesophagus, and (6) the thymus. Their efferent vessels


Fig. 605. —The Roots of the Lungs, etc.


ninate in the thoracic duct and in the right lymphatic duct, or into of the main vessels opening into or forming these ducts.

Innominate Veins.— These vessels are two in number, right and , and each is formed by the junction of the internal jugular and clavian veins behind the inner end of the clavicle. They both in the superior mediastinum.

The right innominate vein is about an inch in length, and passes vnwards with a slight inclination inwards. At the level of the lower der of the first right costal cartilage, close to the sternum, it unites ft the left innominate vein to form the superior vena cava. Laterally s closely related to the right phrenic nerve and right pleura; its dial relation is the upper part of the innominate artery, and behind s the right vagus nerve.






1032


A MANUAL OF ANATOMY


The left innominate vein is about 3 inches in length, and pas obliquely inwards and downwards from left to right. As stated, joins its fellow of the right side to form the superior vena cava, front of it there are the upper part of the manubrium sterni, origins of the sterno-hyoid and sterno-thyroid muscles, and the rema of the thymus. Behind it are the origins of the innominate, left comir carotid, and left subclavian arteries; the left vagus and left phre nerves; and two superficial cardiac nerves from the cervical porti( of the left vagus and left sympathetic. Below it there is the arch of 1 aorta.

There are no valves in the innominate veins.

Tributaries. —Each vein receives the following tributaries: (1) 1 vertebral vein; (2) the inferior thyroid vein; (3) the internal mamm: vein; and (4) the first posterior intercostal vein. The last-nan vessel, however, sometimes opens into the vertebral vein, and 00 sionally the right inferior thyroid vein opens into the left innomin; vein. The left innominate vein receives, as an additional tributa the left superior intercostal vein.

Development. —The right innominate vein is developed from that port of the right primitive jugular vein which intervenes between the place wh it receives the right subclavian vein and the place where the transverse v joins it.

The left innominate vein is developed from the venous network between primitive jugulars.

Superior Vena Cava. —This vessel is formed by the union of the rig and left innominate veins behind the lotver border of the first rig costal cartilage close to the sternum. It is about 3 inches in lengi and descends almost vertically to the level of the upper border of t third right costal cartilage, where it opens into the postero-super: angle of the right atrium of the heart. In its course it pierces t fibrous pericardium. The upper half of the vessel is extrapericardi and lies in the superior mediastinum; but the lower half is intrape cardial, and lies in the middle mediastinum.

Relations—Upper Half— Lateral. —The right phrenic nerve a: the right pleura. Medial. —The lower part of the innominate artei Lower Half— Internal. —The ascending aorta. Posterior. —The root the right lung. The serous pericardium covers the lower part the vessel except over about its posterior fourth.

The superior vena cava is destitute of valves.

Tributaries. —The chief tributary is the vena azygos after it h arched forwards over the right bronchus. It opens into the superi vena cava immediately before that vessel pierces the fibrous pe: cardium. Other minute tributaries are pericardial and mediastin veins.

Development. —The portion of the superior vena cava above the vena azyg is developed from that part of the right primitive jugular vein which lies beh the point where it is joined by the transverse jugular vein; and the portion bel the vena azygos is developed from the right duct of Cuvier.



THE THORAX


1033


nferior Vena Cava. —This vessel enters the thorax by perforatingcentral tendon of the diaphragm, and immediately afterwards

ceived within the fibrous pericardium. Its course in the thorax

-actically nil, as it may be said to open at once into the posteroior angle of the right atrium of the heart.

Phoracic Aorta. —The thoracic aorta extends from the base of the ventricle of the heart to the level of the lower border of the body le twelfth thoracic vertebra. At this point it passes through the ic opening of the diaphragm, and enters upon the abdominal part

s course. It passes at first upwards and to the right; it then


606. —Vena Azygos and Right Sympathetic Chain, showing Ganglia and the Greater and Lesser Splanchnic Nerves arising from it.

Ph.N., phrenic nerve.

T s in an arched manner upwards, backwards, and to the left, over root of the left lung; and finally descends in close contact with vertebral column, lying at first upon its left side, but subsequently ■ont of it. It is therefore conveniently divided into three parts— ely, the ascending aorta, the arch of the aorta, and the descending a.

Mcending Aorta. —The ascending aorta commences at the base lie left ventricle of the heart, behind the left border of the sternum, level with the lower margin of the third left costal cartilage, and -minates at a point behind the right border of the sternum on a level












1034


A MANUAL OF ANATOMY


Fig. 607.—Transverse Section through Fourth Thoracic Vertebra (after Symington).

























THE THORAX


io35



















A MANUAL OF ANATOMY


1036

with the upper margin of the second right costal cartilage. Its co is upwards and to the right, with an inclination forwards. It lk the middle mediastinum, and within the fibrous pericardium, w ensheathes it, and for about the first i| inches of its course it is enclc

along with the adjacent portion of the pulmoi trunk, in a sheath formed by the serous par the pericardium. The ascending aorta meas about 2 inches in length. At its commencen it presents three dilatations, which corresp to the aortic sinuses in the interior, and opposite the segments of the aortic valve, sinuses are situated one' in front and behind. Along the right side of the vessel t] is a somewhat extensive dilatation, called great sinus of the aorta.

Relations — A nterior. —The infundibulum the right ventricle, the pulmonary trunk, the right auricle at first, and subsequently first piece of the body of the sternum, f] which it is separated by the pericardium, ri pleura, and anterior margin of the right li Posterior .—The right pulmonary artery, fi Fig. 609.— Ascending which it is separated by the fibrous pericardii

(Intrapericardial) an q the j e ft a trium, from which it is separa

with its Three by the transverse smus. Right. — I he supe:

Large Branches. vena cava and the right atrium. Left .—'

pulmonary trunk.

Branches. —These are the two coronary arteries, right and left.

The right coronary artery arises from the anterior aortic sir Passing forwards between the right auricle and the pulmonary tru it enters the right atrio-ventricular groove, which it traverses fr front to back as far as the commencement of the inferior interv tricular groove. At this point it gives off the inferior interventricr branch. It then enters the posterior part of the left atrio-ventrici groove, in which it anastomoses with a branch of the left coron; artery. The inferior interventricular artery traverses the inferior ini ventricular groove as far as the region of the apex, where it anas moses with the anterior interventricular artery from the left coron; artery.

The right coronary artery furnishes branches to the right atri and to both ventricles. One, of large size, called the right margi artery, passes along the right border, towards the apex.

1 he left coronary artery arises from the left posterior aor sinus, and is at first concealed by the pulmonary trunk. It pas forward between the pulmonary trunk and the left auricle, and gn off the anterior interventricular branch. It then enters the left atr ventricular groove, which it traverses from front to back, anastomosi posteriorly with a branch of the right coronary artery. The anter



THE THORAX


1037


jentricular artery traverses the anterior interventricular groove r as the region of the apex, where it anastomoses with the inferior ventricular branch of the right coronary artery, he left coronary artery furnishes branches to the left atrium and )th ventricles. One, of large size, called the left marginal artery,

s along the left border, towards the apex.

svelopment. —The ascending aorta, along with the pulmonary trunk, is aped from the truncus arteriosus, in which the bulbus cordis teminates. ls divided by a spiral septum into aorta and pulmonary trunk.

rch of the Aorta. —The arch of the aorta commences behind the border of the sternum on a level with the upper margin of the id right costal cartilage, and terminates on the left side of the body


Fig. 610.—The Arteries of the Heart seen from in Front, the Heart being supposed to be Semi-Transparent.

Le fourth thoracic vertebra, at the lower border of which it becomes iescending aorta. It passes upwards, backwards, and to the left, ping over the root of the left lung, and when it reaches the left of the body of the fourth thoracic vertebra it descends. The ht to which the arch reaches corresponds to the centre of the ubrium sterni, which is about 1 inch below the upper border of manubrium. It lies in the superior mediastinum, and its left is in close relation with the left pleura.

delations — Anterior .—The left phrenic and left vagus nerves, the ler being anterior to the latter. Between these two nerves are the

rior cervical cardiac branch of the left sympathetic, and the inferior

ical cardiac branch of the left vagus, both on their way to the super1 cardiac plexus, which they form; and the left superior intercostal




A MANUAL OF ANATOMY


1038

vein on its way to join the left innominate vein. All these structu are overlaid by the left pleura. The remains of the thymus constit an additional anterior relation. Posterior. —The trachea, deep card plexus of nerves, oesophagus, thoracic duct, and left recurrent laryng nerve. Superior .— The left innominate vein, and the origins of following three great arteries, named in order from right to left, £ also from before backwards: the innominate, the left common carol and the left subclavian. Inferior .— The left bronchus, the bifurcat of the pulmonary trunk, the superficial cardiac plexus of nerves, left recurrent laryngeal nerve, and the ligamentum arteriosum. 1 last-named.fibrous cord is attached to the back part of the concav of the arch immediately beyond the level of the origin of the ] subclavian artery.

The arch presents a constriction immediately beyond the ori of the left subclavian artery, called the aortic isthmus , and this succeeded by a short fusiform dilatation, known as the aortic spin (of His). These features are best marked in the foetus.

Branches. —These are three in number—namely, the innomina left common carotid, and left subclavian arteries. They arise in the on named, proceeding from before backwards, and also from right to le

Innominate Artery.— This vessel is the first and largest of the th branches which arise from the arch of the aorta. It springs from 1 upper aspect of the arch rather above the level of the upper bon of the second right costal cartilage, and it terminates behind 1 upper border of the right sterno-clavicular joint by dividing into 1 right common carotid and right subclavian arteries. It is from to 2 inches in length, its direction is upwards and outwards, and lies in the superior mediastinum.

Relations — Anterior .— The right half of the manubrium ster with the origins of the right sterno-hyoid and sterno-thyroid muscl the left innominate and the right inferior thyroid veins; the ri£ sterno-clavicular joint; and some remains of the thymus. Posterior The trachea at first, but as the artery ascends obliquely to the ri£ it leaves the front of the trachea and is placed on the right side. 1 three cervical cardiac branches of the right sympathetic also lie behi the artery on their way to the deep cardiac plexus. Right. —The ri£ pleura; the innominate vein, with the right vagus nerve behind the superior vena cav^; and the right phrenic nerve. Left. —The 1 common carotid artery and the trachea, in this order from bet upwards.

Branches.— These are terminal, and are two in number—name the right common carotid and the right subclavian. The artery, a rule, gives off no branches in its course. Occasionally, however, gives origin to a vessel of variable size, called the arteria thyroidea i'i (lowest thyroid artery). The interest attached to this occasioi branch is that, in ascending to the isthmus of the thyroid gland in i neck, it lies in front of the trachea, and would be endangered in 1 operation of tracheotomy.


THE THORAX


1039


arieties. —(1) The innominate artery may be shorter or longer than usual, n cases of high bifurcation the artery may so encroach upon the trachea as

endangered in tracheotomy.

jeft Common Carotid Artery in the Thorax. —This vessel arises from ipper aspect of the arch of the aorta, just to the left of, and posterior


Trachea


Innominate

Artery


Rt. Superior Intercostal Artery

Arch of._, Aorta


Left Common Carotid Artery — Scalenus Anterior Muscle

... Left Vagus Nerve

Left Subclavian Artery (Third Part)

Left Phrenic Nerve

Left Superior Intercostal Artery


Cardiac Branches of Vagus and Sup. Cervic. Symp. Ganglio 1

Superficial Cardiac Plexus


Left Bronchus


Descending

Thoracic

Aorta


CEsophagus


Intercostal Vessels and Nerve


. Abdominal Aorta


Fig. 611.—Dissection of the Posterior Wall of the Thorax.


the origin of the innominate artery. It lies in the superior mediasim, and its direction is upwards and to the left. Having reached posterior aspect of the left sterno-clavicular joint, it enters upon cervical part of its course.

Relations — Anterior .—The left half of the manubrium sterni, 1 the origins of the left sterno-hyoid and sterno-thyroid muscles,













1040


A MANUAL OF ANATOMY


but these structures lie at a little distance from the vessel; the L innominate vein; and some remains of the thymus. Posterior. —T trachea at first, and subsequently the left recurrent laryngeal nen the oesophagus (which here deviates slightly to the left of the trache; and the thoracic duct. Right.- —The innominate artery at first, ai later the trachea. Left. —The left vagus and left phrenic nerves, wi the superior cervical cardiac branch of the left sympathetic and t inferior cervical cardiac branch of the left vagus; the first and the 1< superior intercostal veins as they pass to the left innominate vei and the left pleura and lung.

The thoracic portion of the left subclavian artery is on the left < and posterior to, the vessel, but at a little distance from it.

The thoracic portion of the left common carotid artery gives < no branches.

First Part of the Left Subclavian Artery in the Thorax. —This ves< arises from the upper aspect of the arch of the aorta a little to the 1( of, and posterior to, the origin of the left common carotid artery, lies deeply in the superior mediastinum, and is almost parallel to t thoracic portion of the left common carotid, its course being neai vertical.

Relations— Anterior. —The left common carotid artery; the left vag and left phrenic nerves, with the superior cervical cardiac branch of t left sympathetic and the inferior cervical cardiac branch of the 1( vagus, all these nerves lying between it and the left common carol artery; and the left innominate vein. Posterior. —The oesophagus a] the thoracic duct. Right. —The trachea and the left recurrent larynge nerve. Left. —The left pleura and the inner aspect of the left lur the latter being grooved by the vessel.

The thoracic portion of the left subclavian artery gives off branches.

Varieties of the Aorta —1. Position.— (a) The arch of the aorta may rise high as the upper border of the manubrium sterni, or it may stop short of t level of the centre of the manubrium, (b) It may have been derived from a rh aortic arch instead of a left.

2. Branches of the Arch and their Positions. —Varieties in these respects ; very numerous. The normal number of branches arising from the arch is thr There may be, however, only one branch, or, on the other hand, there may as many as six. When there is a reduction in the number of branches, it usually due to the left common carotid arising with the innominate from a comm trunk. The most common additional branch is the left vertebral artery, its pl< of origin being between the left common carotid and left subclavian arteri The right vertebral artery sometimes arises from the arch, but this is somewl rare. An arteria thyroidea ima may arise from the arch between the innomin; and left common carotid arteries. In rare cases the internal mammary arte or the inferior thyroid, may spring from the arch. The innominate artery n be absent, in which cases the right subclavian and right common carotid he independent origins. Under these circumstances the right subclavian art may be the last of the branches from the arch, and, when this is so, in order reach the right side of the neck, it crosses in front of the vertebral colur lying behind the oesophagus, or more rarely between the trachea and oesophagus.




THE THORAX


1041


velopment of the Arch of the Aorta and its Branches. —The arch of t>rta, between the innominate artery and the left subclavian, is the ed fourth aortic arch of the embryo. It is thus of the same develop


4


ig. 612.—The Aorta in the Thorax, and the Principal Arteries

of the Head and Neck.


^rch of the Aorta Aortic Isthmus Aortic Spindle descending Aorta -oronary Arteries (from Ascend' ing Aorta) nnominate Artery ^eft Common Carotid -eft Subclavian ^ight Common Carotid


10. Right Subclavian

11. External Carotid

12. Internal Carotid

13. Maxillary

14. Superficial Temporal

15. Vertebral

16. Internal Mammary

17. Thyro-cervical Trunk

18. Inferior Thyroid

19. Transverse Cervical


20. Suprascapular

21. Superior Thyroid

22. Lingual

23. Facial

24. Occipital

25. Posterior Auricular

26. Ascending Pharyngeal

27. Transverse Facial

28. Posterior Intercostals

29. Lig. Arteriosum


d value as the innominate and first part of the right subclavian. Beyond ft subclavian origin it is formed from a part of the left dorsal aorta. The unate, as said above, is a portion of the right fourth aortic arch, and the

66






1042


A MANUAL OF ANATOMY


left common carotid is a forward-running branch from this fourth arch, as i common carotid on the right side; these two vessels, although their actual a is in doubt, are frequently said to represent the ventral aortce of lower form interpretation of some practical value even if not absolutely correct (see p. et seq.). The left subclavian is an intersegmental artery, enlarged because < relation to the limb; its origin was from the dorsal aorta opposite to the enti of the fourth aortic arch. The ligamentum arteriosum is the remnant o: sixth aortic arch .

For the description of the descending aorta, see p. 1089.

Pulmonary Trunk. —This is the great vessel which, by mean its right and left divisions, carries the venous blood from the r ventricle of the heart to the lungs. It is therefore an exampl an artery which conveys venous blood, and in this respect resem the umbilical arteries of the foetus. It arises from the infundibu of the right ventricle of the heart, on a level with the upper ma of the third left costal cartilage at its junction with the stern It is directed upwards and backwards, and after a course of al 2 inches breaks up into two divisions, right and left, within the < cavity of the arch of the aorta. The vessel lies in the middle mec tinum, and along with the ascending aorta it is contained within pericardium, the serous portion of which forms one common shi for the two arteries over about the first ij inches of their course

Relations — Anterior .—The sternal extremity of the second intercostal space and second left costal cartilage, and the left pL and left lung. Posterior .—The root of the ascending aorta; the c mencement of the left coronary artery; and the left atrium of heart. Right .—The right coronary artery; the right auricle the ascending aorta. Left .—The left coronary artery and the auricle.

The only branches of the trunk are the two terminal divisions.

The right pulmonary artery passes outwards to the right, be. the ascending aorta and superior vena cava, to the root of the 1 lung, where it divides into two branches, upper and lower. The u; branch is distributed to the upper lobe, and the lower branch, w is the larger of the two, is distributed to the middle and 1< lobes.

The left pulmonary artery passes outwards to the left, in f of the left bronchus and descending aorta, to the root of the left 1 where it divides into two branches, one for the upper and the c for the lower lobe. The ligamentum arteriosum is attached to upper aspect of its root.

The right pulmonary artery is larger and longer than the left.

Development. —The pulmonary trunk, along with the ascending aon chiefly developed from the truncus arteriosus, but a small portion of it is foj by the commencement of the sixth left arterial arch, which remains connected that portion of the truncus which becomes partitioned off to form the pulmc trunk.

The right and left pulmonary arteries are developed as branches fror sixth left aortic arch near its commencement, the remainder of that arch g rise to the ductus arteriosus of the foetus. I


!




THE THORAX


1043


igamentum Arteriosum.— This is a fibrous cord which is the remains important vessel peculiar to foetal life, called the ductus arteriosus. [tends from the upper aspect of the root of the left pulmonary y to the under surface of the arch of the aorta immediately nd the level of the origin of the left subclavian artery. Its tion is upwards, backwards, and slightly to the left.

uring foetal life the right and left pulmonary arteries are of small size, and uctus arteriosus conveys the greater part of the venous blood from the ventricle of the heart into the aorta at a point beyond the origin of the left avian artery. None of this blood, therefore, can pass into the great vessels 1 spring from the upper aspect of the arch of the aorta, evelopment. —The ductus arteriosus is developed from the dorsal part of xth left aortic arch.

'ulmonary Veins. —These vessels carry the arterial or oxygenated I from the lungs to the left atrium of the heart. Though they

alled veins, they contain arterial blood, and in this respect rede the umbilical vein of the foetus. They are four in number,

right and two left, and at the root of each lung the upper of the is on a more anterior plane than the lower. The right veins pass nd the superior vena cava and the right atrium, and the left > pass in front of the descending aorta. All four vessels open into eft atrium on its posterior aspect. On leaving the roots of the lungs veins are said to receive small bronchial tributaries from the cent interpulmonary bronchi and glands.

rhe right pulmonary veins are larger and longer than those of the side.

Tagus Nerves in the Thorax.— These nerves, right and left, differ luch from each other in their course and relations as to require rate descriptions.

rhe right vagus nerve, having descended in front of the first part he right subclavian artery, and having given off its recurrent ngeal branch at the lower border of that vessel, enters the thoracic ty. It then descends in the superior mediastinum behind the >minate vein, and, inclining backwards, it reaches the right of the trachea, along which it courses to the posterior aspect of the of the right lung. Behind the root of the right lung the nerve )mes flattened out and breaks up into numerous branches, which disposed in a plexiform manner, and constitute the right posterior nonary plexus, from which branches are given off to the right lung, m. the lower part of this plexus the nerve issues in the form of two Is, which descend in the posterior mediastinum upon the right side he oesophagus, or gullet, and communicate freely with the corrending cords of the left side. In this manner a plexus is formed, ch is called the oesophageal plexus. Subsequently the two cords he right side unite to form a single nerve, which descends on the ‘erior surface of the oesophagus, and enters the abdomen through oesophageal opening of the diaphragm to be distributed to the -wior surface of the stomach.


1044 A MANUAL OF ANATOMY

The left vagus nerve enters the thoracic cavity between the common carotid and left subclavian arteries, and descends in superior mediastinum behind the left innominate vein. It passes in front of the arch of the aorta, having the left phrenic n on its right side and anterior to it, with the intervention of the supi cardiac nerve from the left superior cervical sympathetic gan^ and its own inferior cardiac branch. At the lower border of the it gives off its recurrent laryngeal branch, and then passes to

posterior aspect of the root of the lung. Behind the root of the lung the nerve, as on the right : becomes flattened out and br up into numerous branches, w are disposed in a plexiform mar and constitute the left posterior monary plexus, from which bran are given off to the left lung. F the lower part of this plexus nerve, as on the right side, is; in the form of two cords, w] descend in the posterior mediastii upon the left side of the oesopha, or gullet, and communicate fr with the corresponding cords of right side. In this manner, as sta a plexus is formed, which is ca the oesophageal plexus. Subsequei the two cords of the left side u to form a single nerve, which scends on the anterior surface of oesophagus, and enters the abdor through the oesophageal opening the diaphragm to be distributed the anterior surface of the stomac Branches. —These are as folio the left recurrent laryngeal; card from the right nerve; pulmona pleural; oesophageal; and p cardial.

The left recurrent laryngeal nerve arises from the left vagus in fr of the arch of the aorta on a level with its lower border. It pas backwards within the arch at the place of attachment of the li mentum arteriosum, and then turns upwards behind the arch. Hav reached the groove between the trachea and the oesophagus, it asce: therein to the neck, where its subsequent course and distribution will described. In the thorax the nerve, which contains fibres derived fr the cranial root of the accessory nerve, furnishes a few cardiac branc to the deep cardiac plexus as it winds round the arch of the aorta.


Fig. 613. — Scheme of Vagus Nerve in Thorax and Abdomen (Flower).

C.P. Branches to Cardiac Plexus P.P.P. Branches to Posterior Pulmonary Plexus

A.P.P. Branches to Anterior Pulmonary Plexus

T.S.G. Branches from Upper Thoracic Ganglia of Sympathetic P.G. (Esophageal Plexus G.B. Gastric Branches





THE THORAX


1045


ie right recurrent laryngeal nerve is extra-thoracic, inasmuch as

es from the right vagus at the root of the neck, and it winds

[ the first part of the right subclavian artery.

e left recurrent laryngeal nerve turns round the ligamentum arteriosum

e this structure is the remnant of the arterial arch within the sixth

il arch, of which the recurrent laryngeal is the nerve. Among the visceral

in front of this the nerves are in the anterior parts of their arches, in

f the arterial stems, but in the sixth visceral arch the vessel, having to >ack to reach the arch, lies in it in front of the nerve. Thus the nerve is t round the ligament when the heart and large vessels assume a more 1 position with reference to the head and neck. On the right the sixth il arch disappears early, and as the fifth artery is a very short-lived ure, the nerve catches against the fourth artery, the first part of the right tvian. It is interesting to observe that in those cases in which the right ivian arises from the left end of the arch of aorta, and passes to the right d the oesophagus, there is no right fourth aortic arch; the nerve consequently es against the third arch, internal carotid, running thus directly to the v.

he cardiac branches of the right vagus are two or three in number, they descend upon the trachea to the deep cardiac plexus. (The iac branches on the left side are derived, as stated, from the recurrent laryngeal nerve as it winds round the arch of the 1.)

he pulmonary branches are arranged in two sets, anterior and erior. The anterior pulmonary branches are two or three in her, and arise from the parent trunk before it disappears behind root of the lung. They pass to the anterior aspect of the root, being joined by sympathetic twigs, they form the anterior pulary plexus, which is reinforced by twigs from the deep cardiac us, and in the case of the left anterior pulmonary plexus by twigs 1 the superficial cardiac plexus. The branches of the anterior nonary plexus enter the lung, and accompany the ramifications he interpulmonary bronchi.

rhe posterior pulmonary branches arise from the vagus nerve ind the root of the lung. They are larger and more numerous 1 the anterior branches, and, being joined by twigs from the >nd, third, and fourth thoracic sympathetic ganglia, they form posterior pulmonary plexus. The branches of this plexus, like those he anterior, enter the lung, and accompany the ramifications of interpulmonary bronchi. The pleural branches are distributed to mediastinal and visceral pleurae, particularly in the region of the im.

The oesophageal branches arise chiefly from the oesophageal plexus dw the level of the roots of the lungs, and they are distributed to the tion of the oesophagus which occupies the posterior mediastinum ler oesophageal branches, however, arise above the level of the ts of the lungs, and are distributed to the portion of the oesophagus ich occupies the superior mediastinum.

The pericardial branches arise from the oesophageal plexus, and are tributed to the pericardium, which they enter from behind.


A MANUAL OF ANATOMY


1046


Cardiac Plexus. —The cardiac plexus is one of three large prew bral plexuses associated with the sympathetic system, the other —namely, the cceliac and the hypogastric—being situated in abdominal cavity. The plexus is situated partly in the conca of the arch of the aorta, and partly upon the trachea above the bifu tion and behind the aortic arch. It is formed by branches of vagi and sympathetic nerves, and consists of two portions, super! and deep, which communicate with each other.

The superficial cardiac plexus, which is comparatively smal situated in the concavity of the arch of the aorta between the ! mentum arteriosum and the right pulmonary artery. It is for by (1) the superior cardiac nerve from the left superior cervical s pathetic ganglion, and (2) the inferior cervical cardiac branch of left vagus nerve. These two nerves descend over the arch of aorta, lying between the left phrenic and left vagus nerves. At place where the two nerves join there may be a small ganglion, w is known as the cardiac ganglion (ganglion of Wrisberg).

Branches. —The plexus gives branches to the left anterior monary plexus, and, having received a considerable accession of fi from the right half of the deep cardiac plexus, it is prolonged into right coronary plexus.

The deep cardiac plexus, of larger size than the superficial situated upon the trachea immediately above the bifurcation behind the arch of the aorta. It is formed by (1) all the car branches of the right cervical sympathetic ganglia—namely, supe: middle and inferior—and of the right vagus—namely, superior inferior; (2) one or two cardiac branches from the right recur laryngeal nerve; (3) one or two cardiac branches from the right va in the thorax; (4) the middle and inferior cardiac branches of the cervical sympathetic trunk; (5) the superior cervical cardiac bra of the left vagus; and (6) the cardiac branches of the left recuri laryngeal nerve. It is arranged in two halves, right and left, wl communicate with each other. Each half receives the follov branches:


Right Half.


Left Half.


1. The three cardiac branches of

the right cervical sympathetic.

2. The two cardiac branches of the

right vagus, in the neck.

3. The cardiac branches of the right

recurrent laryngeal.

4. The cardiac branches of the right

vagus, in the thorax.


1. The middle and inferior cai

branches of the left cer sympathetic.

2. The superior cardiac brand

the left vagus, in the neck.

3. The cardiac branches of the

recurrent laryngeal.


Branches. —The right half of the deep cardiac plexus gives (1) branches to the right anterior pulmonary plexus; (2) bran< to the right coronary plexus. The left half of the deep cardiac pkj gives off (1) branches to the left anterior pulmonary plexus; (2) bran( to the left coronary plexus. j


THE THORAX


1047


$.R


Fig. 614.—Scheme of the Sympathetic Trunk in the Neck, and

of the Cardiac Plexus (Flower).


S.C.G. Superior Cervical Ganglion.

md G.P. Branches to Vagus and Glosso-pharyngeal , 3c, 4c. Branches to Upper Four Cervical Nerves .P Carotid Plexus P. Cavernous Plexus •G. Branch to Ciliary Ganglion '.P. Deep Petrosal •P. Greater Superficial Petrosal .N. Nerve of Pterygoid Canal •N. To In f erior Ganglion of Vagus H. To Hypoglossal -.P. To External Carotid Plexus •P. To Pharyngeal Plexus •N. Superior Cardiac Nerve

M.C.G. Middle Cervical Ganglion.

5c. To Fifth and Sixth Cervical Nerves •P. To Inferior Thyroid Plexus •N. Middle Cardiac Nerve


I.C.G. Inferior Cervical Ganglion.

7c, 8c. To Seventh and Eighth Cervical Nerves V.P. To Vertebral Plexus S.P. To Subclavian Plexus I.C.N. Inferior Cardiac Nerve


F.T.G. First Thoracic Ganglion


Cardiac Plexus.

C.B.Pn. Cardiac Branches of Vagus S C P Superficial Cardiac Plexus G.W. Cardiac Ganglion D C.P. Deep Cardiac Plexus R A.P.P. Right Anterior Pulmonary Plexus L.A.P.P. Left Anterior Pulmonary Plexus R.C.P. Right Coronary Plexus L.C.P. Left Coronary Plexus








1048


A MANUAL OF ANATOMY


Coronary Plexuses. —These are two in number, right and left.

The right coronary plexus is formed by branches from (1) superficial cardiac plexus, and (2) the right half of the deep card plexus. It accompanies the right coronary artery, and furnis branches to the right atrium and right ventricle of the heart.

The left coronary plexus is formed by branches which are derh chiefly from the left half of the deep cardiac plexus. It accompar the left coronary artery, and furnishes branches to the left atrium a left ventricle of the heart.

Ganglia are met with in the coronary plexuses, and in the cou of the fibres which supply the walls of" the auricles. They are a present on the fibres which supply the walls of the ventricles the region of the atrio-ventricular groove, but nowhere else. In heart of the calf the nerves are easily recognized beneath the visce pericardium, as they pass across the muscular fibres in an obli( manner.

Heart. —The heart is a hollow muscular organ, which, enclo: within the pericardium, is situated in the middle mediastinum, wh it lies obliquely between the two lungs. It is conical in shape, a is free to move within its pericardial sac, except at the base, wh it is connected with the great bloodvessels. Its relation to the thora wall during life is influenced by posture and by the respiratory mo merits. When a person lies upon the left side, or when the prc position is assumed, the organ is more intimately related to the thora wall than in the opposite postures; and during inspiration it is 1 intimately connected with the thoracic wall than during expiration.

General Relations and Topography. —The heart lies obliqu behind the lower three-fourths of the body of the sternum. Ab( two-thirds of the organ are contained in the left half of the thora cavity, and about one-third in the right half. The base is direcl upwards, backwards, and to the right, and lies opposite the bod of the middle four thoracic vertebrae—namely, the fifth, sixth, seven and eighth. The apex is directed downwards, forwards, and to 1 left, and during life it strikes the thoracic wall in the fifth left int costal space if inches below the left nipple, and about £ inch witl the left mammillary line. This point represents the apex-beat, and about 3I inches from the median line of the sternum. The sten costal surface , which is convex, lies behind the lower three-fourths of 1 body of the sternum and the corresponding costal cartilages, right a namely, the third, fourth, fifth, and sixth—more particularly the of the left side. This surface is encroached upon by the pleurae a the thin anterior margins of the lungs. Opposite the cardiac not on the anterior margin of the left lung there is a small portion which uncovered by lung, unless during deep inspiration, and this cor: sponds with the area of precordial dulness. Latham’s circle is tak as defining this area, and the directions for describing the circle a as follows: Make a circle of 2 inches in diameter round a point nr way between the left nipple and the end of the sternum/ Strict


THE THORAX


1049


.king, the area of precordial dulness is triangular in conformity to V-shaped cardiac notch on the anterior margin of the left lung, it may be mapped out by the following lines: one drawn from the tion of the apex-beat to the median lines of the sternum on a level 1 the fourth left costal cartilage; another drawn from the position he apex-beat to the median line of the sternum at the junction he body and xiphoid process; and a third connecting the inner 5 of these two lines, and extending along the middle of the sternum.


>rax, may be indicated with approximate accuracy in the following nner:

Base .—Draw a line across the sternum on a level with the upper rder of the third right and the lower border of the second left costal

















1050


A MANUAL OF ANATOMY


cartilages, and prolong this line for § inch to the right of the sterm and i inch to the left of it.

Inferior Border , or Acute Margin .—Draw a line from the steri end of the sixth right costal cartilage to the position of the apex-be; This line corresponds to the lower limit of the heart.

Right Limit .—Draw a line from the upper border of the third rig costal cartilage, \ inch from the sternum, to the sternal end of t

sixth right costal cartilage. This line shoi be curved outwards to such an extent tf its greatest convexity will be i J inches dista from the median line of the sternum, corresponds with the right limit of the rig atrium.

Left Border, or Obtuse Margin .—Draw line from the lower border of the second 1< costal cartilage, i inch from the sternum, the position of the apex-beat. This line shor be slightly curved outwards, but it must n include the left nipple. It corresponds to t left limit of the heart.

Course of the Circulation. —The interior the heart is divided by two septa (atrial ai ventricular) into two halves, right and le and each half is subdivided by a transvei constriction into two chambers, an upper atrium, and a lower or ventricle, right ai left respectively. The atria, except in t foetus, are completely separated from ea other by a septum, and so also are t ventricles; but the atrium and ventricle each side communicate freely with each oth by the atrio-ventricular orifice. The rig atrium receives the venous blood chiefly fro the superior and inferior venae cavae and t coronary sinus. From the right atrium t blood passes into the right ventricle, ai thence into the pulmonary trunk. The rig and left pulmonary arteries convey it to t lungs, and in passing through the pulmona capillaries it is oxygenated and beeom arterial blood. It is then taken up by the pulmonary venous radick and conveyed to the pulmonary veins, which carry it to the left atriu of the heart. From the left atrium it passes into the left ventric whence it is driven into the aorta. The aorta and its various ran fications convey the arterial blood to the different parts of the bod and thereafter it is returned as venous blood to the right atrium the heart.

Exterior of the Heart. —The exterior of the heart presents distinj


Fig. 616.—To show the Parts of Heart as

SEEN FROM THE FRONT,

when Pericardium is

REMOVED.

VD is the right ventricle, narrowing upwards (infundibulum) to reach pulmonary artery (P). The prominent anterior part of left ventricle (VS) is seen along its left border, and forms the actual apex; the left auricle (AS) shows just above this. The ascending part of aorta (A) comes from the left ventricle, and therefore appears from behind P. AD is the anterior aspect of the right auricle.


THE THORAX


IQ5 1


cations of its division internally into four chambers. These take form of grooves—namely, atrio-ventricular, interatrial, and inter tricular.

The atrio-ventricular groove , which is deep, divides the heart into al and ventricular portions, and surrounds the organ except in it, where the root of the aorta and the pulmonary trunk are situated.

atrial portion is posterior and superior in position, whilst the

itricular portion is anterior and inferior. The right half of the io-ventricular groove contains (i) the right coronary artery, and the small cardiac vein, which latter lies chiefly in its posterior •t. The left half of the atrio-ventricular groove contains (i) the

coronary artery; (2) the right coronary

ery, which lies in its posterior part; a portion of the great cardiac vein, ich lies in its anterior part, and also jhtly in its posterior part; and (4) the unary sinus, which lies in its posterior

rt. ! '

The atrial portion of the heart has the m of a crescent, the horns of which present the auricles, and are directed 'wards. The concavity of the crescent also directed forwards, and lodges the ot of the aorta and the pulmonary ink, the latter being the more anterior the two. Its walls are thin, and it is vided into two atria, right and left. The ternal indication of this division is the ter atrial groove, which is situated verbify on the posterior surface to the left the openings of the superior and inferior mae cavse. This groove corresponds to Le posterior attachment of the atrial ptum in the interior. The greater part

the posterior surface of the atrial portion .

formed by the left atrium. Projecting forwards from the anterior id upper part of each atrium is the auricle (auricular appendix). I ho vo auricles embrace between them the root of the aorta and the

ulmonary trunk. .

The right atrium (right auricle) forms the anterior and right part

f the base of the heart, and is triangular in outline as seen from ie front. The superior vena cava enters its atrium at the posteroiperior angle, and the inferior vena cava at the postero-mferior ngle. Near the latter vein the coronary sinus also opens into the trium. The right auricle (auricular appendix) is prolonged forwards rom the antero-superior angle of the atrium, and inclines to the e t 1 front of the root of the ascending aorta. It is shorter, broader, an ^ss curved than the left auricle, and its margin is notched, but no so


Fig. 617.—A Posterior View of the Heart, showing Left Atrium (LA) receiving Pulmonary Veins (PV).

This is the highest and most posterior cavity. The right atrium (RA) is seen beside it, "and the left ventricle (LV) is visible below and in front on its left side. The coronary sinus (SV) runs transversely between the atrium and the ventricle.



1052


A MANUAL OF ANATOMY


much so as is that of the left auricle. The right atrium is travers< by a groove, called the sulcus terminalis , which extends from the fro: of the termination of the superior vena cava to the front and rig] side of the termination of the inferior vena cava. This groove sho\ where the sinus venosus of embryonic life meets the primitive atrium.

The left atrium (left auricle) forms the posterior part and left the base of the heart. It is quadrilateral, and the greater part it lies flattened behind the ascending aorta and the pulmonary trun The pulmonary veins, two right and two left, open into the posteri part of the atrium. The left auricle (auricular appendix) is prolongi forwards from its left aspect, and inclines to the right over the le side of the pulmonary trunk. It is longer, narrower, and more curvi


than the right auricle, and its margin is more deeply notched. T] back of the left atrium is related to the oesophagus, with the inte vention of the pericardium; the small oblique vein of left atrium (ve of Marshall) passes downwards and inwards upon it, to open into tl coronary sinus.

The ventricular portion of the heart is conical, its walls are thic and it is divisible into two ventricles, right and left. The extern indication of this division is the interventricular groove, which co responds to the attachment of the ventricular septum in the interio This groove consists of two parts, anterior and posterior. The anteri interventricular groove extends over the sterno-costal surface of tl heart from the left side of the pulmonary trunk to the inferior bord




THE THORAX


ic>53


he right of, and near, the apex. At this point it becomes continuous

h the inferior interventricular groove. It contains, besides fat, the anterior branch of the left coronary artery, and (2) a part of great cardiac vein. The inferior interventricular groove is situated the inferior surface of the heart, and, as stated, is continuous with preceding. It contains, besides fat, (1) the inferior interven:ular branch of the right coronary artery, and (2) the middle cardiac n.

The ventricular portion of the heart presents an apex, a base, ) surfaces, and two borders. The apex is directed downwards, wards, and to the left, and forms the apex of the heart. The left


Great Cardiac Vein


Left Ventricle


Apex


Arch of Aorta

Superior Vena Cava


Right Pulmonary Veins *

'• Right Atrium


Inferior Vena Cava


Coronary Sinus


Right Coronary Arteiy


Right Ventricle


Pulmonary Trunk


Left Pulmonary Veins


Fig. 619. —The Heart (Posterior View.)


itricle alone enters into its formation. The base is directed upwards,

kwards, and to the right, and is connected with the atria and the

gins of the aorta and pulmonary trunk, the former being behind I the latter in front.

The surfaces are sterno-costal and diaphragmatic. The sternotal surface is convex, and is traversed by the anterior interventricular >ove. As this groove lies near the left border, the greater part of s -surface (about two-thirds) is formed by the right ventricle, and ' remainder b}^ the left ventricle. In post-mortem examinations, before, when the pericardium is opened, the right ventricle is chiefly xised for inspection. On this aspect of the right ventricle there

the anterior cardiac veins. Its upper and left part is somewhat









1054


A MANUAL OF ANATOMY


conical, and is called the infundibulum (conus arteriosus). It gr origin superiorly to the pulmonary trunk. The diaphragmatic surf is flat, and is traversed by the inferior interventricular groove, this groove lies near the inferior border, the greater part of this surf; (about two-thirds) is formed by the left ventricle, and the remaim by the right ventricle. On this aspect of the left ventricle there ; the posterior cardiac veins.

The borders are inferior (right) and left. The inferior border comparatively long, and extends from right to left. It is formed the right ventricle, and is sharp in outline, from which circumstai it is known as the acute margin. The marginal branch of the ri^ coronary artery and one of the anterior cardiac veins lie along

The left border is shorter th the inferior, and is blunt a round, from which circu stances it is known as 1 obtuse margin. The margi] branch of the left corom artery lies along it.

Interior of the Heari Right Atrium (Right Auric —The wall of the auricle marked by a number muscular elevations arran^ as closely-set, vertical, par lei bands, like the teeth a comb, from which circu stance they are called 1 musculi pectanati. Th bands, relatively to ez other, are more or less r icular. They are also presi on the right wall of 1 atrium, being more comb-1 here than in the auric and they terminate posteriorly at a vertical ridge, called the cn termmalis. This crest corresponds in position to the sulcus termini externally, and it has the same significance. Internally and posterio the walls of the atrium are destitute of musculi pectinati, and p sent a smooth appearance. The right atrium presents the follow: openings : the opening of the superior vena cava; the opening of' inferior vena cava; the opening of the coronary sinus; the openings the venae cordis minimae; and the tricuspid orifice.

The orifice of the superior vena cava, which is destitute of a val is situated at the postero-superior angle of the atrium. It is direc downwards and forwards, and the upper part of the crista termin; is continuous with its anterior margin.

The orifice of the inferior vena cava is situated at the poste


Fig. 620.—Diagrammatic Section along Right Side of Heart.

AV, atrio-ventricular valve ; C, trabeculae carneae; E, valve of I VC; FO, fossa ovalis; P, papillary muscle; SV, supraventricular crest; T, opening of coronary sinus.





THE THORAX


1055


erior angle of the atrium, and is directed upwards and inwards,

front of the orifice, and to a certain extent overlapping it, there a crescentic fold of endocardium, which is the remains of the valve the inferior vena cava (Eustachian valve) of foetal life. The conxity of the crescent is continuous with the anterior margin of the fice of the vein, and the inner horn of the crescent is continuous th the anterior limb of the annulus ovalis, to be presently described. ie fold is a somewhat indefinite structure in the adult, being subject much variety as regards size, and sometimes presenting several ■all openings. During foetal fife, however, the valve is of the utmost portance, inasmuch as it directs the blood entering by the inferior na cava through the foramen ovale into the left atrium.

The orifice of the coronary sinus is situated between the valve of 3 inferior vena cava and the tricuspid orifice. It is guarded by a licate semicircular fold of the endocardium, called the valve of the ■onary sinus (Thebesian valve), which, however, is functionally

ompetent.

The foramina venarum minimse (foramina Thebesii) represents Tral minute openings on the wall of the atrium. Some of these are lply blind recesses, whilst others are the orifices of minute veins, led the vence cordis minimce, which return the blood from the wall the atrium.

The atrio-ventricular or tricuspid orifice is situated in the lower i anterior part of the atrium in front of the orifice of the inferior 1a cava, with the intervention of that of the coronary sinus. It is il and in health will admit three fingers. Through this opening s blood passes from the right atrium into the right ventricle, its urn being prevented by the tricuspid valve, which will be described connection with the right ventricle.

The posterior wall of the atrium corresponds to the atrial septum,

I presents for consideration the fossa ovalis and the annulus ovalis. The fossa ovalis is an oval depression which is situated upon the rer part of the atrial septum a little above and to the left of the free of the inferior vena cava. It indicates the position of the amen ovale of the foetal heart, which is a communication between ! two atria through which the blood entering the right atrium by • inferior vena cava passes into the left atrium. The floor of the sa ovalis is very thin, and is bounded above and at the sides by a >minent crescentic margin, called the annulus ovalis. The annulus ieficient below, and the concavity of the crescent is directed downrds. Its anterior limb is continuous with the valve of the inferior ia cava. In some cases a minute oblique communication between

two atria persists in the adult, being situated under cover of the

^er portion of the annulus ovalis.

Interior of the Right Ventricle. —When exposed to view in the ■inary way, the interior of the right ventricle is pyramidal, the

e being directed backwards and to the right, and the apex forwards,

the left, and a little downwards. It is completely separated from


A MANUAL OF ANATOMY


1056


the left ventricle by the ventricular septum, which forms the poster wall of the ventricle, and bulges into it so as to be convex towards In transverse section, therefore, the right ventricle is semilunar, wall, which is about three times thinner than that of the left ventri( is thickest at the base, and becomes thinner towards the apex. 1


\


L. Atriiin


“A. V. orifi


Aortic

Vestibule


Septum


tiG. 621 .—-Longitudinal Section through Heart, opening the Four

Cavities.

Shows the deep situation of the aortic vestibule, between the left A.V. openi and the interventricular septum. The thin upper part of this septum the pars membranacea, which is partly between the aortic vestibule a each of the right-sided cavities. Based on a section given by Tandler.

capacity of the ventricle is about 4 ounces. Its upper and left pz form the infundibulum [conus arteriosus), from the upper part of whi the pulmonary trunk springs. The walls of the infundibulum 2 smooth, but elsewhere the walls of the ventricle are elevated in muscular bands, called trabeculce carnece . These project into t






THE THORAX


1057


y, and from their reticular arrangement they render the wall

irregular. According to the manner in which the trabeculse ese are attached to the wall, they are arranged in three sets: (1) some simple elevations, which are attached to the wall by their entire th, as well as by their extremities; (2) some are attached to the only by their extremities, being free elsewhere; and (3) others ittached only by one extremity. These latter are called papillary

les. They are conical, and their bases are attached to the wall

le ventricle. Their free extremities are connected with a number iform processes, called chordce tendinece, which pass to the margins ventricular surfaces of the segments of the atrio-ventricular e. When the ventricle contracts, the papillary muscles also ract, and by tightening the chordae tendineae they prevent the >s of the atrio-ventricular valve from being swept back into the im. The cusps are therefore maintained in contact during the

ricular systole, and no regurgitation of blood from the ventricle

the atrium is allowed in health. The papillary muscles are ,nged in three groups—anterior, inferior, and septal—and their

s are attached to the walls of the ventricle in the region of the

t of the cavity. The anterior papillary muscle is of large size, inferior is usually broken up into two or more secondary papillary

cles, while the septal muscles are variable both in number and

In most hearts a fleshy column, called the moderator band , is met 1 in the right ventricle, which extends from the ventricular septum he base of the anterior papillary muscle. The term moderator band applied to this bundle in the mistaken belief that it moderated ension of the right ventricle. It is now known to serve for the sage of an important slip of the atrio-ventricular bundle. (The d was noted and drawn by Leonardo da Vinci more than four hunI years ago, and the name of bundle of Leonardo has been suggested it.)

The openings. connected with the right ventricle are two in number amely, the tricuspid and pulmonary, Ihey are situated at the e of the cavity, and are guarded by most important valves. The uspid orifice is situated on the right and posteriorly, whilst the monary orifice is situated on the left and anteriorly, being also on igher level than the other. Vence minimce cordis are said to open

i the right ventricle. . .

The right atrio-ventricular or tricuspid orifice is oval, and admits passage of three fingers. It allows the venous blood to flow from right atrium into the right ventricle, and in order to prevent urgitation of blood from the ventricle into the atrium during the itricular systole it is guarded by an important valve, called the lit atrio-ventricular or tricuspid valve. This valve is composed of ee segments or cusps , which are covered with endocaidium. These >ject into the cavity of the ventricle, and are triangular. The bases the cusps are continuous with one another, and form a ring, which


A MANUAL OF ANATOMY


1058

is attached to the margin of the tricuspid orifice. The largest cus situated in front and to the left of the tricuspid orifice. It interv< between that orifice and the infundibulum, and is known as the ante cusp. Another cusp is situated behind the tricuspid orifice, and i contact with the ventricular septum. It is called the medial c The third cusp is situated to the right near the acute margin, an called the inferior cusp. In the angular intervals between the b parts of the three large cusps there are usually three small cusps.

Each cusp consists of two layers of endocardium, with fibi tissue between them, especially at their central parts. The mi< portion of each cusp is therefore thicker than the marginal porti these latter being thin and transparent. The margins themse


Superior Vena Cava .


Aorta


Annulus Ovahs


Fossa Ovalis


Valve of Inferior Vena Cava


✓ Pulmonary Trunk (opened)


§N — Pulmonary Valves


Orifice of Coronary Sinus

Valve of Coronary &§§!!

Sinus / Inferior Vena Cava

Tricuspid Valve


- Left Coronary Artei j


Ventricular Septun


Left Ventricle


Chordas Tendineae

I

Papillary Muscle

Fig. 622.—The Interior of the Right Auricle and Right Ventrici


are notched. The atrial surfaces of the cusps are smooth, but t ventricular surfaces are roughened by the chordae tendineae, wl are also attached to the margins.

The chordae tendineae are filiform, fibrous processes which connected on the one hand with the wall of the ventricle, and the other with the cusps of the tricuspid valve. Most of them sp from the anterior and inferior papillary muscles, but a few of ti arise from the ventricular septum and from the small papillary t nences upon it. Those which are connected with the anterior papil muscle pass to the interval between the anterior and inferior cu: those which are connected with the inferior papillary muscle and subdivisions pass to the interval between the medial and infe









THE THORAX


1059


>s; and those which are connected with the ventricular septum

to the interval between the anterior and medial cusps. The

lection of the chordae tendineae with the cusps of the valve is of reef old nature as follows: (1) most are connected with the marginal

s of the cusps; (2) others are connected with the thickened central
ion of each cusp; and (3) a few pass to the basal portion of each

), where they are connected with the fibrous ring around the uspid orifice.

rhe pulmonary valve guards the orifice of the pulmonary trunk, prevents regurgitation of blood from the trunk into the right tricle during the elastic recoil of the arterial wall. It is composed

hree semilunar cusps, and the wall of the artery opposite each


Ascending Aorta (opened)


Aortic Semilunar Valves —


Ventricular Septum


Pulmonary Trunk Lunule


Pulmonary Veins


Atrial Septum


Mitral Valve

%

%\ t ',!■/

- Chord® Tendineae


r Papillary Muscle


Trabeculae Carneae <

Apex


Fig. 623. —The Interior of the Left Atrium and Left Ventricle.


ment presents a recess, these recesses being called sinuses. The ve and the sinuses are similar to corresponding structures in mection with the aortic orifice, and will be fully described along h that orifice.

Interior of the Left Atrium.— The musculi pectinati are present V in the auricle, whereas in the right atrium they are present both be auricle and on the right wall of the atrium. The wall of the left him is entirely smooth. The atrium presents five openings— nely, the openings of the four pulmonary veins, and the mitral ice.

The orifices of the four pulmonary veins are situated on the posterior h of either side, two right and two left, and are destitute of valves.










io6o


A MANUAL OF ANATOMY


The auriculo-ventricular or mitral orifice is situated in the ante: part of the floor of the atrium. It is oval, and in health admits i passage of two fingers.

Venee minima cordis are said to open into the left atrium.

The atrial septum presents a slight depression, limited inferio by a faint crescentic ridge, the concavity of which is directed upwar These indicate the position of the foramen ovale of the foetal heart

Interior of the Left Ventricle.—The cavity of the left ventri extends quite to the apex of the heart, and is longer and narrow than that of the right ventricle. It is somewhat conical, the base bei directed backwards and upwards. The ventricular septum rece<

from the cavity, and is cones towards it. In transverse secti<


Left

Ventricle


Right Ventricle


Left Ventricle


therefore, the left ventricle is o\ or nearly circular. The wall of 1 left ventricle is about three tin thicker than that of the right, 1 difference being readily accounl for by the fact that the left ventri is concerned with the systemic c culation, whilst the right ventri has to do with the pulmonary c culation, the latter involving a mr shorter circuit. The wall of 1 left ventricle attains its maximi thickness about the junction the upper fourth and lower thr fourths, and is thinnest in 1 region of the apex. The capac of the ventricle is about 4 ounc


Ventricular Septum

Fig. 624. Transverse Sections of 'ppg portion of the cavity imme

. ateiy below the aortic orifice

A. through apex .(superior view). known as the aortic vestibule, i

B, through ventricles (inferior view). .. . . . . *

walls 01 which are fibrous.

The left ventricle, like the right, is provided with trabeculae carnt They are arranged in a very intricate manner, more particularly the region of the apex and over the posterior wall. The aor vestibule and the ventricular septum, at least over its upper pa are destitute of trabeculae carneae, and present a smooth appearan The papillary muscles are much larger than those in the right ventric they are two in number, anterior and posterior, and they are attaci by their bases to the respective walls of the ventricle, whilst th free ends are connected with the chordae tendineae.

The openings connected with the left ventricle are two in numl —namely, mitral and aortic. They are situated at the base of 1 ventricle in close proximity to each other, and are guarded by imports valves. The mitral orifice is situated on the left and posterior whilst the aortic orifice is situated on the right and anteriorly. 1





THE THORAX


1061


ic orifice is also considerably the higher of the two. Vence minima

lis are said to open into the left ventricle.

The auriculo-ventricular or mitral orifice is oval, and in health fits two fingers. It allows the arterial blood to flow from the left um into the left ventricle, and in order to prevent regurgitation blood from the ventricle into the atrium during the ventricular tole it is guarded by an important valve. This valve is called the auriculo-ventricular, mitral, or bicuspid valve. It is composed two large segments or cusps , with two small cusps in the angular irvals between their basal parts. The cusps are similar in shape


L.


'ig. 625. —Dissection (viewed from above) of the Basal Part of the

Heart.

3 two arterial stems have been removed close to their origins, exposing their valves, while the atria have been cut away a little distance above the atrio-ventricular valves. The coronary arteries are thus exposed for some extent after their origins, the aortic sinuses are partly visible, the coronary sinus is seen opening into the right atrium, and the atrioventricular valves, mitral and tricuspid, are seen closed.


Pulmon. Art.


Coron. Art.


Coron. Sinus Left Atrium


d structure to those of the tricuspid valve, but on account of 3 nature of their work they are thicker and stronger. They 5 disposed obliquely, and are of unequal size. The larger of 3 two is placed in front and to the right of the orifice. It internes between the mitral and aortic orifices, and is known as the terior cusp. The smaller cusp is placed behind and to the left of 3 orifice, and is known as the posterior cusp.

The chordae tendineae are attached to the cusps, as in the case of e tricuspid valve. They are, however, fewer in number, and of safer thickness and strength than on the right side.




1062


A MANUAL OF ANATOMY


Function of the Tricuspid and Mitral Valves. —These valves serve to prev regurgitation of blood from the ventricles into the atria during the ventrici systole. Whilst the ventricle is being filled, some of the blood gets beh the segments of the atrio-ventricular valve—that is to say, between each segm and the wall of the ventricle—and the segments are thus carried towards atrio-ventricular orifice. When the ventricle is filled with blood the segme are in contact, and the ventricular systole now takes place. At the same t: the papillary muscles contract. Blood is forced against the segments of the va' but it cannot in health enter the atrium, because the segments are maintai in close contact, and are prevented from being swept back into the auricle by chordae tendineae, which are under the control of the papillary muscles. If tl were no papillary muscles, in which case the chordae tendineae would spi directly from the wall of the ventricle, then the segments of the valve would be held tight, but would, under the pressure of the blood, be driven back into atrium, and regurgitation of blood would of necessity occur. The explanai of this lies in the fact that when the ventricle contracts a kind of screwing or wringing movement takes plac§ in its wall, as, so to speak, in wringing a towel. The effect of this peculiar action is to approximate successive part: the ventricular wall to the atrio-ventricular orifice, and this would have effect of relaxing the chordae tendineae, and so allowing the segments of the va to be driven back into the atrium. The chordae tendineae, however, spring fi papillary muscles, and these are elevations of the wall of the ventricle direc

Orifice of Nodule Orifice of

Coronary Artery { Lunule Coronary Artery


Fig. 626.—Cusps of the Aortic Valve.


towards the atrio-ventricular orifice. During the wringing movement, theref( of the ventricular wall in systole the papillary muscles, as stated, contract, ; so maintain the chordae tendineae taut, or tightly drawn.

When the mitral valve opposes the entrance of blood into the left ventr the cardiac affection is known as mitral obstruction (stenosis). When mitral valve is incompetent, and allows regurgitation of blood to take place fi the left ventricle into the left atrium, the cardiac affection is known as mi regurgitation (incompetence).

The aortic orifice is circular, and is separated from the mitral ori: by the anterior cusp of the mitral valve. It is guarded by the ao; valve, which by means of its cusp prevents regurgitation of bl( from the aorta into the left ventricle during the elastic coil of arterial wall. It is composed of three semilunar cusps or segmei consisting of fibrous tissue, covered on their ventricular surfaces endocardium, and on their arterial surfaces by the endothelial lin of the artery. Each cusp is attached by its convex border to wall of the artery at the place where it springs from the ventri The other border of the cusp is free, and is directed away from ventricle. Each cusp, therefore, is so disposed as to allow the bl<























THE THORAX


1063


)ass freely into the aorta from the left ventricle. The free border

ach cusp is strengthened by a band of fibrous tissue, and at the

tre of the border there is a small swelling, called the nodule [corpus ntii). This gives rise to a slight projection, and on either side of he border is concave. The attached convex border of each cusp Iso strengthened by fibrous tissue. In addition to these fibrous

kenings, fibrous tissue pervades each cusp from the nodule to the

iched border, with the exception of the portions immediately )w the lateral concave parts of the free border. These portions in ti cusp are semilunar, and are called the lunules. They are the mest parts of the cusp, and are transparent, consisting practically udocardium and the endothelial lining of the artery.

The interior of the wall of the aorta presents three well-marked jsses, each of which is placed opposite a segment of the valve. These isses are called the aortic sinuses (sinuses of Valsalva), and they are dised as anterior, left posterior, and right posterior respectively. The erior sinus presents the orifice of the right coronary artery, and the posterior sinus presents the orifice of the left coronary artery. Each is, together with the corresponding cusp of the aortic valve, forms nail pocket, and the three pockets open away from the left ventricle hat is to say, in a direction corresponding to the normal blood-flow.

Function of the Aortic Valve— This valve serves to prevent regurgitation of )d from the aorta into the left ventricle during the elastic recoil of the arterial i close to the heart. During the ventricular systole, when the blood is being r en through the aortic orifice, the aortic valve assive, and its three segments are applied to arterial wall. During the elastic recoil of the

rial wall, however, the valve is in action. The
effect of the elastic recoil is to force sufficient

)d backwards towards the left ventricle to close aortic valve. This blood enters the pockets ned by the aortic sinuses and the cusps of the ^e. The cusps are pressed towards the centre of aortic orifice, and they come into contact in following manner: the three nodules come into

e contact at the centre of the aortic orifice, and

dose what would otherwise be a small space, and respective lunules are closely pressed against another. In this manner the aortic orifice is lpletely closed, and regurgitation of blood into left ventricle is in health effectually guarded inst. It will be evident that the strain of the kward pressure of blood must be borne by those tions of the segments which are strengthened fibrous tissue extending from each nodule to attached border of each cusp. Though the ules are thin and weak, nevertheless, being, so to speak, doubled up against ! another, the more they are pressed upon the more closely they fit together. When the aortic valve offers opposition to the entrance of blood into the fa, the cardiac affection is called aortic obstruction (stenosis). On the other id, when the aortic valve is incompetent, and allows regurgitation of blood take place into the left ventricle, the cardiac affection is called aortic regurgiion (incompetence).


Fig. 627. —The Aortic Sinuses and the Aortic Valves, seen from above.

The right coronary artery (left in figure) is seen coming from the anterior sinus; the left artery is arising from the left posterior sinus.


A MANUAL OF ANATOMY


1064

The pulmonary valve, which guards the orifice of the pulmon; trunk, is similar to the aortic valve, and the preceding descript is for the most part applicable to it. The cusps of the pulmon; valve are, however, weaker than those of the aortic valve, and 1 sinuses are destitute of any arterial orifices. These sinuses are dispo: as posterior, right anterior, and left anterior respectively.

The function of the pulmonary valve is similar to that of 1 aortic valve.

Ventricular Septum. —This septum completely separates the ri^ and left ventricles. The external indications of its attachments ; the anterior and inferior interventricular grooves. It is thick, and for i most part fleshy. It is thickest in the region of the apex, and becon thinner towards the base of the ventricles. It bulges into the ri^ ventricle, so as to be convex on that aspect, whilst it recedes from 1 left ventricle, so as to be concave towards it. The upper or ba part of the septum presents anteriorly a small portion which is destiti of muscular fibres. This portion is thin (see Fig. 621) and consi of fibrous tissue, covered on either side by endocardium.

It is known as the membranous part of the septum, and is develop from the fused A.V. cushions of embryonic life. It forms the ri^ and posterior part of the wall of the aortic vestibule immediat< below the aortic valves. Its upper part separates the cavity of 1 vestibule from the right atrium, while its lower part is between ventricles', these relations can be seen in Fig. 621.

Topography of the Orifices of the Heart.-r— The pulmonary orif is situated on a level with the upper margin of the third left cos cartilage at its junction with the sternum. The aortic orifice, whi is more deeply placed than the pulmonary, is situated behind the 1 border of the sternum on a level with the lower margin of the th costal cartilage.

The tricuspid orifice lies behind the body of the sternum oppos the fourth intercostal spaces and fourth and fifth costal cartilag The mitral orifice, which is placed very deeply, is situated behind 1 left border of the sternum on a level with the fourth left costal cartila The anterior atrio-ventricular groove corresponds with a line dra from the third left to the sixth right costal cartilage, and it is on t line that the two atrio-ventricular orifices are necessarily found.

Cardiac Bloodvessels—Arteries. —The nutrient vessels of the he are the coronary arteries, right and left, which arise from the root the ascending aorta. For a description of these vessels, see p. 1036

Veins. —The cardiac veins are as follows: the great cardiac ve the coronary sinus; the posterior cardiac veins; the middle card vein; the small cardiac vein; the anterior cardiac veins; the oblic vein of left atrium; and the venae cordis minimae or smallest card veins. With the exception of the last-named cardiac veins (ve cordis minimae), all the others are seen upon the exterior of the hee

The great cardiac vein commences at the apex of the heart, 2 ascends in the anterior interventricular groove alongside of the antei



THE THORAX


1065


ventricular branch of the left coronary artery. In this part of its se it is more properly called the anterior interventric.ular vein. of large size, and receives tributaries from both ventricles and the ventricular septum. On reaching the atrio-ventricular ye it enters the left division of that groove, in which it courses y with the left coronary artery. Having turned round the left of the heart, it joins the left extremity of the coronary sinus, which it is continuous. The name coronary, which was sometimes 1 to this vessel, is strictly applicable to it only where it lies in the atrio-ventricular groove.


Fig. 628. _Heart viewed from below and behind, showing the

Arterial and Venous Distributions here.

The coronary sinus is the dilated terminal part of the great cardiac 1. It is about 1 inch in length, and occupies a portion of the terior part of the left atrio-ventricular groove. Its left extremity Dntinuous with the great cardiac vein, and its right extremity opens > the right atrium between the valve of the inferior vena cava and tricuspid orifice, the opening being guarded by the valve of the Dnary sinus. At the place where the coronary sinus is continuous h the great cardiac vein there is a valve, which is composed of two nents.

The coronary sinus is the persistent left horn of the sinus venosus. The posterior cardiac veins ascend upon the posterior surface of left ventricle, and open partly into the coronary sinus, and partly



io66


A MANUAL OF ANATOMY


into the contiguous portion of the great cardiac vein. One of tl is known as the left marginal vein.

The middle cardiac vein, which is of large size, commences at apex of the heart, and passes along the inferior interventric groove with the inferior interventricular branch of the right coror artery. It receives tributaries from the adjacent surface of the ri ventricle and from the ventricular septum, as well as a few f: the left ventricle, and opens into the right extremity of the coror sinus.


Fig. 629. —Diagram showing the Position of the Heart and its Valvl Orifices in Relation to the Anterior Wall of the Thorax.


R.A. Right Atrium R.V. Right Ventricle L.A. Left Atrium L.V. Left Ventricle A.A. Arch of Aorta In. Innominate Artery


R.S. Right Subclavian Artery

R. C.C. Right Common Carotid Artery L.C.C. Left Common Carotid Artery L.S. Left Subclavian Artery

S. V.C. Superior Vena Cava


Numbers on Sternum.

1. Tricuspid Orifice 3. Mitral Orifice

2. Pulmonary Orifice 4. Aortic Orifice


The small cardiac vein occupies the right atrio-ventricular gro in company with the right coronary artery, and opens into the ri extremity of the coronary sinus. It is subject to some variat but it usually receives tributaries from the contiguous parts of the ri atrium and right ventricle, including the anterior cardiac veins.

The anterior cardiac veins ascend on the front of the right ventri and open into the small cardiac vein. One of them is known as right marginal vein.

The oblique vein of left atrium (oblique vein of Marshall), whic

a persistent part of the left duct of Cuvier, passes downwards and inw;





THE THORAX


1067

the posterior aspect of the left atrium, and opens into the left emity of the coronary sinus, its orifice being destitute of a valve.

evelopment. —The oblique vein of left atrium represents the terminal portion e left duct of Cuvier.

rributaries of the Coronary Sinus. —These are as follows: (1) the t cardiac vein; (2) some of the posterior cardiac veins, others of e veins opening into the great cardiac vein; (3) the middle cardiac

(4) the small cardiac vein; and (5) the oblique vein of left atrium,

h the exception of the last-named tributary, all the others are dded with valves at their terminal orifices, but elsewhere they destitute of valves.


Fig. 630. —The Veins of the Heart as seen from in Front.

The heart is supposed- to be semi-transparent.

The venee cordis minimae (smallest cardiac veins) are not visible >n the exterior of the heart. They are very minute, and they open ) the right atrium, their orifices constituting some of the foramina arum minimarum. Similar minute veins are said to open into the atrium, and also into both ventricles.

Lymphatics.—The lymphatic vessels of the heart form two netks—subendocardial and subpericardial. The vessels are ultitely collected into two trunks, right or posterior, and left or erior. The right trunk receives the lymphatics of the right side he heart, and the left trunk takes up those of the left side. Each tik accompanies the corresponding coronary artery, and both pass kwards on either side of the pulmonary trunk. Having pierced pericardium, they terminate in the superior mediastinal or cardiac nds.






io68


A MANUAL OF ANATOMY


Nerves.—The nerves of the heart are derived from the super and deep cardiac plexuses, and through these from the vagus svmpathetic nerves. The branches do the atria are derived p from the deep cardiac plexus, and partly from the coronary plex They form a gangliated plexus on the surface of each atrium her the epicardium, and from this plexus branches proceed to the mus wall. The branches to the ventricles are derived from the right left coronary plexuses. These branches lie upon the surface of ventricle beneath the epicardium, and in the heart of the calf the; readily recognizable as delicate, thread-like streaks. Minute ga are met with at intervals on these nerves in the region of the ba the ventricles, but none on those nerves which lie over the lower thirds of each ventricle. The branches which enter the mus^ substance of the ventricular walls form plexuses, but are dest of ganglia.


Fig. 631. —The Superficial Muscular Fibres of the Heart in the Region of the Apex (C. Gegenbaur).


Structure of the Heart. —The cardiac wall is composed of muscular t which is known as the myocardium. This is intimately covered by the vi layer of the serous pericardium, this layer being called the epicardium, an

cavities of the heart are lined with a mem which is known as the endocardium.

The epicardium resembles a serous mem in structure, and is covered by endoth( Beneath the epicardium there is a va amount of fat, which is chiefly met with i atrio-ventricular and interventricular groov The endocardium is a smooth, delicate brane, destitute of bloodvessels, and coven its internal surface by endothelium. It co of a connective-tissue basement membram taining elastic fibres, and is continuous th: the arterial and venous orifices with the 1 intima of the vessels. It enters into the f tion of the segments of the atrio-ventricula semilunar valves.

Fibrous Tissue. — The atrio-ventriculai

arterial orifices of the heart are each surroi by a ring of fibrous tissue, and these rings, : case of the atria and ventricles, connect them together. The fibrous tiss these rings furnishes that which is met with in the segments of the various v In the triangular interval between the aortic and the two atrio-ventr orifices there is a collection of dense fibrous tissue, of the consistence of cartilage, which is connected with the fibrous rings just referred to, and ' represents the os cordis of the ox. ’When a heart is boiled the fibrous tis dissolved, and the atrial portion can be separated from the ventricular poi Myocardium. —The muscular tissue of the auricles is mostly distinct that of the ventricles, the fibrous rings at the atrio-ventricular orifices vening between the two, and serving to connect them.

Atria. —The muscular fibres of the atria are arranged in a superfici; common to both atria, and a deep set confined to each atrium. The supe fibres are disposed transversely, and some of them enter the atrial septum, are best marked in front. The deep fibres are arranged in two sets, loope< circular. The looped fibres arch vertically over the atrium, their extrei being attached to the ring of fibrous tissue which surrounds the atrio-ventr orifice. The annular fibres are present in the auricle around the venous or and around the fossa ovalis. The walls of the atria, though muscular, are


The whorled arrangement is well shown.


THE THORAX


1069


ntricles. —The muscular fibres of the ventricles are, as stated, mostly

t from those of the atria, and are disposed in a very complicated manner,

spring for the most part from the rings of fibrous tissue which surround trio-ventricular orifices. The superficial fibres descend obliquely towards jex, where they are disposed in a twisted or whorled manner, after which pass on to the inner surface of the left ventricle. Some of them become iuous with the papillary muscles of that ventricle, whilst others ascend as

ical layer on the inner surface of the ventricle to be attached to the left


632. —Anterior View of Heart of a Young Subject dissected after Long Boiling, to show the Superficial Muscular Fibres (Allen Thompson), f. (From Quain’s ‘ Anatomy.’)

figure is planned after one of Luschka’s, but its details were chiefly taken from an original preparation. The aorta, b', and pulmonary trunk, a', have been cut short close to the arterial (semilunar) valves, so as to show the anterior fibres of the atria; a, superficial layer of the fibres of the right ventricle; b, that of the left; c, c, anterior interventricular groove; d, right atrium; d' , its auricle, both showing chiefly perpendicular fibres; e, upper part of the left atrium; between e and b ', the transverse fibres which behind the aorta pass across both auricles; e', auricle of left atrium; /, superior vena cava, around which, near the atrium, circular fibres are seen; g, g / , right and left pulmonary veins with circular bands of fibres surrounding them.

)-ventricular fibrous ring. The superficial fibres are common to both

xicles.

the remaining fibres are very numerous, and must be described separately -ach ventricle. The principal fasciculi of the left ventricle spring from the atrio-ventricular fibrous ring, and they pass more or less obliquely towards apex. In their course they turn inwards, and enter the front part of the Ticular septum interiorly. Some of them now pass upwards to the base of ventricle to be attached to the collection of dense fibrous tissue, of the conTice of fibro-cartilage, already described; others pass across to the posterorior wall of the right ventricle, where they partly end in a papillary muscle,




1070


A MANUAL OF ANATOMY


and partly pass to be attached to the right atrio-ventricular fibrous ring; i a third set pass to the postero-inferior wall of the left ventricle, where become circular in direction. The principal fibres of the right ventricle are the superficial fibres, continuous with those of the left ventricle, and spring the fibrous rings around the atrio-ventricular and pulmonary orifices. ' on the postero-inferior surface of the right ventricle pass into the ventr: septum, and having traversed it obliquely forwards and upwards, they from it, and become continuous with the deep fibres of the left ventricle. r on the sterno-costal surface of the right ventricle also pass into the ventr: septum, and having traversed it obliquely backwards and downwards, they on to the postero-inferior wall of the left ventricle. Those from the in aspect of the right ventricle enter the lower part of the ventricular septum

sino-atriai node


Fig. 633. —The Sino-atrial Junction (after Tandler).


ascend in the septum to the collection of dense fibrous tissue of the consisten fibro-cartilage at the base. Although the ventricular muscular fibres are disj for the most part obliquely, there are some annular fibres, but these are con to the thickest part of each ventricular wall.

Fibres of Purkinje. —These fibres are situated between the endocardium the cardiac muscular tissue. They consist of elongated cells united at their so as to form chains. The central part of each cell contains granular protopl within which there are two nuclei; and the peripheral part presents trans 1 striations. These cells are probably vestiges of an early condition of ca; muscular fibres.

Sino-atrial Node. —In the region of the sulcus terminalis is a small oval (Fig. 633) measuring about 10 mm. in length and from 3 to 5 mm. in w where the muscular fibres are arranged so as to form a delicate network













THE THORAX


1071


■atrial node or the node of Keith and Flack. It is believed to be the spot

  • e the contraction of the heart begins and from where the wave of contraction

eeds over the heart.

Ltrio-ventricular Bundle (Figs. 634 and 635).—This bundle constitutes the atrio-ventricular muscular connection, and functionally is of a conducting ire. It begins in the atrio-ventricular node, which is situated in the central >us body of the heart a little below the opening of the coronary sinus into right ventricle. The node consists of an intricate network of muscular fibres rmingled with, and embedded in, fibrous tissue. Entering the node are


Sup. Vena


Fossa Ovalis


Ascending Aorta


ve of Inferior ena Cava


^alve of anary Sinus


if. Vena Cava


rio-ventricular Node


Right Fasciculus of Atrio ventr. Bundle


Pulmonary

Artery


Moderator Band


Right Ventricle


634-—The Atrio-ventricular Node and the Right Fasciculus of the Atrio-ventricular Bundle as seen from the Cavity of the Right Ventricle (after Tandler).


es of an indefinite but probably atrial origin. From it proceeds a single die, which represents the main stem of the atrio-ventricular bundle. This n passes forwards along the upper margin of the muscular portion of the tricular septum, lying immediately below the membranous part, and beneath anterior part of the base of the medial cusp of the tricuspid valve. In this ation the main stem breaks up into two fasciculi—right and left. Each of these aculi enters the septal wall of the corresponding ventricle, and divides into nches which ramify beneath the endocardium, where they form part of the tern of Purkinje’s fibres. Ultimately the terminal ramifications blend with muscular fibres of the ventricles and papillary muscles. A slip from the















1072


A MANUAL OF ANATOMY


right fasciculus passes to the anterior papillary muscle of the right vent] within the moderator band. To open this band and discover the slip is perl the simplest way of exposing the bundle.

The fibres of the atrio-ventricular bundle are pale, and are furnished i nerve-fibres and ganglia. The clinical significance of the bundle has refert to Stokes-Adams disease, or heart-block.

Structure of the Cardiac Valves. —Each segment of the tricuspid and m valves consists of two layers of endocardium, enclosing between them fib tissue which is derived from the fibrous ring around the corresponding a ventricular orifice. Each segment of the aortic and pulmonary valves


Em. 635.— The Left Fasciculus of the Atrio-ventricular Bundle

SEEN ON THE VENTRICULAR SEPTUM FROM THE CAVITY OF THE L

Ventricle (after Tandler).

consists of two layers of endocardium, enclosing between them fibrous tis which is derived from the fibrous ring around the corresponding arterial orif The segments of all the-valves are destitute of bloodvessels.

Minute Structure of the Myocardium. —Cardiac muscle is composed of tra versely striated fibres, but these differ so much from ordinary striated volunt muscular fibres as to require a special description. They possess no sarcolemr they branch freely, and adjacent branches unite, so that an intricate netw< is formed by them, and the transverse strias are fainter and less regular tl those of voluntary muscle. Each fibre and its branches are broken up inti series of short quadrangular muscle corpuscles, arranged in rows or chains, 2 separated from one another by cross-marks. Each muscle corpuscle conta













THE THORAX


1073


ucleus, which occupies the centre of the corpuscle, and the corpuscle presents tudinal striae as well as transverse. A cardiac muscular fibre, as well as anches, is therefore a chain of muscle corpuscles, each of which has a nucleus centre, and there is an absence of sarcolemma. height of the Heart. —The average weight of the

of the adult male is 10^ ounces, and of the adult

le 8 |- ounces.

ize. —The size of a normal heart has been compared ie closed hand of the individual person, development of the Heart. —In the absence of definite mation, the human heart must be considered as ig primarily from the fusion of vessels in the edges Le advancing mesoderm in the protocardiac area of embryonic plate. Moreover, these vessels must be ned to lie in the visceral portion of this mesoderm,

>ugh the presence of a pericardial split at such an ' stage is doubtful; thus the heart would be in assoDn with the roof of the yolk-sac, and, when reversal 3 place, with the floor of the fore-gut, to which it would

tached by its mesodermal covering. The single tube

ting from the fusion enlarges rapidly, standing away . the roof of the pericardium, and drawing after it Ding so a dorsal mesocardium, which ' suspends ’ it . the roof. The existence of a ventral mesocardium sry doubtful; if it does occur, it disappears at an edingly early stage.

'he single-looped cardiac tube formed in this way nds forward from the septum transversum, where its er end is continuous with the sinus venosus, which is into it. Its anterior end turns up as the aortic or rial stem or truncus arteriosus, entering the mesolal floor of the fore-gut, where it divides. The true iac tube, lying between these two fixed extremities,

. shows three primary dilatations, or primitive (single) chambers—the atrium Fig. 638), into which the sinus venosus opens directly; the ventricle (V); the bulbus cordis (B), from which the aortic stem issues. The dorsal mesoium, seen in the figure, disappears in its central area very quickly, thus


Fig. 636. — Cardiac Muscular Fibres,

SHOWING THEIR

Transverse Stride, Divisions, Junctions, and Position of the Nuclei.


• 637. —Scheme showing Four Successive Stages in the Development of the Heart (F. Testut’s ‘ Anatomie Humaine ’).

x. Arterial Bulb. 2 . Ventricle. 3* Atrium.

4. Veins opening into the Sinus Venosus.


dng a passage from one side to the other dorsal to the heart, and between arterial and venous ends; this is the transverse sinus of the adult perilium.

Sections through the heart show at this and succeeding stages that an inner ocardial tube forms a cellular structure, separated by a subendocardial

68
































































io 7 4


A MANUAL OF ANATOMY


space from an outer myocardial tube of contractile mesoderm cells. The sp is occupied by subendocardial fluid, probably contained in greatly disten< cells; it is invaded later by the growing myocardium, on which the endocan layer is then laid, the result being the intracardiac network characteristic of true cardiac tube. The three parts of the cardiac tube enlarge rapidly, atrium and ventricle particularly, the result being, as shown in the sec( diagram in the figure, that the bulbus is now directed backwards as well upwards, the large atrium is beginning to lap round it on each side from behi and the ventricle is situated ventrally between the two. Other results also fol this rapid growth; the sinus venosus is gradually drawn into the pericardial ca\ at the venous end, and the truncus arteriosus—though not nearly to so gr a degree—at the arterial end.



Fig. 638. —Schematic Figures of Early Heart.

In the first the heart tube is shown from the left in the pericardium (P), and 1 a single atrium (A), ventricle (V), and bulbus (BC). Opening into it behi is the sinus venosus (SV) embedded in the septum transversum above a in front of the liver-bud. A complete dorsal mesocardium (DM) is prese: this quickly breaks through and disappears in the dotted area. The secc figure shows the effect of growth of the tube without corresponding incre; in distance between its terminal attachments. The third diagram illustra the positions in the bent tube assumed by the dorsal (D) and ventral ( cushions in the A.V. and arterial regions. R, L, are right and left venc valves beside the opening of the sinus venosus.


The tube is narrowed into an atrio-ventricular* canal between the dilal atrium and ventricle, and here endocardial cushions (A . V. cushions) are ma (by the subendocardial tissue), which partly block the passage of the A.V. can dorsal and ventral cushions are formed first, right and left, smaller ones being add later. At the aortic orifice arterial cushions are similarly produced rather m< slowly. All these structures are concerned in the development of valves.

In the fourth week the heart, seen from the front, presents a surface appe; ance such as is shown in Fig. 642. Some of the parts of the adult heart can recognized here in a rudimentary state, but the cavity within is still undivid being a single passage from venous to arterial end. The division into ri£ and left passages must now be described; it is convenient to take the cavit


  • Frequently written A.V. for brevity.





THE THORAX


1075


itely, but it should be underthat the division goes on in rious parts more or less at the time.

Atrial Septa and Atria. —As

nus venosus is drawn out into ericardium from the septum rersum, its opening into the 1 is found to be no longer in, but on the right of the e line; this is probably due ferences in growth-rate of the des of the atrium. The opento the atrium is. guarded by s valves, right and left. As the a enlarges, a septum primum rs as a falciform edge (Fig. 640) ig round the upper wall of the r a little to the left of the left s valve. It quickly extends

the front and back walls, mg in this way the upper and

A.V. endocardial cushions, large interatrial opening enI by this septum above the )ns is the foramen primum. septum becomes deeper (Fig. and the foramen primum is ately closed by the meeting of the free edge of the septum with the A. V. cushions ; efore this occurs a foramen secundum appears as the result of breaking


g. 640. —Hearts of Embryos of 4-5 Mm. and 10 Mm. respectively.

t wall of right atrium cut away in each case to show deepening of septum )rimum (S. I.); F.i, foramen primum; F.2, foramen secundum; S.V., anus venosus. Venous valves are not shown.

gh of the upper part of the septum. This is seen at an early stage in the d figure in Fig. 640.


Fig. 639.—Section through Cardiac Tube in 2-5 Mm. Embryo, showing Endocardial Tube (E), Subendocardial Space (S), and Myocardial Tube (M).












A MANUAL OF ANATOMY


1076

The septum secundum* develops as a low, falciform, and fairly thick e on the upper wall a little distance to the right of the first septum, and after foramen secundum has appeared. Its lower and posterior end runs into left venous valve—which is not shown in Fig. 640—and its anterior end is on the upper and front wall. It overhangs the foramen secundum on the ri It increases very slightly in height, but its anterior end, extending round front wall, reaches the dorsal A.V. cushion here, and becomes continuous 1 the lower end of the joined venous valves; it will be noticed again with t! and it is only necessary to say here that it forms the annulus ovalis.

The opening of the sinus venosus, guarded by its two venous valves, li little to the right of the septal structures low down on the posterior wall, two valves, projecting into the atrial cavity, are joined above and prolongec the wall as an upper fornix; owing to the shortness of the left valve, thei no proper lower fornix. The upper fornix, large and developed early, t forward along the upper wall, and is lost on the upper front wall; it mak prominent edge, sometimes referred to as the ‘ septum spurium.’

The lower fornix, or, more truly, the lower end of the right valve, reaches hinder or ventralf A.V. cushion. The space on the back and upper walls, betv the septum primum and the sinus valves and upper fornix, is known as intersepto-valvular space ; the septum secundum projects into this from abo

The dorsal and ventral A.V. cushions fuse during the sixth week, divi< the A.V. canal into right and left channels. When this occurs, the lower fo extends and reaches the lower front end of the septum secundum, which has 1 seen to have reached the dorsal cushion.

The opening of the sinus into the atrium gets larger, the right valve stre ing out towards the right, the left coming against the septum primum obliterating the lower part of the intersepto-valvular space; it degener here, but some remnants of it may be found on the septum. The right v; forms the valve of the inferior vena cava, attached below and in front to remnant of the septum secundum, and being lost above and behind as the remr of the upper fornix, the crista terminalis . The enlargement is associated a the increasing size of the opening into the sinus of the inferior vena cava schemes in Fig. 641).

It is really the right horn of the sinus venosus that is engaged in this enla ment, which makes it become a part of the right atrium, that part into w] the venae cavae open; the original atrial cavity on this side is pushed outw by its enlargement, and forms only the auricle. The left horn of the s: venosus, forming the coronary sinus, , becomes descriptively only a seconc vessel opening into the large right horn, and the spur between the opening the two horns, at first some distance from the atrium, comes up (Fig. 641 its level, and finally becomes the part of the valve of the inferior vena cava 1 lies between the openings of the coronary sinus and inferior vena cava; corresponding part of the right venous valve makes the valve of the coroi sinus, as in the figure.

Thus the right atrium of the adult heart is developed from the right 1 of the sinus venosus so far as its atrium is concerned, the original atrium ( forming the auricle. The valve of the inferior vena cava is formed from right venous valve and the spur between the horns, the valve of the coronary s\ from the lower part of the right valve, and the septum is a compound of sep primum (septum ovale) and septum secundum (annulus or limbus ovalis).

The foramen ovale (foramen secundum) usually remains patent to a si extent for many years.

  • Two distinct structures seem to be confused in the descriptions givei

this septum. One is apparently only the upper remnant of the septum prm above the secondary foramen; the other is the one described here, and app< to be in reality the proper septal structure between the left and right sides. :

f The nomenclature of these cushions, as seen from the auricular aspect, be understood from the third diagram in Fig. 638.





THE THORAX


io 77


e cavity of the left atrium is produced in a somewhat similar manner. A common pulmonary vein, made by junction of right and left branches, ad opening into the left atrium at the end of the first month close to the n primum. It gradually enlarges, increasing in diameter, but not pronately in depth. Thus its right and left branches come to open into a r which, by its increase in diameter, is pushing the original atrium away ds the left. Still enlarging, the venous cavity takes up its right and left hes into itself, thus leading to their next two branches on each side coming


. 641. —First Figure: Atrial Cavities exposed by Removal of the Upper and Front Wall in an Embryo of 4-5 Mm.

atrio-ventricular opening; RVV, right venous valve, marking off sinus enosus, into which common cavity open the right and left horns of the inns (RHSV, LHSV). The left venous valve is not yet formed. The smaining figures, semi-diagrammatic, show the taking up of the sinus ito the atrium; the right atrial wall only is removed, leaving the septum rimum (SEPT. I.) in position, with the foramina (FOR. I. and II.) above nd below it. ISVS, intersepto-valvular space; LVV, left venous valve; VC, opening of inferior vena cava.

2n directly into the cavity. In this way the atrium is made from dilated inary veins, the auricle representing the original true atrium. ie A.V. canal, as already said, is divided into right and left A.V. openings e fusion of the dorsal and ventral endocardial cushions. The persisting ires are guarded by right and left cushiohs, with the corresponding ends ! fused central pair. The fusion occurs about the sixth week, and about ime time the foramen primum closes on their atrial aspect, and the venir septum is nearing its completion on their other side.

Ventricles and Bulbus Cordis.— In Fig. 642 the 4-5 mm. heart is viewed the front, and the common ventricle is seen to bulge somewhat to the ying to the left of the bulbus, and on the whole rather below it. The





A MANUAL OF ANATOMY


1078


companion drawing shows this heart with the front wall removed fror ventricle and bulb; the cavities of these two parts are seen to be separated j by a prominent bulbo-ventricular ‘ spur ’ or angle, which, by its presence, c the opening into the bulb to lead out of the right extremity of the ventr: cavity to the right, in front of, and rather below the atrio-ventricular ape: This aperture is seen guarded by its endocardial cushions.

The ventricular cavity is already showing an early state of division right and left ventricles, for a low septum is visible extending back to the in


Fig. 642. —Views from the Front of Hearts of Embryos of the Fo and Fifth Weeks (4*5 Mm. and 10 Mm.) (from Reconstructions)

On the right are shown the interiors of these hearts, the front walls of the tricles and bulbs, and to some extent of the atria, having been rem< l.a., l.v., left auricle and ventricle; r.v., right ventricle; r.b.r., right b ridge; art. cush., endocardial cushions at beginning of arterial trunk; sept., interventricular septum.


A.V. cushion. This septum is really little more than the original floor o cavity persisting at its original level, the two subdivisions of the cavfh larging downwards on each side of it. Thus the right ventricle starts existence as a bulging of the common ventricle; this bulging can be seen oi surface view of the heart.

Turning now to the 10 mm. embryo (Fig. 642), it is to be noticed tha bulbo-ventricular spur has decreased much in prominence; this is due to a atrophy and disappearance, so that the bulbar opening is now above the








THE THORAX


1079


e right-hand end of the A.V. aperture. The ventricles have become deeper the septum proportionately higher, but that the septum has not grown ird is evident from the fact that it retains its old level of attachment to the - A.V. cushion.

t the 15 mm. stage (not shown) the process of reduction of the bulboicular angle has gone even farther, the whole left and back wall of the having practically disappeared, so that the arterial cushions are, in this very near to the A.V. cushions. At the same time the greater part of the opening is, as a result, now brought directly under the passage into the ining bulbus.

urning back to the 10 mm. specimen (Fig. 642), certain changes within >ulb itself are to be seen. These consist in the development of two bulbar S. The right ridge is seen almost entire; it begins above just below the ial cushions (with the right one of which it is continuous), and passes down back on the right bulbar wall, to end in a blunt extremity just to the right


Fig. 643.—To show Method of Division of Bulbar Region and

Formation of Aortic Vestibule.

(Explanation in text.)

le A.V. opening. The left ridge starts below the left lateral aortic cushion, extends downwards and forwards on to the left front wall of the bulbus, his part has been cut away in the figure, the ridge is only partly seen cut ss. These two bulbar ridges thus overhang a deep channel, which can be in the figure, traceable downwards and to the left towards the left ventricle, each which its groove would be continued in front of the A.V. cushions and ve the edge of the ventricular septum, ihis channel becomes the aortic inel, or aortic vestibule of the complete heart, closed in, as will be described, he fusion of the ridges with each other, and with the edge of the septum.

In the 15 mm. stage, when the spur and the associated bulbo-ventricular - on the surface have disappeared, the atrophy affects mainly the wall of the 5 behind and below the left ridge, but this is nevertheless shorter than the t ridge, thus exhibiting the general tendency to shortening of this region.

complete division of the bulbar region and separation of the two ventricles

1 follow; the way in which this happens is schematically shown in Fig. 043.









io8o


A MANUAL OF ANATOMY


In these schemes the front wall of the right ventricle only is supposed to ] been removed with that of the bulb, so that the interventricular septum (w in the previous figures has only been seen in part) is now seen as a whol< not only reaches the lower A.V. cushion, but runs into the upper cushion corresponding situation, making a free falciform edge between these two po The free edge forms the boundary of the interventricular foramen, the d( wall of which is made by the cushions. The dorsal and ventral cushions j leaving now two lateral atrio-ventricular openings, one on each side of the p of the septum and interventricular foramen. In the first diagram the bulbar ridge is seen at a and the right at b\ these are continuous above 1 the left (/) and right (r) arterial cushions respectively; these cushions are fn so that a pulmonary orifice [pa) is between them and the ventral cushion


Fig. 644.—Bulbo-ventricular Region (15 Mm.).

The first figure shows the bulbar ridges in position, the second shows the ao channel, the ridges and parts of the walls being cut away. S, upper of interventricular septum; A, the fused (lateral) arterial cushions; D, dorsal arterial cushion.

The two small figures show how the septum between aorta and pulmon artery meets the fused lateral arterial cushions, leaving three semilu rudiments to each artery. D, V, dorsal and ventral cushions.

The second plan shows how the descriptive position of the definite cr results from a small amount of rotation from right to left.

and separated by these from the aortic orifice, which lies between them and dorsal cushion. The aortic orifice leads into the aortic channel (ao), wh overhung by the bulbar ridges, passes downwards and to the left in front of A^V. cushions, and through the interventricular foramen into the left ventri When fusion occurs between the A.V. cushions it affects those parts that m the floor of the aortic channel— i.e., the cushions bounding the transv( sht and the upper part of the right lateral slit—leaving the lower part (av) the right lateral slit as the permanent right opening.

In the second diagram the mode of closure is illustrated. The right bul ndge grows towards the left across the right lateral A.V. orifice—between closed and unclosed parts—and just reaches the attachment of the ventrici septum to the lower cushion. The left ridge, in contact from its early st;





THE THORAX


1081


the upper part of the septum, begins to extend along the free margin of this ; dent of its growth along this margin is indicated by the dotted line. The idge in this way reaches the right ridge by growth along the edge of the ventricular foramen, and by fusion between the two ridges the aortic channel fed in and separated from the (right) cavity continuous with the pulmonary 3. In the third figure the actual conditions (a little simplified) are shown embryo of the sixth week, in which the various parts are in the process iction and consolidation; it may be noted that a certain amount of extension sue from the fused arterial cushion takes place between the upper parts 3 two bulbar ridges.

Dr descriptive purposes the dorsal wall of the bulbar region has been given rth in the figure greater than it really possesses; owing to the disappearance 3 left dorsal wall with the bulbo-ventricular spur, the dorsal arterial cushion ictically next to the A.V. cushions, so that the ' floor ’ of the aortic channel >elow the aortic orifice is made by the fused A.V. cushions; this is the memus part of the ventricular septum, separating the aortic channel (aortic Dule) from the right atrium. The ventral wall of the aortic vestibule is made le fused bulbar ridges, and it is evident that the interventricular foramen, ugh it no longer affords a passage between the left and right ventricles, sts as the opening into the aortic vestibule (from the general cavity of the ventricle) to the right of the left A.V. orifice. The remnants of the A.V. ons, presenting as pouting lips in the ventricular cavities, and continuous

with the endocardial covering of the muscular network of the ventricles,

ne atrio-ventricular valves, modification in the network producing the chordce yiece and papillary muscles. On the left the cushion lips are placed vertically e the vertical slit, and the two valves derived from them lie naturally een the opening and the aortic vestibule and the left marginal wall respecy On the right the vertical lips (Figs. 643 and 644) separate the orifice from ieptum and the right marginal wall respectively, but in addition there is a >verse flap derived from (or in association with) the right bulbar ridge e this crosses the line of the orifice, and this flap separates the orifice from Dulmonary channel, and hence becomes the anterior (infundibular) cusp. umming up the description given of the formation of the parts, it may be that the infundibulum is a remnant of the bulbus cordis, but its dorsal wall oduced by fused bulbar ridges; the cavity of the aortic vestibule is also a part lat of the bulbus, with an added * ventricular ’ part brought into existence he disappearance of the bulbo-ventricular spur; the membranous part of ventricular septum marks the position of fused A.V. cushions, the interricular foramen remains as the opening into the aortic vestibule from the ral cavity of the left ventricle; and the A.V. valves are derived from the cushions, the anterior cusp of the right valve being an additional structure lected with the growth of the right bulbar ridge.

Tie arterial (semilunar) valves are developed by hollowing out of their arterial ices from the arterial cushions already mentioned. These are four m number

  • ht and left lateral, dorsal, and ventral. The lateral cushions fuse, coning the single orifice into two—ventral or pulmonary, and dorsal or aortic,

division of the bulbar region below these cushions has been described, and bulbar ridges which make the dividing wall have been seen to be continuous se with the fused lateral cushions; in a similar way the dividing wall between two arteries above them is continuous with the fused lateral cushions. I he arteries become completely separated, the separation extending through valvular region, and incompletely involving the bulbar region, thus the original cushions are divided (Fig. 645) into six, three for each orifice, these are hollowed into the arterial valves; the pulmonary orifice has the tral flap and two postero-lateral, the aortic opening has two antero-lateral the dorsal flap. Towards the end of intra-uterine life, however, the heart ergoes a rotation from right to left to such an extent as to place the root o pulmonary trunk in front and to the left of the root of the aorta. 1 he a, as well as the pulmonary trunk, is involved in this rotation, and the seg

1082


A MANUAL OF ANATOMY


ments of the pulmonary and aortic valves are now permanently alterec position. The relations of the various segments in the adult are as folic the cusps of the pulmonary valve are disposed as two anterior, right and : and one posterior ; whilst the cusps of the aortic valve are one anterior and posterior, right and left.


Fig. 645.— Schemes to show Formation of Arterial Valves froi

Arterial Cushions.

A, P, ventral and dorsal cushions. The second scheme shows the division

the four cushions into six. The third scheme shows the effect of rctai

on the descriptive positions of the valves.

The rotation just referred to also explains why the left ventricle of the ac heart is chiefly postero-inferior in position, comparatively little of it appeal on the sterno-costal surface of the adult heart.

Peculiarities of the Foetal Circulation. —The structures peculiar the foetus in connection with the circulation of the blood are follows:

1. Foramen ovale. 4. Umbilical arteries.

2. Valve of the inferior vena cava. 5. Umbilical vein.

3. Ductus arteriosus. 6. Ductus venosus.

The foramen ovale is an oval opening in the atrial septum, to the fourth month of intra-uterine life it is quite free, but af that period the valve of the foramen ovale gradually extends upwai on the left side of, and beyond, the annulus ovalis, and acts as a val during the latter months of foetal life. The blood can then only fl from the right atrium into the left, its return being prevented this valve.

The valve of the inferior vena cava is of large size during foe

life, and is associated with the orifice of the inferior vena cava at 1 postero-inferior angle of the right atrium. It is a crescentic fold of t endocardium, which extends between the anterior margin of t orifice of the inferior vena cava and the anterior horn of the annu. ovalis. Its situation is such as to direct the blood entering the ri£ atrium by the inferior vena cava to the foramen ovale.

The ductus arteriosus connects the pulmonary trunk to the ai of the aorta at a point immediately beyond the origin of the 1




THE THORAX


1083


Flavian artery, and conveys most of the blood from the right

ricle to the descending thoracic aorta.

rhe umbilical arteries (hypogastric arteries), right and left, are proved from the common iliac arteries to the umbilicus, through which ) leave the body of the foetus, and pass along the umbilical cord >e distributed to the foetal part of the placenta. They convey the ure blood of the foetus to the placenta.

rhe umbilical vein extends from the foetal part of the placenta >ugh the umbilicus to the inferior surface of the liver, where it joins left branch of the portal vein. After parting with its right and left aches the umbilical vein is prolonged, under the name of the tus venosus, to the inferior vena cava, which it joins at the fossa vena cava of the liver. The umbilical vein conveys pure blood n the placenta into the body of the foetus.

Foetal Circulation.— The right atrium receives blood from the erior and inferior vense cava 4 , and from the coronary sinus. The erior vena cava returns the venous blood from the head and neck, upper limbs, and the thoracic portion of the trunk; and the inferior 1a cava returns the blood from the lower limbs, the abdominal tion of the trunk, and the placenta. The placental blood is pure, l reaches the inferior vena cava in two ways: (1) a large quantity it is conveyed directly into the inferior vena cava by the ductus iosus; and (2) some of it circulates through the liver in the branches the portal vein, and is then conveyed to the inferior vena cava by i hepatic veins. The blood entering the right atrium by the inferior 1a cava is necessarily of a mixed nature, being partly placental and

  • tly venous.

The impure blood which enters the right atrium by the superior la cava, having received a small quantity of the mixed blood which

ers by the inferior vena cava, passes through the right atrioitricular orifice into the right ventricle, and from thence is driven

0 the pulmonary trunk. A small quantity of it is conveyed to the lgs by the right and left pulmonary arteries, which at this peiiod j of small size, and it is returned from the lungs to the left atrium the pulmonary veins. By far the greater part of the right ventricular )od, however, enters the ductus arteriosus, and is con\eyed by it the aorta immediately beyond the origin of the left subclavian artery. >ne of this blood, therefore, enters the three great vessels which ring from the arch of the aorta. The whole of it descends in the scending thoracic and abdominal portions of the aorta, and has a ofold destination. Part of it is distributed to the abdominal and lvic viscera, and the lower limbs, whence it is returned by the »rtal vein and inferior vena cava; but the greater part of it is conyed out of the bodv of the foetus to the placenta by means ot the nbilical arteries. Having been purified in the placenta, it is returned ence by the umbilical vein into the body of the foetus. This placental ood, as stated, reaches the inferior vena cava in two ways. P ar t y rectly by means of the ductus venosus, and partly indirectly by


1084


A MANUAL OF ANATOMY


means of the hepatic veins after having circulated through 1 liver.

A small quantity of the mixed blood which enters the right atrii by the inferior vena cava mingles with the venous blood which ent that cavity by the superior vena cava; but by far the greater part it is directed by the valve of the inferior vena cava to the forarr ovale, through which it passes into the left ventricle. Here it recen the blood which has been returned from the lungs by the pulmom


Internal Jugular Vein Common Carotid Artery

\fi/ o


Subclavian Vessels


Superior Vena Cava


Foramen Ovale Orifice of Inferior Vena Cava

Valve of Inferior Vena Cava Inferior Vena Cava


Ductus Arteriosus Pulmonary Artery

Left Auricle


Left Ventricle


Hepatic Veins

Aq-Right Ventricle


Inferior Vena Cava Aorta


Common Iliac Vein


External Iliac Vessels


Ductus Venosus

Left Branch of Portal Vein


— Right Branch of Portal Vein


-Portal Vein

Umbilical Vein Umbilicus


— Umbilical Arteries - Umbilical Vein


Umbilical Cord


Umbilical Arteries

Fig. 646. —Diagram of the Organs of Circulation in the Foetus The arrows indicate the course of the circulation.


veins, and then it passes through the left atrio-ventricular orifice ir the left ventricle. From the left ventricle it is driven into the aou and the greater part of it passes into the innominate, left comm carotid, and left subclavian arteries, to be distributed to the bra head and neck, and upper limbs, as well as to the substance of the he£ by the coronary arteries. A small quantity, however, of this mix blood passes into the descending thoracic aorta, and mixes with t venous blood entering by the ductus arteriosus. The blood is return to the right atrium of the heart from the brain, head and neck, ai















THE THORAX


1085


sr limbs, by the superior vena cava, and from the substance of heart by the coronary sinus.

Changes at Birth.—At birth respiration is established, and the rs perform their respiratory function; the right and left pulmonary ries undergo rapid enlargement; and the placental circulation is rely arrested. The umbilical arteries become obliterated and Lsformed into fibrous cords, except at their. roots, where they list as the internal iliac arteries. The umbilical vein becomes terated, and is now known as the ligamentum teres of the liver. ductus venosus becomes transformed into a fibrous cord, called ligamentum venosum, which occupies the fissure of that name in liver. The foramen ovale is closed by the valve of the foramen \e becoming adherent to the margin of the annulis ovalis on its left i. In some cases, however, this union is incomplete, and a minute ning persists, through which a small probe may be passed. In y rare cases a fairly large opening may remain, as in the condition ,wn as morbus cceruleus. As viewed from the interior of the left urn, the upper crescentic border of the valve of the foramen ovale isible upon the atrial septum, and above this border there is a slight session. The ductus arteriosus becomes obliterated, and persists a fibrous cord, called the ligamentum arteriosum, which passes n the root of the left pulmonary artery to the arch of the aorta nediately beyond the origin of the left subclavian artery.

The closure of all the peculiar structures associated with the

al circulation is usually complete from the eighth to the tenth day

er birth.

Trachea in the Thorax.—dhe thoracic portion of the trachea extends m the level of the upper border of the manubrium sterni to the el of the intervertebral disc between the bodies of the fourth and h thoracic vertebrae, where it divides into the two bronchi, right and 1. It occupies a median position in the superior mediastinum, and length is about 2 -| inches. As in the neck, it is cylindrical and n in front and at the sides, but posteriorly it is flattened and mem mous, where it rests upon the oesophagus. . .

Relations— Anterior. —The manubrium sterni, and the origins ot 3 sterno-hyoid and sterno-thyroid muscles; the remains of the ymus; the origins of the innominate and left common carotid series, and the left innominate vein; and the arch of the aorta, which s upon it immediately above its bifurcation into the two bronchi, th the intervention of the deep cardiac plexus of nerves. R° s ~ ior. —The oesophagus, which in an upward direction inclines rtially to the left of the trachea. Right. —The right vagus nerve; e innominate artery after it has left the front of the trachea, and e right pleural sac. Left. —The arch of the aorta and the e mmon carotid artery after these have left the front of the trachea, e left subclavian artery; and the left recurrent laryngeal nerve. Bronchi.—The bronchi, right and left, commence at the bifuica>n of the trachea, and each passes to the hilum of the coriespond

io86


A MANUAL OF ANATOMY


ing lung, where its ramifications commence. As in the trad each bronchus is cylindrical and firm in front and at the sides, posteriorly it is flattened and membranous. There being cerl differences between the bronchi, a separate description is requi for each.

The right bronchus is about i inch in length up to the point wf it gives off its first, or eparterial, branch. It has about six ca laginous rings, and is larger than the left bronchus. It is more vert:

than the left bronchus,


Epiglottis


Greater Horn of Hyoid Bone Lesser Horn of Hyoid Bone

Body of Hyoid Bone —


Thyro-hyoid Membrane - Levator Glandulae \ Thyroides Muscle /

Thyroid Cartilage -Crico-thyroid Ligament

Pyramid ” Cricoid Cartilage " Lateral Lobe of Thyroid Gland Isthmus

Right Bronchus Eparterial Bronchus,


Hyparterial Bronchus.^


Trachea

Left Bronchus


Fig. 647. —The Hyoid Bone, Larynx, Trachea, Bronchi, and Thyroid Gland (Anterior View).


therefore coincides with direction of the trachea t greater extent than its felL

Relations— Superior .—" vena azygos arches over it open into the superior v< cava. Posterior. —The ri{ vagus nerve.

About 1 inch from commencement the rij bronchus gives off a brar from its outer side wh passes to the upper lobe the right lung. This brar is known as the eparter bronchus, because it ari; above the right pulmonc artery. The rest of the ri£ bronchus is spoken of as bei hyparterial.

The left bronchus is abc

2 inches in length. It I about twelve cartilaginc rings, and is smaller than t right bronchus on account the smaller size of the 1< lung. Its course is more c lique than that of its fello


and it is directed downwards and outwards beneath the arch of aorta to the hilum of the left lung.

Relations— Anterior. —The left pulmonary artery, which sut quently lies above it. Posterior. —The oesophagus and the descend thoracic aorta.


The left bronchus has no eparterial branch.

When the interior of the trachea is viewed from above, as in usii the laryngoscope, the openings of the two bronchi are seen to 1 separated by a ridge which is situated to the left of the median lin and more of the interior of the right bronchus than of the left is visibl Partly on this account, and partly by reason of the more vertic













THE THORAX


1087


tion of the right bronchus, as well as its larger size, a foreign - getting into the trachea is more apt to descend into the right chus than into the left.

'he structure of the trachea will be described in connection with description of the windpipe in the neck.

Esophagus in the Thorax. —The oesophagus or gullet extends from pharynx to the stomach. In the first part of its course it lies ie neck, and this portion will be found described in connection with region. The thoracic part (see Fig. 651) extends from the level he upper border of the manubrium sterni to the level of the / of the eleventh thoracic vertebra, where, ng previously passed through the oesophaopening of the .diaphragm, it terminates

he cardiac orifice of the stomach. Its

se is not quite vertical. At its commencet the thoracic portion lies partially to the of the middle line, but as it descends it es to occupy a median position about the 1 of the fifth thoracic vertebra, and in>rly it again inclines partially to the left, ccupies the superior and posterior mediasI spaces, and lies in front of the verte. column, accurately following the thoracic 3ro-posterior curve.

Relations— Anterior .—The trachea as low

he intervertebral disc between the bodies

he fourth and fifth thoracic vertebrae; the it pulmonary artery; the root of the left [ichus; the posterior wall of the pericardium nsite the back of the left atrium of the rt; and the vertebral portion of the diaagm. Posterior .—The vertebral column; longus cervicis muscles, especially the left; thoracic duct and vena azygos; the right terior intercostal arteries; the upper and er transverse azygos veins; and interiorly descending aorta. Right .—The right erior and posterior mediastinal pleurae. Left. The thoracic portion the left subclavian artery; the upper part of the thoracic duct, left superior mediastinal pleura above and the left posterior iiastinal pleura just before it pierces the diaphragm, and the cending aorta, except inferiorly.

The right and left vagus nerves are intimately related to the cesoigus. They are at first disposed laterally, and their branches give i to the oesophageal plexus. Subsequently the right vagus nerve cends on the posterior surface of the oesophagus, and the left on

anterior surface, in which positions they accompany the gul et

ough the oesophageal opening of the diaphragm.


Fig. 648.—To show Relations between Aorta, Trachea and (Esophagus (from the Front).




io88


A MANUAL OF ANATOMY


Blood-supply—Arteries. —These are (i) the oesophageal brai of the descending aorta, (2) the oesophageal branches of the left gc artery, and (3) twigs from the left phrenic artery. In the necl oesophagus receives branches from the right and left inferior tin arteries.

The veins accompany the corresponding arteries, and term: in the vena azygos and the two venae hemiazygos.

Lymphatics. — These pass to posterior mediastinal glands whic mainly in front of the oesophagus.

Nerves. —These are derived fron vagus and sympathetic nerves.


S


Structure. —The wall of the oesopl consists of three coats—namely, muse submucous, and mucous.

The muscular coat is thick, and is posed in two layers, an external longitu and an internal circular.

The longitudinal muscular fibres ar< tached superiorly to the upper part o: median ridge on the posterior surface o cricoid cartilage, and from this point descend as two flattened bands, one on e side of the tube. These expand and meet, giving rise to one continuous 1 which completely surrounds the oesophe Interiorly they are continuous with longitudinal muscular fibres of the stoir Accessory fleshy slips are described as pai from this layer to the back of the trac the back of the root of the left bronc the pericardium, and the left pleura.

The circular muscular fibres are con ous superiorly with the lower fibres of


Fig. 649.— Diagram to show _ __ a __ j _

Pleural Relations (Thick inferior constrictor muscles of the pha: Black Lines) of (Esophagus and interiorly with the circular, and (Frontal Section). with the oblique, muscular fibres of

stomach.

The muscular tissue of the oesophagus is of the striated variety over abou upper third of the tube, but elsewhere it is of the plain or non-striated vai

The submucous coat consists of loose areolar tissue, which contains larger bloodvessels and the mucous glands.

The mucous membrane is thick, and is thrown into longitudinal fold account of the loose disposition of the submucous coat. The portion of it the submucous coat consists of plain muscular fibres, which are arranged 1 tudinally. This portion is known as the muscidaris mucosce, and it is marked in the lower part of the oesophagus. The inner surface of the mi coat is provided with numerous papillae, and it is covered by stratified squai epithelium, which is thrown into elevations by the papillae.

The mucous glands are racemose, and are situated in the submucous 1 Their ducts are large and long, and on their way to the free surface son them traverse small collections of lymphoid tissue.

Development. —The oesophagus is developed from that part of the for( which succeeds to the portion from which the pharynx is developed. At fh is very short, on account of the imperfect development of the neck. As, howi




THE THORAX


1089


leek becomes formed, and as the stomach descends, the oesophagus becomes rated.

descending Aorta. —The descending aorta, which is the continuaof the aortic arch, commences on the left side of the body of fourth thoracic vertebra on a level with its lower border, and linates at the lower border of the body of the twelfth thoracic ebra. At the latter level it* passes through the aortic opening lie diaphragm, and enters upon the abdominal part of its course, vessel lies in the posterior mediastinum, and its course is down

Stratified Epithelium Mucous Membrane Muscularis Mucosae

Submucosa


ircular Muscular Fibres


Longitudinal Muscular Fibres


- Mucous Gland


Fibrous Sheath


Fig. 650.—Transverse Section of the Wall of the (Esophagus.

is and medially, so that, though at first on the left side of the vertecolumn, it subsequently takes up a position in front of it. Relations — Anterior .—From above downwards, the root of the lung; the pericardium; the oesophagus; and the vertebral portion

he diaphragm. Posterior .—The bodies and intervertebral discs

tioracic vertebrae below the fourth; and the upper and lower transie azygos veins. Right .—The oesophagus superiorly; the thoracic t; and the vena azygos. Left .—The left superior and posterior Liastinal pleurae; and the upper and lower left azygos veins. In}dy the oesophagus inclines slightly to the left. It is to be noted

69





























logo


A MANUAL OF ANATOMY


that the oesophagus has a threefold relation to the descending ac At first it lies upon the right side of the vessel; then directly in f: of it; and finally it inclines slightly to its left side.

Branches. —These are as follows: bronchial, pericardial, cesopha^ mediastinal, posterior intercostal and subcostal.


Trachea


Left Common Carotid Artery Scalenus Anterior Muscle


Innominate

Artery


Left Vagus Nerve


Rt. Superior Intercostal Artery


_ Left Subclavian Artery (Third Part)

Lefi Phrenic Nerve


Arch of.., Aorta


Left Superior Intercostal Artery


Cardiac Branches of Cer Sympathetic Ganglia Vagus

- Superficial Cardiac Plexi


Left Bronchus


. Descending Thoracic Aorta


(Esophagus


Posterior Intercostal Vesiels and Nerve


- Abdominal Aorta


Fig. 651 —Dissection of the Posterior Wall of the Thorax.


The bronchial arteries supply the lungs and the bronchial lymph glands. They are usually three in number—one right and two 1 The right bronchial artery arises from the aorta in common with upper left bronchial artery, or sometimes from the first right poste intercostal artery. The two left bronchial arteries, upper and lo\
















THE THORAX


1091


directly from the aorta near each other. The arteries enter the

ective lungs behind the bronchi, and in their further course and -ibution they follow the ramifications of he bronchial tubes, fhe bronchial veins accompany the corre ponding arteries. The

vein opens into the vena azygos; and the left vein opens either

the superior vena hemiazygos or into the left superior interal vein. The bronchial veins are conrably smaller than the corresponding ries.

rhe pericardial branches supply the pos >r part of the pericardium, rhe oesophageal branches are numerous, arise at irregular intervals. Superiorly 7 spring from the right side of the aorta, inferiorly from its anterior wall. They stomose freely with one another along wall of the oesophagus: superiorly with oesophageal branches of the inferior

oid arteries, and inferiorly with the

phageal branches of the left gastric ry, the latter branches entering the ■ax through the oesophageal opening of diaphragm.

The mediastinal branches are very minute, supply the lymphatic glands and areolar le in the posterior mediastinum.

The posterior intercostal arteries are ar^ed in pairs, and are nine in number on 1 side. They are destined for the lower 5 intercostal spaces, the first two spaces lg supplied by the superior intercostal

ry, which is a branch of the second part
he subclavian on the right side, and of

first part on the left side. They arise in

s from the posterior wall of the descendaorta, and pass outwards upon the bodies
he vertebrae to the posterior extremities
he intercostal spaces. The arteries of

right side pass behind the oesophagus, thoracic duct, and the vena azygos; l those of the left side pass behind the erior and inferior venae hemiazygos acding to their level. The arteries of both sides pass behind the ipathetic trunk. The upper right posterior intercostal arteries longer than those of the left side, on account of the position of the cending aorta on the left side of the vertebral column. All the sries lie behind the parietal pleura. Each artery, on entering an ircostal space, lies at first between the parietal pleura and the


Fig. 652.—To show the Relations to Each Other of the Aorta, Thoracic Duct, Azygos Vein, and Intercostal Arteries (Anterior View).




1092


A MANUAL OF ANATOMY


posterior intercostal membrane. Its course is outwards and slig] upwards, and partly on this latter account, but chiefly on acco of the downward slope of the rib, it soon gains the lower borde: the upper rib. At a point corresponding to the angle of the rib


artery pierces the posterior intercostal membrane, and passing betw< the external and internal intercostal muscles, it enters the costal gro( of the upper rib. In this position it courses forwards, and ends anastomosing with the upper anterior intercostal branch of the inter



























THE THORAX


1093


unary artery, or of its musculo-phrenic branch, according to the

he companion intercostal vein lies above the artery, and the

sponding intercostal nerve lies below it. The order of structherefore, in the costal groove, from above downwards, is as

ws: intercostal vein, intercostal artery, and intercostal nerve, upper seven posterior intercostal arteries are confined to the costal spaces which they occupy; but the lower two—namely, 3 in the tenth and eleventh intercostal spaces—ultimately leave i spaces, and pass into the abdominal wall, where they have been

ibed in connection with the abdomen.

•ranches. —These are posterior, giving off a spinal branch; collateral costal; and lateral cutaneous.

he posterior branch arises from the posterior intercostal artery as vessel enters the posterior extremity of an intercostal space. It is backwards, in company with the posterior primary division of the isponding spinal nerve, between the adjacent transverse processes, ■e it lies internal to the superior costo-transverse ligament. Ope the intervertebral foramen it gives off its spinal branch , which

  • s the vertebral canal through the foramen to be distributed to

sseous and ligamentous walls, as well as to the spinal cord and its branes. The posterior branch, continuing its course backwards, les into a medial and lateral branch, which supply the muscles integument of the back.

he collateral intercostal artery arises from the main posterior interil opposite the angle of the rib. It passes obliquely downwards outwards to the upper border of the lower rib, along which it >es, lying between the external and internal intercostal muscles, riorly it ends by anastomosing with the lower anterior intercostal

h of the internal mammary artery, or of its musculo-phrenic

"h, according to the level.

he lateral cutaneous branches accompany the lateral cutaneous dies of the corresponding intercostal nerves to the integument, he first posterior intercostal artery—namely, that which lies in bird intercostal space—furnishes a branch, of variable size, which ids over the neck of the third rib to the second intercostal space, branch anastomoses with the second posterior intercostal artery, h is a branch of the superior intercostal, and may even replace it. he subcostal arteries , right and left, are the last branches of the ending thoracic aorta. They are serially continuous with the rior intercostal arteries above, and with the lumbar arteries below, vessel winds round the side of the body of the twelfth thoracic bra, and, passing beneath the lateral arcuate ligament of the iragm, enters the wall of the abdomen, where it lies along the lower t of the twelfth rib. These vessels will be found described in action with the abdomen (see p. 848).

he first and second intercostal spaces receive their arteries from uperior intercostal artery, which is a branch of the second part


1094


A MANUAL OF ANATOMY


of the subclavian on the right side, and of the first part on the side. Having descended in front of the neck of the first rib to posterior extremity of the first intercostal space, the vessel furni the first posterior intercostal artery to that space, and it also g off the second posterior intercostal artery, which descends in f of the neck of the second rib to the second intercostal space, stated, the second posterior intercostal artery receives a branch f the third posterior intercostal artery, which ascends over the : of the third rib.

Development of the Descending Aorta. —The upper portion of the descei

aorta is developed from that part of the left primitive dorsal aorta whicl between the fourth left aortic arch and the place of junction of the two prin dorsal aortae. The greater portion of it, however, results from the union c two primitive dorsal aortae. The posterior intercostal arteries are deve^ from thoracic intersegmental arteries.

Posterior Intercostal Veins. —The intercostal veins are eleve: number on either side, and each lies in the costal groove above corresponding posterior intercostal artery. In the region of the a of the rib each vein receives the collateral intercostal vein, which acc panies the artery of that name. At the posterior extremity o intercostal space each vein receives a large posterior branch, w returns blood from the muscles and integument of the back, external vertebral venous plexus, and the vertebral canal. Witt exception of the upper three or four veins, all the other intero veins pass inwards, behind the corresponding sympathetic cord to the bodies of the thoracic vertebrae, from which they receive s twigs. Their mode of termination differs on the two sides. On right side the veins, having passed behind the oesophagus, termi in the vena azygos. On the left side the lower four veins—namely eighth, ninth, tenth, and eleventh—open into the inferior vena h azygos; and the succeeding three (or four)—namely, the fifth, s: and seventh (and, it may be, the fourth also)—open into the sup vena hemiazygos.

The first posterior intercostal vein of each side accompanies corresponding superior intercostal artery, and terminates in innominate vein, or, it may be, in the vertebral vein, of its own si(

The second and third posterior intercostal veins (and, it may be fourth) of each side unite to form the superior intercostal vein, right superior intercostal vein, after a downward course, joins the u part of the vena azygos. The left superior intercostal vein fori loop which lies in front of the arch of the aorta, and opens intc left innominate vein. It sometimes receives the left bronchial as a tributary.

Summary of the Posterior Intercostal Veins—Right Posterior Inter Veins. —The first opens into the right innominate vein, or sometimes into the vertebra] vein. The second and third (and, it may be, the fourth also) to form the right superior intercostal vein, which opens into the vena a2 The lower eight (sometimes the lower seven) are direct tributaries of the ' azygos.


THE THORAX


1095


Left Posterior Intercostal Veins. —The first opens into the left innominate n, or sometimes into the left vertebral vein. The second and third (and, it ,y be, the fourth also) unite to form the left superior intercostal vein, which 3ns into the left innominate vein. The fifth, sixth, and seventh (and, it may the fourth also) terminate in the superior vena hemiazygos. The eighth, ith, tenth, and eleventh are tributaries of the inferior vena hemiazygos.

The left superior intercostal vein is developed from two sources. The upper vt is formed by the portion of the left anterior cardinal vein below, and jacent to, the commencement of the transverse jugular vein. The lower part 'ormed by the upper portion of the left cardinal vein.

Intercostal Glands. —These glands form a chain on either side of the vertebral umn, in line with the necks of the ribs. The main glands of each chain lie


g. 654.— Vena Azygos and Right Sympathetic Chain, showing Ganglia and the Greater and Lesser Splanchnic Nerves arising from it.

Ph. N, phrenic nerve.

the posterior parts of the intercostal spaces, and one or two glands accompany ch posterior intercostal artery for a very short distance.

The intercostal glands receive their afferent vessels from (1) the posterior half the costal pleura, (2) the posterior halves of the external and internal interstal muscles, (3) the deep muscles of the back, and (4) the vertebral canal, leir efferent vessels, on either side, pass to the thoracic duct; those from the >ver four or five spaces usually unite to form a trunk which, running vertically wnwards, pierces the diaphragm, and opens into the thoracic duct near its mmencement, or it may be into the cisterna chyli itself.

The efferents of the upper right intercostal glands sometimes open into a >ht broncho-mediastinal lymphatic trunk, which terminates in the right tnphatic duct.

The right superior intercostal vein is developed from the anastomotic channels iiich connect the upper three thoracic segmental veins of the right side. •














A MANUAL OF ANATOMY


1096


The Venae Azygos et Hemiazygos Veins.—The vena azygos (ve azygos major) commences in the abdomen as the right ascendi lumbar vein , and enters the thorax through the aortic opening of t diaphragm, lying on the right side of the aorta, the thoracic dr intervening. It then ascends, under cover of the oesophagus, up


Right Lymphatic Duct


Right Innominate Vein

Superior Vena Cava.Right Superior Intercostal Vein.


Vena Azygos —\


Thoracic Duct—A


Posterior Intercostal Glands

Cistema Chyli Right Ascending Lumbar Vein..


Inferior Vena Cava__.


Thoracic Duct


S 3 Left Innominate Vein

IT'

- Left Superior Intercostal Vein L. Arch of Aorta


- Superior Vena Hemiazygos


Upper Transverse Azygos Vein


— Lower Transverse Azygos Vein

— Ninth Posterior Intercostal Vein


- Inferior Vena Hemiazygos


-.Left Subcostal Vein


__Quadratus Lumborum —Left Ascending Lumbar Vein


--Abdominal Aorta


— Iliac Crest -Psoas Major

—.Uiacus


.'xCommon Iliac Arteries


Fig. 655.—The. Thoracic Duct, Azygos and Hemiazygos Veins, and

Posterior Intercostal Glands.


the bodies of the thoracic vertebrae, crossing in its course the rig posterior intercostal arteries. Having reached the level of the fif thoracic vertebra it leaves the vertebral column, and arching forwar over the right bronchus it opens into the superior vena cava ju! before that vessel pierces the pericardium. In the thorax the vei














THE THORAX


1097


is continues to lie on the right side of the aorta, the thoracic duct /ening.

ributaries. —These are as follows:

The right subcostal vein.

The lower seven (sometimes the lower eight) right posterior

ostal veins.

The right superior intercostal vein.

The right bronchial vein.

Some oesophageal veins.

Some pericardial veins.

The lower and upper transverse azygos veins, he inferior vena hemiazygos (vena azygos minor inferior) commences 3 abdomen as the left ascending lumbar vein, and enters the thorax iercing the left crus of the diaphragm. It ascends upon the bral column to the level of the eighth thoracic vertebra, lying in of the lower posterior intercostal arteries, and it takes up the • four left posterior intercostal veins. It then crosses the vertebral in from left to right under the name of the lower transverse azygos passing behind the descending aorta and thoracic duct, and ing into the vena azygos, ributaries. —These are as follows:

1. The left subcostal vein.

2. The lower four left posterior intercostal veins.

3. Some oesophageal veins.

he superior vena hemiazygos (vena azygos minor inferior) is formed le union of the fifth, sixth, and seventh left posterior intercostal

(sometimes also the fourth). At the level of the seventh thoracic

bra it crosses the vertebral column from left to right under the 5 of the upper transverse azygos vein, passing behind the descending 1 and thoracic duct, and opening into the vena azygos. It comicates above with the left superior intercostal vein, and below the inferior vena hemiazygos, ributaries. —These are as follows:

. The fifth, sixth, and seventh left posterior intercostal veins etimes also the fourth).

. The left bronchial vein, as a rule.

. Some oesophageal veins.

he superior and inferior venae hemiazygos, which are subject to 1 variation, sometimes unite to form one transverse azygos vein, he other hand, the hemiazygos veins are not infrequently multiple, multiple openings into the vena azygos.

unmary of the Azygos and Hemiazygos Veins—Vena Azygos. This vessel /es (1) the right subcostal vein; (2) the lower seven (sometimes the lower ) right posterior intercostal veins; (3) the right superior intercostal vein;

right bronchial vein; (5) some oesophageal veins; (6) some pericardial

and (7) the lower and upper transverse azygos veins,

iferior Vena Hemiazygos. —This vessel receives (1) the left subcostal vein; lower four left posterior intercostal veins; and (3) some oesophageal veins.


A MANUAL OF ANATOMY


1098

Superior Vena Hemiazygos. —This vessel receives (1) the fifth, sixth, seventh (sometimes also the fourth) left posterior intercostal veins; (2) tb bronchial vein, as a rule; and (3) some oesophageal veins.

The vena azygos and the inferior vena hemiazygos, through connection with the ascending lumbar veins, establish communica with the inferior vena cava and with the common iliac veins or < of their tributaries. They therefore form important channels by wh considerable quantity of blood is returned from the lower limbs abdominal wall in cases of obstruction of the inferior vena cava, vense azygos et hemiazygos frequently communicate with the renal v


Fig. 656.—To show the Derivation of the Azygos Veins.

First figure shows original symmetry, the primitive jugular (PJ) on each joining the cardinal (C) to make the duct of Cuvier (D), which enter sinus venosus (SV); the duct of Cuvier is intrapericardial. In the se figure the left innominate vein (LIV) is formed, taking over the left ju and subclavian drainage, and leading to the appearance of a f superior cava.’ Further changes on left side affect the cardinal, which is rec in size and broken in various ways, such as in the next figure. The ' sup intercostal vein ’ here is seen to be formed from cardinal (C) and terr piece of jugular (PJ), and at the junction of these parts the duct of G (D) is present as an obliterated remnant; the lower left intercostals ( to the right vein by two cross-connections. The longitudinal left vein persist, with connections, or (as in figures) the lower left veins may separately, or may join to form one large transverse vessel, or some n fication of these variations may be found.

Development. —The azygos vein is developed at its upper end from terminal part of the right cardinal vein; below the mid-thoracic level it is r by supracardinal (periganglionic) reaching the cardinal through an interme* piece of subcardinal. The hemiazygos veins (lower) are derived from the supracardinal, developing transverse retro-aortic connections. The V hemiazygos (left superior intercostal) is partly cardinal and (at its termina primitive jugular (see Fig. 656).

Subcostal Veins .—These are two in number, right and left, they are serially continuous with the intercostal veins. Each v( enters the thorax from the abdomen by passing behind the lat


THE THORAX


1099


late ligament of the diaphragm. As stated, the right vein opens 1 the vena azygos, and the left into the inferior vena hemiazygos.

Anterior Primary Rami of the Thoracic Spinal Nerves.— These are Ive in number on each side. The first eleven enter intercostal


aces, and are called the intercostal nerves. The last, which belongs the abdomen, lies along the lower border of the twelfth rib, and is Ued the subcostal nerve (‘ last dorsal nerve ). At the posterioi tremities of the intercostal spaces the intercostal nerves are near















IIOO


A MANUAL OF ANATOMY


the sympathetic trunk, and each nerve is connected with the adjace sympathetic ganglion by two rami communicantes, which are nee! sarily very short. One of these rami, being composed of spinal fibr is white, and the other, which consists of sympathetic fibres, is gr\ Each intercostal nerve lies below the corresponding artery, and, li it, lies between the parietal pleura and the posterior intercos membrane as far as the angle of the rib. Its subsequent course cor:sponds to that of the artery. The first intercostal nerve is of sm; size, because the greater part of the anterior primary ramus of tj first thoracic nerve takes part in the formation of the brachial plexij The second intercostal nerve sometimes gives off a small bran^ which ascends to join the portion of the anterior primary ramus the first thoracic nerve which takes part in the brachial plexus. Tj further course and distribution of the intercostal nerves belong to tl thoracic and abdominal walls, in connection with which they willfound described.

Thoracic Duct. —The thoracic duct commences in the abdony in a dilatation, called the cisterna chyli (receptaculum chyli), which situated in front of the bodies of the first and second lumbar vertehi! and terminates by opening into the angle of junction of the interij jugular and subclavian veins of the left side. It is about 18 inci in length, and enters the thorax from the abdomen by passing throu the aortic opening of the diaphragm, where it lies between the aoil on the left and the vena azygos. In this position it ascends in t thorax, resting upon the vertebral column, the right posterior inti costal arteries, and the lower and upper transverse azygos veil being under cover of the oesophagus. Up to the level of the four, or fifth thoracic vertebra it occupies the middle line. At this level passes behind the arch of the aorta, inclining to the left of the mid( line. It then ascends in close contact with the left side of the oesophagi and behind the thoracic portion of the left subclavian artery. In t] position it enters the root of the neck on the left side, where it ascen upon the left side of the oesophagus between the left common carol and left subclavian arteries. At about the level of the seven cervical vertebra it describes a curve, and passes outwards, forwarc and downwards in contact with the dome of the left pleura. It ne inclines inwards, and terminates by opening into the angle of junctk between the internal jugular and subclavian veins of the left sic In the lower part of the thorax the thoracic duct is of smaller calit than in the upper part. Its course is somewhat undulating, ar when distended it presents a beaded appearance, especially in t upper part, due to the number of valves with which it is provide Sometimes the duct divides into two branches in the lower part the thorax, which reunite at a higher level. The duct is freely provid with valves, especially in its upper part, and at its termination there’ an important valve, consisting of two segments, which are so direct as to prevent effectually the reflux of chyle, or the flow of blood in the duct.




THE THORAX


IIOI


he thoracic duct receives lymphatic vessels from the following es: (i) the lower limbs; (2) the abdomen and its viscera, except of the lymphatics from part of the upper surface of the liver; le left half of the thoracic wall; (4) the left lung and the left half e heart; (5) the lower right intercostal spaces; (6) the left upper

and (7) the left side of the head and neck. Most of the lymphatics

e right half of the thorax and those of the right lung and right of the heart pass to the right lymphatic duct, for the description lich see the section dealing with the neck.

horacic Lymphatic Glands. —These are arranged in several groups ollows: internal mammary; intercostal; innominate; anterior astinal; posterior mediastinal; tracheo-bronchial, and caval. he internal mammary lymph glands (sternal lymph glands) will iund described on p. 996. They receive their afferent vessels from tie anterior parts of the upper six intercostal spaces; (2) the inner on of the mammary gland; (3) the lymphatics accompanying the rior epigastric artery from the upper part of the anterior abdominal

(4) the lymphatics accompanying the musculo-phrenic artery

the anterior parts of the seventh, eighth, and ninth intercostal es, and from a portion of the diaphragm; and (5) the lymphatics . the anterior set of diaphragmatic glands. The efferent vessels le right glands terminate in the right lymphatic duct, and those

Le left glands in the thoracic duct. .

die intercostal lymph glands are situated on either side of the sbral column, where they lie in the intercostal spaces, there being l one to three in each space. They receive their afferent vessels l (1) the posterior parts of the intercostal spaces; (2) the parietal ra; (3) the vertebral canal; and (4) the deep muscles of the back, efferent vessels of the left intercostal glands open into the thoracic

. On the right side the efferent vessels from the lower glands

to the thoracic duct, but those from the upper glands open into

right lymphatic duct. ..11

rhe innominate lymph glands (superior mediastinal lymph glands)

n the superior mediastinum in relation to the arch of the aorta the innominate veins; they are continuous with the posterior iastinal and tracheo-bronchial glands below and with the chain >unph glands along the recurrent laryngeal nerves above. Ihey ive their afferent vessels from the pericardium, the heart, trachea, phagus, and the thymus in early life, and their efferent vesse s

to the thoracic duct and right lymphatic duct. .

fhe innominate lymph glands (anterior mediastinal lymph glands)

a the lower part of the anterior mediastinum in front of the penium. They receive their afferent vessels from (1) the median portions tie right and left lobes of the liver in the vicinity of the lalci orm nent; (2) the adjacent portion of the diaphragm; (3) the anterior of the pericardium. Their efferent vessels pass to the interna

unary lymph glands. . . , .

the posterior mediastinal lymph glands are situated m the posterior


1102


A MANUAL OF ANATOMY


Auriculo temporal Nerve Facial Nerve

Posterior Auricular Nerve >,

Glosso-pharyngeal Nerve Accessory Nerve


Hypoglossal Nerve

] Superior Laryngeal Nerve Vagus Nerve

Middle Cervical Sympathetic Ganglion

Recurrent Laryngeal Nerve Cardiac Branches of Vagus


Ri >ht Posterior Pulmonary Plexus

Vena Azygos Vascular Branch

Intercostal Vessels f and Nerve l

Ramus Communicans

Sympathetic Trunk


Abdominal Aorta


Right Ansa Subclavia


First Thoracic Ganglion


Phrenic Nerve


Root of Right Lui


. Right Vagus N< on (Esophagi

(Esophageal I J le:


Liver (cut)

Left Vagus Ner

Descending Aor Thoracic Duct


Lesser Splanchic Nerve Greater Splanchnic Nerve •

Lowest Splanchic Nerve


| Branches of V / on Stomac


Right Coeliac Gangl

— Coeliac Plexus

Superior Mesenteric Arl and Plexus


Greater Occipital Nerve


Hypoglossal Nerve


Sup. Cervical Symp. Ganglion External Carotid Artery Internal Carotid Artery

Sympathetic Trunk

Com. Car. Art. and Symp. Plexus Phrenic Nerve


Renal Artery and Plexus


S.V.C. Superior Vena Cava


Fig. 658.—Nerves of the Right Side of the Face, Neck, and Thor/

(Hirschfeld and Leveille). * I




















THE THORAX


1103


iastinum, along the course of the descending aorta and oesophagus. j receive their afferent vessels from the oesophagus, the posterior of the pericardium, and the vertebral portion of the diaphragm, r efferent vessels pass, for the most part, to the thoracic duct.


, 659.—A Dissection of the Right Apical Region to show the Stellate Ganglion (viewed from below after removal of the Pleura).

iddition to the subclavian vessels, the lower two brachial nerves are seen, with the ganglion and the superior intercostal artery.

The tracheo-bronchial lymph glands are very numerous, and are iated partly in the angle between the trachea and bronchi, partly ween the two bronchi, and partly at the root of each lung. They very dark in colour, and receive their afferent vessels from the lungs 1 the visceral pleurse. Their efferent vessels pass to the thoracic 't and right lymphatic duct.


t











iio4


A MANUAL OF ANATOMY


n.c.


n,C


The caval glands are situated in contact with the limited tho: portion of the inferior vena cava. They receive their afferent ve from the bare area of the posterior surface of the liver, and also t deep lymphatics of that organ which accompany the hepatic veir the fossa for inferior vena cava. Their efferent vessels pass to

thoracic duct. One of these glands often be found lying upon the inf< vena cava within the fibrous pericardi The Thoracic Part of the Sympatl System. —The sympathetic system in thorax consists of (i) two gangli: trunks, right and left; and (2) a vertebral plexus — namely, the car plexus. The latter plexus has 1 already described. The gangliated tr lies on each side of the vertebral coll behind the parietal pleura, and superf to the posterior intercostal vessels, presents, as a rule, eleven ganglia, first or stellate ganglion is situated at inner end of the first intercostal sp and probably is formed by the fusioi two originally distinct ganglia; the sec ganglion lies on the head of the third and the other ganglia follow in more less regular sequence, lying on the he of the ribs until the last two ganglia reached; these lie upon the sides of bodies of the eleventh and twelfth thor; vertebrae. The first thoracic ganglioi the largest of the thoracic series, and 1 previously known as stellate ganglion. sympathetic trunk leaves the thorax Fig. 660. — Scheme of the passing behind the inner part of


R.C.


R C,




s.s


Thoracic Part of the me dial arcuate ligament of the diaphra Flower) an d so enters the abdomen.


r to 12. Thoracic Ganglia

R. C. Rami Communicantes

B.D. Branches of Distribution from Upper Ganglia

G.S. Greater Splanchic Nerve and Ganglion

S. S. Lesser Splanchnic Nerve L. S. Lowes t Splanchnic Nerve


Branches — 1. Of Communicatioi

These are called the rami communicant Two of these, one white and the 0 grey, pass between each ganglion and adjacent intercostal nerve. The w fibres are of spinal and the grey of s pathetic origin. From the proximity of the ganglia to the intercc nerves the rami communicantes are necessarily short.

2. Of Distribution. —From the upper five ganglia small vase branches are given off, which are distributed to the coats of the thor; aorta. From the second, third, and fourth ganglia pulmor branches are given off to the posterior pulmonary plexus. From




THE THORAX


1105


^anglion downwards the three splanchnic (‘ visceral ’) nerves— »r, lesser, and lowest—are given off.

le greater splanchnic nerve arises by five separate roots from the sixth, seventh, eighth, and ninth ganglia, the fibres of the upper being traceable in the sympathetic trunk as high as the second ion. The roots arch obliquely forwards and downwards upon des of the bodies of the adjacent vertebrae, and by their union form a large nerve, which pierces the crus of the diaphragm and nates in the cceliac ganglion. The greater splanchnic nerve ins a large number of spinal fibres, which impart to it a white r and firm consistence. The right nerve presents a small ganglion before it leaves the thorax, called the splanchnic ganglion , there may be one on the left nerve. The greater splanchnic

gives vascular branches to the lower part of the thoracic

>•

he lesser splanchnic nerve arises by two roots from the ninth and l ganglia. It pierces the crus of the diaphragm, and terminates e aortico-renal ganglion of the coeliac plexus, he lowest splanchnic nerve, which is sometimes absent, arises ne root from the eleventh ganglion. It either passes behind the al arcuate ligament of the diaphragm or through the crus, and it inates in the renal plexus. When the lowest splanchnic nerve sent, its place may be taken by a branch from the lesser splanchnic

2k

araganglia. —Situated in close relationship to the sympathetic lia are small bodies to which the name of paraganglia has been 1. They consist of chromaphil tissue like that which forms the ilia of the suprarenal glands, and probably secrete a substance h is excitory to non-striped muscle.

he diaphragm will be found described in connection with the •men.


The Joints of the Vertebral Column.

. Joints of the Bodies of the Vertebrae.— These joints belong to class of secondary cartilaginous joints. Ihe ligaments are as ws: the anterior longitudinal ligament, the posterior longitudinal nent, and the intervertebral discs.

he anterior longitudinal ligament (anterior common ligament) is a

e band of white glistening fibres, which extends over the anterior ices of the bodies of the vertebrae and intervertebral discs. It nds from the axis to the first segment of the sacrum, and its fibres lisposed longitudinally. Ihe most superficial fibres extend fiom a n vertebra to the fifth below it; the intermediate fibres pass from ven vertebra to the third below it; and the deepest hbies pass 1 a given vertebra to the one immediately below it. The fibres are ly attached to the intervertebral discs and margins of the vertebial ies, but very loosely to the centres of the bodies, on account of the

70


iio6


A MANUAL OF ANATOMY


presence of bloodvessels. The anterior longitudinal ligamen broadest in the lumbar region, and thickest in the thoracic region, is thicker opposite the centres of the bodies than elsewhere, an these situations it fills up the concavities, and so renders the fror the column less undulating than it otherwise would be. Over lateral surfaces of the bodies a few scattered fibres are present, w pass from one vertebra to that below. In the sacral region the ant< longitudinal ligament is lost in the periosteum of the bone, br reappears lower down as the anterior sacro-coccygeal ligament, anterior longitudinal ligament is serially continuous superiorly with anterior atlanto-occipital membrane.


Posterior Band of Superior Costo-transverse Ligament

Anterior Band of Superior Costo-transverse Ligament


Three Slips of i Radiate Ligament p


Intra-articular Ligament"


- Anterior Longitudinal Ligament


-■-Hi— Intervertebral Disc


Fig. 66i.—Ligaments of the Bodies of the Vertebrae and Joints of

Heads of the Ribs on the Right Side.


The posterior longitudinal ligament (posterior common ligamenl

situated within the spinal canal, and extends over the poste surfaces of the bodies of the vertebrae and intervertebral discs. I broader above than below, and consists of glistening fibres, wl extend from the axis to the first coccygeal vertebra, its sacral p however, being very narrow and delicate. Its fibres are firmly attac to the intervertebral discs and margins of the vertebral bodies, but t are separated from the centres of the bodies by the transverse ven communications between the basivertebral veins. In the cerv: region the ligament is of almost uniform breadth, being expanded c the vertebral bodies, as well as over the intervertebral discs. In thoracic and lumbar regions, however, it is narrow opposite vertebral bodies, and broad opposite the intervertebral discs, margins, therefore, present dentations, which give it a denticula































THE THORAX


1107


trance. The arrangement of its fibres is similar to the arrangeof those of the anterior longitudinal ligament. The posterior

udinal ligament is serially continuous superiorly with the

Drana tectoria.

be intervertebral discs are situated between the adjacent surfaces e bodies of the vertebrae, and they constitute the chief bond of l between them. Their outline corresponds to that of the bodies sen which they are placed, and they are elastic and compressible, pt in early life, the first or highest disc is situated between the bodies e axis and the third cervical vertebra, and in the adult the last west disc is situated between the bodies of the fifth lumbar and sacral vertebrae.



l 662. —Posterior Longitudinal Fig. 663. —Intervertebral Discs

Ligament of the Bodies of the (Anterior View).

Vertebrae.

£ach disc is composed of a circumferential fibrous part, disposed le form of superimposed laminae, and a central portion, the nucleus 1 osus , which is soft and pulpy. The annulus fibrosus forms more 1 half of the disc, and is composed of fibrous tissue and fibroilage. As seen in transverse section the laminae are arranged

entrically around the nucleus pulposus , which they closely embrace

compress. The fibres of which they are composed are arranged >arallel bundles, which extend obliquely between the adjacent ices of the vertebral bodies, being attached to the layer of hyaline ilage which covers them. The fibres of successive laminae pass Tiely in opposite directions, and are disposed thus X. The outer nae consist of fibrous tissue, but the majority are composed of white )-cartilage. As seen in vertical section the outermost laminae are

















no8


A MANUAL OF ANATOMY


bent outwards, and those around the nucleus pulposus are bent inw; towards it, this arrangement contributing to the elasticity of the ve bral column. The nucleus pulposus consists of a soft, elastic, pi substance, having a lobate arrangement. Being surrounded compressed on all sides by the annulus fibrosus, when a section i disc is made the nucleus pulposus, being relieved from press projects beyond the level of the cut surface. It is composed ( cellular reticulum, supported by a delicate fibrous stroma.

The nucleus pulposus is a persistent portion of the notochord.

The intervertebral discs form about one-fourth of the lengtl the vertebral column, and are thickest in the lumbar region, the cervical and lumbar regions they are deeper in front than beh and they give rise to the curve forwards in the cervical region, wl they increase the forward curve in the lumbar region. In the thor


region they are of uniform depth. Throughout the column t are intimately connected with the anterior and posterior longitudi ligaments, and, in the thoracic region, with the radiate ligaments ; the intra-articular ligaments of the heads of most of the ribs, the cervical region the discs are not present at either lateral asf of the opposed surfaces of the bodies. In these regions there i synovial space on either side, between the projecting lateral lip of upper surface of the lower body and the bevelled lateral margin of lower surface of the upper body. The opposed surfaces are cove by cartilage, and there is an indistinct capsular ligament.

2. Ligaments of the Laminae. —These are called the ligame flava (ligamenta subflava). They are strong, thick plates of yel elastic tissue, which connect the laminse together, and they ext from the axis to the first sacral segment. They are best seen from interior of the vertebral canal, and as they extend between the vertel











THE THORAX


1109


2S they close in the canal in these situations. Each ligamentum im extends from the root of the articular process to the place e the lamina joins its fellow to form the spinous process. At point it comes into relation with the ligament of the opposite a small interval being left between the two for the passage of 3. Superiorly the ligament is attached to the anterior surface le upper lamina a little above its lower border, and inferiorly it tached to the upper border, and adjacent part of the posterior ice, of the lower lamina. The ligamenta flava are wider in the ical and lumbar regions than in the thoracic region, and over the ter part of the latter region, as viewed from the exterior, they are ealed from view by the imbricated laminae. Their importance ists in their great elasticity, which enables them to maintain the


G< 666._Ligamenta Flava in the Lumbar Region (Anterior View).

Ihe pedicles have been sawn through, and the vertebral bodies removed.

tebral column erect, and to restore it to the erect position after it

been bent forwards. . . A

3. Ligaments of the Articular Processes. —Ihe joints between the

cular processes belong to the class of synovial joints of the le variety. The articular surfaces are covered by cartilage, and joint is surrounded by a capsular ligament s lined with a synovial nbrane. These ligaments are disposed moie looselj 7 in the cervical

ion than elsewhere. . .

4. Ligaments of the Spines.— These are supraspinous and mter The supraspinous ligament consists of longitudinal fibres which nect the extremities of the spines. It extends from the spine the seventh cervical vertebra to the spine of the fourth sacral ment, and its fibres are arranged in a manner similar to those of anterior longitudinal ligament. In the cervical region the supralous ligament is replaced by the ligamentum nuchae. ihe inter




















































I IIP


A MANUAL OF ANATOMY


spinous ligaments, which are thin and membranous, are situ between adjacent spines, to the margins of which they are atta( from root to tip. They are strongest in the lumbar region, and in neck they are replaced by deep processes of the ligamentum nucl

5. The intertransverse ligaments. —These consist of scattered fil which pass between the extremities of the transverse processes in thoracic and lumbar regions. In the neck they are replaced by intertransverse muscles.

Movements. —The movements allowed in the vertebral column are fle: extension, lateral movement, rotation, and circumduction.

Flexion and extension are freely allowed in the cervical and lumbar reg: In the thoracic region these movements are very limited on account of (1) small amount of intervertebral substance, and (2) the imbrication of the lam Lateral flexion is allowed in the cervical, thoracic, and lumbar regions, bi the neck it is associated with rotation. During these combined movemeni lateral flexion and rotation in the neck one inferior articular process g upwards and forwards on that which is opposed to it, whilst the other inf< articular process glides downwards and backwards on the one opposed t< Pure rotation is allowed in the thoracic region round an axis corresponding the centre of a circle of which the surfaces of the articular processes form ments. This centre is necessarily anterior to the articular processes, corresponds pretty nearly with the centres of the bodies of the vertebra, the lumbar region rotation is impossible, for the following two reasons: (1) centre of the circle of which the articular processes form segments is poste to these processes; and (2) the articular processes are so disposed as to be loc In the lumbar region circumduction is allowed, which consists in a combina of flexion, extension, and lateral movements.

Summary of Movements—-Cervical Region. —(1) Flexion and extension;

(2) a combination of lateral flexion and rotation. Thoracic Region. —(1) Fie: and extension, but only to a limited extent; (2) lateral flexion; and (3) ] rotation. Lumbar Region. —(1) Flexion and extension; (2) lateral flexion;

(3) circumduction.

The joints of the atlas, axis, and occipital bone will be foi described in the section dealing with the head and neck.


The Joints of the Ribs, Costal Cartilages, and Sternum.

1. Ribs—Costo-vertebral Joints. —These are divided into joints

the heads of the ribs and costo-transverse joints.

The Joints of the Heads of the Ribs. —These unite the heads of ribs to the bodies of the thoracic vertebrae, and they are sometii spoken of as the capitular joints. They belong to the class of syno 1 joints of the plane variety. The articular surfaces are the facets the heads of the ribs and the costal facets on the sides of the hoc of the thoracic vertebrae—that is to say, the lower facet of the verte above and the upper facet of the vertebra below, the intervertet disc intervening between the two. In the case of the first, the ter the eleventh, and the twelfth vertebrae there is only one facet, and corresponding intervertebral discs do not enter into the joints, uni in the case of the first joint, into which the disc between the sevei cervical and first thoracic vertebrae may enter.


THE THORAX


mi


aments.—These are as follows
radiate, capsular, and intra

lar.

e radiate ligament (anterior costo-central ligament) or stellate

jnt consists of strong white fibres which are attached to the or margin of the head of the rib. From this point the fibres e inwards in three bands, one of which passes upwards to be Led to the body of the vertebra above, a second horizontally is to be attached to the intervertebral disc, and a third vards to be attached to the body of the vertebra below, e case of the first, tenth, eleventh, and twelfth joints, into }f which only one vertebra enters, the ligament is composed of ands, instead of three. In the first joint the lower band passes

body of the first thoracic vertebra, and the upper band to the


jsterior Band of Superior 'osto-transverse Ligament

Vnterior Band of Superior -osto-transverse Ligament


• Anterior Longitudinal Ligament


- Intervertebral Disc


Radiate Ligament —


>7.—Ligaments of the Bodies of the Vertebra and Joints of the Heads of the Ribs on the Right Side.


of the seventh cervical. In each of the tenth, eleventh, and th joints the lower band passes to the body with which the head e rib articulates, and the upper band to the body of the vertebra

e.

he capsular ligament is incomplete, and consists of thin loose 5, which cover the posterior, superior, and inferior aspects of

°int. ,

he intra-articular ligament consists of short stout fibres, which id from the ridge on the head of the rib, separating the two facets, ie intervertebral disc. It divides the joint into two complete vial cavities, and it is wanting in the first, tenth, eleventh, and

Eth joints. . . .

here are two distinct synovial membranes in those joints which

































1112


A MANUAL OF ANATOMY


are provided with an intra-articular ligament—namely, from second to the ninth inclusive—one being above the ligament and other below it. In those joints in which the intra-articular ligan is absent—namely, the first, tenth, eleventh, and twelfth—ther only one synovial membrane.

Arterial Supply. —Branches from the posterior intercostal arterie

Nerve-supply. —Branches from the intercostal nerves.

Costo-transverse Joints. —These belong to the class of sync joints of the plane variety. The articular surfaces are the facet the tubercle of the rib and the facet on the anterior aspect of extremity of the transverse process of the thoracic vertebra.

Ligaments. —These are as follows: posterior costo-transve inferior costo-transverse, superior costo-transverse, and capsular.

The lateral costo-transverse ligament (posterior costo-transv ligament) is a strong flat band, situated on the posterior aspect of joint, and extending from the extremity of the transverse process the non-articular part of the tubercle of the rib. The directior its fibres is outwards.

The inferior costo-transverse ligament (middle costo-transv

ligament) consists of short strong fibres which pass between the poste surface of the neck of the rib and the anterior surface of the adjac transverse process—namely, that with which the tubercle of the articulates. Its fibres, which are disposed horizontally, extend fi the joint of the head of the rib to the costo-transverse joint. 1 ligament is rudimentary in the eleventh and twelfth ribs.

The superior costo-transverse ligament is a broad flat band, lat< in position, the fibres of which pass from the crest on the upper bor of the neck of the rib to the lower border of the transverse pro( immediately above, in the vicinity of its tip. Its fibres are direc upwards and outwards, and its outer border is continuous with posterior intercostal membrane. A feeble band of fibres, medial the preceding, extends from the back of the neck of the rib, below crest, to the lower aspect of the transverse process immediately abc close to its base, being termed the posterior costo-transverse ligamen

The superior costo-transverse ligament is wanting in the case the first rib.

The capsular ligament is formed in part by the lateral cos transverse ligament, and elsewhere by a thin loose membrane, fibres of which are attached lateral to the articular processes, is absent in the case of the eleventh and twelfth ribs.

The synovial membrane is single and small.

Arterial and Nerve Supply. —Offsets from the posterior branc of the intercostal arteries and nerves.

The costo-transverse joints are wanting in the case of the eleven and twelfth ribs, and sometimes in the case of the tenth.

Costo-chondral Joints. —These belong to the class of fibrous joii The outer extremity of the costal cartilage is implanted in the o pit on the anterior extremity of the rib, and the union is effected




THE THORAX


1113


continuity which takes place between the periosteum of the rib the perichondrium of the cartilage.

2. Costal Cartilages—Sterno-Costal Joints. —These belong to the s of synovial joints, except in the case of the first joint, which mgs to the class of primary cartilaginous joints. The cartilages ch take part in these joints are the first seven on either side,

e being received into the costal pits or facets on the side of the

num.

The ligaments are capsular, sterno-costal, and in the case of the >nd joint at least intra-articular.

rhe Capsular Ligaments —The anterior part is a triangular band, the er fibres of which ascend upon the sternum, and the lower descend, 1 st the intervening fibres pass horizontally forwards. They de


Fig. 668. —The Sterno-costal Joints (Anterior View). rhe second, third, and fourth joints of the left side are seen in section.

sate with those of the opposite side, and blend with the tendinous 'es of origin of the pectoralis major muscle.

The posterior part of the capsular ligament is disposed in a manner Lilar to the anterior ligament.

The sterno-costal ligaments pass from the upper and lower borders

he costal cartilage to the side of the sternum.

The intra-articular ligament is present in the second joint, and may present in some of those succeeding to it. Its fibres extend horiitally between the centre of the sternal end of the second costal tilage and the plate of fibro-cartilage between the manubrium and ly of the sternum. It divides this joint into two complete synovial dties.

The first joint has no synovial membrane, the first costal cartilage ng directly united to the manubrium sterni. The second joint, as ted, has two synovial membranes, one above and the other below J intra-articular ligament. The succeeding joints have each usually






iii4


A MANUAL OF ANATOMY


one synovial membrane, but sometimes one or more of them ms have two.

Arterial Supply. —The perforating branches of the internal mammai artery.

Nerve-supply. —The intercostal nerves as they are becoming tl anterior cutaneous nerves.

Interchondral Joints. —These belong to the class of synovial join of the plane variety. The cartilages involved are usually the sixt' seventh, and eighth, but sometimes also the ninth, and it may be tl fifth, and even the tenth. The lower border of each cartilage projec downwards, and comes into contact with the upper border of tl cartilage below. Each joint is surrounded by fibres disposed in tl form of a capsule, and it is provided with a synovial membrane.

Arterial Supply. —The musculo-phrenic branch of the intern; mammary artery.

Nerve-supply. —The adjacent intercostal nerves.

3. Sternal Joints. —The joint between the manubrium and bod of the sternum belongs to the class of secondary cartilaginous joint; The opposed surfaces are covered by hyaline cartilage, and a plat or disc of fibro-cartilage is interposed between them, which is connecte at either side with the intra-articular ligaments of the second sterm costal joint. This disc may contain a small cavity. In front c and behind the joint there are ligamentous fibres which are dispose longitudinally.

The entire sternum is strengthened by its dense periosteum, b the radiating fibres of the sterno-costal ligaments, and by the tendinor fibres of origin of the pectoralis major muscles.

Movements of the Ribs. —The movement allowed at the joints of the hear of the ribs and costo-transverse joints is of a gliding nature, and takes place an upward and downward direction. During this movement the rib rotat round the costo-vertebral axis, which corresponds to a line passing obliquej through the joint of the neck of the rib, the neck of the rib, and the costo-tran verse joint. Owing to the curve and downward inclination of the rib, tl result of this rotation is that the anterior and lateral parts of the rib are elevate< Simultaneously, on account of the obliquity of the axis of rotation, the anteric part of the rib is carried forwards, and along with it the sternum, thus increasir the antero-posterior diameter of the thorax. The lateral part of the rib, and to certain extent the anterior part also, are carried outwards, thus giving rise t eversion of the lower border of the rib, and at the same time the angle betwee the rib and its costal cartilage is opened out. In this manner an increase in tl transverse diameter of the thorax is produced. During the elevation of tl anterior and lateral parts of the rib and the eversion of its lower border tl movement takes place round the costo-sternal axis, which corresponds to a lii drawn from the costo-central joint of one side to the corresponding stern< costal joint. It is usual to liken this movement to the movement of the hand of a bucket.

In the case of the first rib elevation and depression are the chief movemen allowed, the amount of eversion being trivial, inasmuch as the axis of rotatic is almost transverse. In the case of the second, third, fourth, fifth, and six! ribs elevation and depression, along with eversion, are allowed, the axis of rotatio in each case becoming successively more oblique. The seventh, eighth, nintl and tenth ribs, in which the costo-transverse articular surfaces are almost fla'


THE THORAX


n 15


ides rotating round the costo-vertebral axis, also rotate round the costonal axis. In the case of these ribs elevation is accompanied by a backward cement, and depression by a forward movement. These backward and vard movements take place more freely in the case of the eleventh and lfth ribs, which have no costo-transverse joints. At the sterno-costal joints movement is limited, and consists elevation and depression, together ti forward and backward movement.

At the interchondral joints slight ing movement is allowed.

Muscles concerned in Respiration.— jrdinary quiet inspiration the muscles cerned are as follows: (1) the diaagm; (2) the external and internal

rcostal muscles, assuming Haller’s

v to be correct; (3) the levatores tarum; (4) the serratus posterior suior; (5) the serratus posterior inferior;

. (6) the quadratus lumborum as being iliarv to the diaphragm, the serratus terior inferior being also auxiliary, inary quiet expiration is due to (1) the

tic recoil of the lungs, (2) the elastic

)il of the thoracic wall (costal cartiis and sternum), (3) the sterno-costalis scle, and (4) the muscles of the anteroral wall of the abdomen, which press Ily upon the abdominal viscera, and reby push the diaphragm upwards ards the thorax.

In forced inspiration the following scles come into play: (1) the scaleni; the sterno-mastoid; (3) the serratus srior ; (4) the pectoralis major and toralis minor; and (5) the latissimus

si. As auxiliary muscles there are the trapezius, levator scapulae, and rhom1 muscles, which, by their action upon the scapula, fix the shoulder.

In forced expiration the muscles of the antero-lateral wall of the abdomen with considerable strength, and now depress those ribs with which they connected, and necessarily also the sternum. By some authorities the atus posticus inferior is regarded as being concerned.

In inspiration the thoracic cavity is enlarged in its vertical, antero-pos terior, transverse diameters. The increase in the vertical diameter is due to the traction and descent of the diaphragm; the increase in the antero-postenor neter is caused by the anterior parts of the ribs, and along with them the num, being carried forwards; and the increase in the transverse diameter rought about by the eversion of the lower borders of the ribs, and the opening of the angles between the ribs and their costal cartilages.


Fig. 669.— Diagram showing the Axes of Rotation of the Ribs (from Halliburton’s ‘ Handbook of Physiology ').

A, B, axis passing from the joint of head of rib to chondro-sternal joint; a, b, axis passing through costotransverse and joints of heads of ribs. (The movement round the axis A, B resembles the raising of the handle of a bucket.)


CHAPTER XIII DEVELOPMENT OF VASCULAR SYSTEMS

Principal Arteries and Veins.

It was shown at the beginning of this book (pp. 51, 91) that the vase system, in its earliest stages, came into existence as the result of the establishn of connections between networks of channels formed on the yolk-sac, in body-stalk, and in the embryonic body; an extension from the body-stall


Fig. 670. —Scheme of Earliest Circulatory System. (Founded on Eternc

The lower figure is a diagrammatic section to show position of aortae and umbil veins (UV). Am, amnion; N, neural groove; coe, intra-embryonic coelom

the chorion (where similar channels are possibly formed also) puts tl anastomosing systems into relation with the growing villi.

The primitive circulation would seem to be possible through channels est lished in this way at an early stage in embryonic formation; such might represented schematically as in Fig. 670. In this figure it can be seen t

1116







DEVELOPMENT OF VASCULAR SYSTEMS


1117


ns (vitelline) pass up the wall of the yolk-sac to reach the posterior part of ! embryonic rim, where they join a vein coming from the body-stalk and ming forward to enter the primitive heart-tube. This (C) is a very short )e, doubled in origin, which runs back towards the bucco-pharyngeal area (bp), ing off here two primitive aortcs, which pass back on each side of the area the future membrane, and continue their course caudally to reach the bodylk. As they pass back in the embryo they give off vitelline branches downrds on to the wall of the yolk-sac; later, as the somites form, they will be found give intersegmental branches running dorsally between the somites. When

y reach the chorion they are distributed throughout it and to its villi.

The veins which return the blood in this early circulation must come into stence, of course, with the * arteries,’ and can be said in general terms to



r. 671. — Schemes founded on Conditions in an Embryo of About Twelve Somites, in which the Intra- and Extra-embryonic Ccelomic Cavities are Continuous.

se from the common vascular network as enlargements of its ‘ peripheral ’ t, the ‘ central ’ vessels becoming arterial. Thus veins are found extending the heart along the embryonic rim, which receive the blood returning through body-stalk; these veins (uv), are the umbilical veins, which, passing forward ng the margins of the embryonic plate, reach the anterior end of the heart,e in this margin. The vein is shown in black in the figure, where only the sels of the left side are seen; actually there are two primitive aortae and two bilical veins.

The conditions illustrated in the last figure are those present in the embryo, which there are as yet no somites and no body cavity continuous with the ernal coelom. The result of somite formation, with the reversal of the erior end of the embryonic plate, is shown in the next figure (Fig. 671),





nt8


A MANUAL OF ANATOMY


where the heart is now reversed, and the arterial end points forward, while paired aortae run upwards beside the bucco-pharyngeal membrane and then ti back; intersegmental branches are appearing now. It can be seen now, moreo\ that well-defined vitelline veins are reaching the venous end of the heart (n posterior) by passing up the front of the yolk-sac; the earlier posterior ve have disappeared. The splitting of the embryonic rim by the ccelomic extens leaves the vitelline arteries on the splanchnic wall, but puts the umbilical ve in the somatic wall, close to the continuity of this wall with the amnion; thi: shown in the section in Fig. 671.

The paired aortae lie oh the roof of the primitive pharynx, and receive in t situation ‘ aortic arches ’ from the ventrally placed arterial trunk and vessi but behind the pharynx they fuse into a single vessel, which divides again ii two as it approaches the hinder end; these two umbilical arteries pass into • body-stalk.

Development of Principal Arteries.

The arterial end of the heart opens into a dilated arterial sinus, from wh right and left arteries run into the pharyngeal arches, passing through th to join the right and left dorsal aortee which are lying on the roof of the primit pharynx. All told, there are six of these aortic arches (or pharyngeal artei arches) on each side, but they are never present at any one moment in th totality. They appear from before backward, like the mesodermal arches which they lie. The first is possibly the direct descendant of the primitive ao: of its side, passing dorsally round the bucco-pharyngeal membrane; in any c; it is found very early, before reversal is nearly completed. The second aor arch comes a little later. The third, when it appears, seems to take on the din supply of blood to the dorsal aorta at its anterior end, where this vessel is givi branches to the growing neural (brain) tube, and the first and second arcl break up rapidly and disappear, except for their upper and lower ends for soi little time. The fourth arch appears at about the same time as the third, i fifth is very small and short-lived, like the rudimentary mesodermal arch in whi it lies, and the sixth appears behind this. All these arterial arches, then, appt as vessels running ventro-dorsally within their corresponding pharyngeal arch and conveying blood from the ventrally-placed arterial sinus to the dor aortae for distribution.

The presence of the arterial sinus makes the details of further developmt slightly different in the human embryo from those in lower forms, but t differences are only slight, and the main evolution of the adult pattern frc that of the aortic arches is in line with the generalized vertebrate evolutic Such a generalized conception of the system of aortic arches is that (Fig. 6; given by Rathke many years ago, on which the special variations found amo vertebrates can be worked out. The plan shows the arterial arrangemei flattened out, so that, from the arterial stem, right and left ventral aortce r forward (below the pharynx) and give off at intervals the six aortic arches reach the d or sal aortas (above the pharynx). Small branches pass from i sixth arches into the lungs, evidently the future pulmonary arteries, while f anterior end of each dorsal aorta is carried (beyond the scheme) into the cran cavity as a cerebral artery. It may be added here that eight intersegmen: branches arise from each dorsal aorta, the lowest coming off about oppos or just below the fourth arch on each side; seven of these arteries are cervic but the first is cranial, accompanying the hypoglossal.

Disregarding the gill-bearing vertebrates, we may come at once to 1 Amniota, where the differences in the various phyla are classifiable easily on t scheme. In the first place it is a general rule that the third aortic arch is devot to supplying the brain, while the fourth becomes the main stem for the sup], of the body. Thus the third arch plus the dorsal aorta in front of it becon; the internal carotid, and the fourth arch becomes the ‘ arch 5 of the syster aorta, from which facts it can be assumed that the dorsal aorta between 1 third and fourth arches loses its function, is stretched out, and disappea




DEVELOPMENT OF VASCULAR SYSTEMS


1119


e matter of the two fourth arches, these persist in the reptiles ; the right one 5 the systemic arch in birds, and the left one in mammals. he human conditions are thus shown (Fig. 672) on the scheme as mammalian, first two arches disappear, leaving the ventral aorta opposite them as nal carotid; the third, with the dorsal aorta in front of it, forms the nal carotid; the dorsal aorta behind it, between it and the fourth arch, •pears; the ventral aorta between third and fourth becomes the common id. The original symmetry is disturbed behind this. The fourth left arch s part of the systemic arch, but not the whole of it; the dorsal part of this is formed by dorsal aorta, and the ventral end is the beginning of the ventral

this is represented on the right side by the innominate artery. The right

i arch becomes part of the right subclavian; the whole of the left subclavian he terminal piece of the right subclavian are of intersegmental value. Behind


External Carotid


'ig. 672.—Scheme of the Aortic Arches and their Destination.


e the fifth arches disappear; the left sixth remains as the ductus arteriosus; right sixth disappears except for its ventral end, from which the right lonary artery arises. The common arterial trunk is divided by a septum a dorsal part continuous with the sixth arches, and a ventral part for the ral aortae, and this septum extends towards the heart in a spiral manner, nee the changing relations of pulmonary artery and ascending aorta; this vessel represents the common trunk and its systemic subdivision, binally, right dorsal aorta disappears behind the right fourth arch, so that the rest ie thoracic aorta comes from the fused vessels.

n the human embryo there is no ventral aorta giving origin, as in the scheme, 11 the arterial arches, but if we look at the arterial sinus as having the value hortened ventral aortae conjoined, this difficulty disappears. In any case difference is not of much importance, big. 673 gives, in the uppei row, is showing the changes in the human embryo as seen from the left. The

















1120


A MANUAL OF ANATOMY


external carotid showing here may be a new formation, but might be some dr< out persisting remnant of the ventral supply to the early anterior arches, the common carotid is either part of the third arch or a drawn-out portion o sinus; it is a very difficult question to decide. The lower figure shows


biG. 673. —Plans to show Changes in Human Embryo: Upper Row f

Left, Lower from Right.

Aortic arches and their remnants numbered in Roman figures.

conditions on the right side; the carotid developments are as on the left, but fourth arch is part of the subclavian, and the dorsal aorta disappears behind

In estimating and following the changes which occur in the art< arches in the neck it must be remembered that the head grows forw leaving structures behind it which were originally ventral to it; th what is really meant when the heart, for example, is said to ‘ desce



Fig. 674.— Plans to show how the Embryonic Relations between Ner and Arteries are exhibited in the Adult Condition.

The growth of the head and elongation of the neck straighten out carotids, while the connection of the fourth arch with the trunk keeps it 1 the heart.

The relationship between the arterial stems (in the pharyngeal arc] and the nerves of the arches is of interest from the point of view of the nor relations in the adult, and also in cases where the adult conditions are unusu






DEVELOPMENT OF VASCULAR SYSTEMS


1121


The nerves of the first four arches lie near the grooves in front of them, and thus in front of the arteries which lie more or less in the middle of the mesomal masses. In the sixth arch, however, possibly because its artery runs k to it and is formed relatively late, the artery lies in front of the nerve. In

ases the nerve, having crossed the dorsal aorta on its lateral side, then turns

ards to gain the visceral surface; thus they all cross obliquely the lines of ir corresponding arteries, but whereas the first four cross in front of their sels, the last crosses behind it. It follows that, when the neck is elongated the vessels drawn out, they are drawn over the nerves of the arches behind m. Thus the internal carotid (third arch) has the superior laryngeal (fourth arch ve) deep to it, while its own nerve, the glosso-pharyngeal, is superficial to it rsal aorta). The fourth aortic arch (arch of aorta and right subclavian) has the irrent laryngeal deep to it, but this nerve on the left turns first round the mentum arteriosum because it crosses behind that artery in the sixth arch.

The fifth arch, with its artery and nerve, is a tiny and transient formation, only brought into description to complete the various systems. Its artery may be as in Fig. 673, or may arise from the arterial sinus and end in one of the neighbouring arches, or even in the dorsal vessel, or may even arise from the proximal part of the sixth artery.

It disappears early and completely.

The right subclavian artery, as shown in the scheme, has its first part formed n the fourth right aortic arch, and its terminal piece from the seventh cervical srsegmental artery. Between these two there is a portion of the right dorsal ta; there is considerable doubt about the limits of these various parts.

There are two well-known varieties of the right subclavian artery of developntal interest. In one the artery arises from the descending thoracic aorta, the other it arises from the left end of the arch of the aorta; in both cases it ses behind the oesophagus to gain the right side. The first of these varieties ms to be an example of persistence of the right dorsal aorta ; the same explanation iometimes given for the second variety, but with much less probability, and would seem to be more probably an example of anastomosis between the two sal aortw. In both cases the fourth aortic arch has evidently disappeared the right side, and as a result the right recurrent nerve turns round the next h in front— i.e., it runs directly downwards to the lower border of the larynx , sing deep to the internal carotid.

Intersegmental Branches : Vertebral Artery. —The first intersegmental artery en by each dorsal aorta accompanies the hypoglossal nerve. After this come en cervical intersegmental vessels. These pass back between the somites, ich they supply, and give branches also to the neural formations lying ernal to these. Since the cranial end of the dorsal aorta is about to be stretched

in the internal carotid, and the next part of it is about to disappear, it is

dent that, if these intersegmental arteries are to continue to supply the uctures mentioned, they must be provided with another artery of origin, e provision is made very early in their history in the form of a longitudinal istomosis connecting them together some little distance from their origins.

An anastomosis of such a sort is a normal occurrence among the intersegmental vessels in the trunk. Usually it remains very small or disappears, but is seen occasionally in the adult, especially in the thoracic region. In the ordinary way, however, it is only in the cervical region that it enlarges and becomes functionally important.

This longitudinal anastomosis ends caudally in the seventh cervical intermental artery. Thus, when the origins from the dorsal aorta fail, the series vessels obtains its blood from this seventh artery. The longitudinally running 'tebral artery is thus made up of these bits of interarterial anastomosis, the ginal intersegmental vessels persisting as its branches. The portion above the as, however, which has a different relation to the issuing nerve, is of another [ue, being the enlarged intersegmental spinal or neural branch.


1122


A MANUAL OF ANATOMY


The origin of a vertebral artery precedes that of the corresponding subcla 1 artery, so that the subclavian artery is originally a lateral branch of the verte artery. As the development proceeds, however, the subclavian artery incre in size, and greatly exceeds the vertebral artery, the latter vessel being : regarded as a branch of the subclavian.

Origin of Left Vertebral Artery from Aortic Arch. —This, the commo additional branch arising from the arch, is probably an example of the sistence (see Fig. 675) of the sixth intersegmental origin from the dorsal ac with the portion of this aorta remaining as far as the level of the fourth ac arch.

The thoracic and abdominal intersegmental arteries have been refe to already in connection with the aorta.


Fig. 675. —Development of Cervical, Intersegmental, and Vertebra

Arteries, according to Scheme.

The intracranial prolongation of the dorsal aorta on each side is an exan of the enlargement of a neural branch arising from the beginning of this ari and running dorsally into the paraxial tissue round the brain; the dorsal a< itself lies on the upper in-turned ends of the visceral mesoderm of the arc below the layer of paraxial mesoderm. This terminal neural branch en the paraxial layer beside Rathke’s pouch, and, in the adult, pierces the d mater here. Before reaching this, the internal carotid lies on the roof of tubo-tympanic recess, covered by the otic capsule; much later, this cap: extends its ossification partly round it, enclosing it in the carotid canal, bi portion of the artery, still unenclosed, lies in front of this and crosses (as it in the foramen lacerum) the anterior margin of the recess, the auditory tube,

The ramifications of the cerebral arteries are formed in accorda with the growth of the parts of the brain, which is surrounded by a vasci network from a relatively early stage. These vessels are dealt witl part in the section on the central nervous system.



































DEVELOPMENT OF VASCULAR SYSTEMS


1123


•teries of Limbs. —The arteries of the upper limb have been already considered, the lower limb, the accepted views on their development are in large part lptions based on comparative anatomical observations, direct observation » human embryo being an undertaking of great difficulty.

) W er Limb. —At the beginning of the second month the main artery accoms the sciatic nerve, passes deep to the rudiment of the popliteus, and runs

en the primordia of the leg bones to the foot. This ‘ axial ’ vessel is
cted with a small plexus on the extensor aspect of the limb, from which at

ir stage the femoral artery will form. As the femoral channel enlarges, axis ’ vessel sends a secondary branch down superficial to the popliteus, hen degenerates above the level of its connection with the femoral; this dary branch divides to form the tibial arteries, anastomosing with the lal interosseous trunk, which has already given off the anterior tibial, and becomes a small branch of this. The inferior gluteal artery, the popliteal, •art of its middle genicular branch, are remains of the original ‘ axis ' supply,


Fig. 676.— The Venous Trunks of the Septum Transversum of

the Human Embryo (His).

X.X. Upper separated portions of Umbilical Veins R.U.V. Right Umbilical Vein L.U.V. Left Umbilical Vein

V.P. Venous Loops round Gut V.V. Vitelline Veins

the peroneal and perhaps part of the arterial structures in the sole are ed from its interosseous prolongation; the two femoral arteries and the snous branch of the descending genicular artery, when present, are remains e femoral extensor plexus.

Development of the Principal Veins (p. 5 1 ) he primitive veins form two groups. One group returns the blood from the sac and the placenta; and the other group returns the blood from the head neck, anterior limbs, body-wall, mesonephric bodies, and posterior limbs, first group comprises: (1) the vitelline veins, in connection with which the il vein is developed; and (2) the umbilical veins. The second group consists ) the anterior cardinal or primitive jugular veins; (2) the posterior cardinal

and (3) the subcardinal veins; they drain into the veins (or ducts) of

2r on each side. The veins of each group are arranged in pairs, right and


J.V. Primitive Jugular Vein

.V. Cardinal Vein

V.C. Right Duct of Cuvier /.C. Left Duct of Cuvier


























A MANUAL OF ANATOMY


1124

Sinus Venosus. —This is the venous space made by the confluence of veins of the body; it discharges directly into the common atrium the bloo receives from the veins. It is placed in the septum transversum (pp. 46 and and consists of two ‘ horns,' each of which is made by the junction of the umbili vitelline, and Cuvierian veins of its own side. As described in the developrr of the heart, the right horn is taken up into the right atrium, the left horn becon the coronary sinus. The vitelline veins reach the sinus venosus by rum in the visceral wall to the septum transversum, the others get to the septuir

the body-wall. 1

1. Vitelline Veins and Portal Veins— These veins are developed early, they return the blood from the yolk-sac. They enter the body of the emt along the vitelline duct, and finally open into the sinus venosus after traver the septum transversum. Within the body they ascend parallel with each ot at first in front of, and subsequently on either side of, the duodenal portio the primitive intestinal tube. In the latter region on the caudal side of


Fig. 677. _Schemes to show Formation of Portal Vein from Doi

Connecting Loop between the Right and Left Vitelline Veins.

hepatic bud they become connected by three transverse anastomotic ves two of which lie across the ventral aspect of the gut, and one being placed 0 dorsal aspect. The first or lowest anastomotic vessel lies on the ventral as of the gut; the second or middle vessel is dorsal to the gut; and the tnir highest, like the first or lowest, is ventral to the gut. This is shown m tne

scheme in Fig. 677. , . ,

By means of these three anastomotic vessels two venous rings—lowe caudal, and upper or cephalic—are formed around the duodenal portion oi primitive intestinal tube, these rings constituting the sinus annularis. t their formation the two divisions of the liver-bud are breaking up into ne cylinders, and these are giving off secondary cylinders. Owing to these ne] developments the vitelline veins cease to communicate directly with tne . venosus. The portions of the vitelline veins above the upper duodenal ve ring (shown in Fig. 676 to proceed from its sides) become surrounded hepatic cylinders, and invaded by the secondary cylinders. In this ma




DEVELOPMENT OF VASCULAR SYSTEMS


1125


portions of the vitelline veins are freely subdivided into blood-channels,

1 are known as sinusoids (Minot). These sinusoids form a network which >ies the meshes of the network formed by the branches of the hepatic cylinders, veins which convey blood from the upper duodenal ring to the hepatic oids are now known as the vence advehentes, and they become the right and \ivisions of the portal vein. The veins which carry the blood from the tic sinusoids to the sinus venosus are known as the vence revehentes, and they ne the hepatic veins.

runk of the Portal Vein. —The portions of the two vitelline veins which id in front of the primitive duodenum lie close together and parallel with other. These portions fuse for a short distance, and form a single venous , which opens into the first, or lowest, ventral anastomotic vessel, or, in ■ words, into the lower part of the lower duodenal venous ring. This short receives the veins of the primitive intestinal tube, and it forms the root e portal vein. The primitive portal vein, therefore, receives its blood from tie yolk-sac, and (2) the primitive intestinal tube within the abdomen. The r ventral anastomosis and the right vein immediately above it quickly

ipear (Fig. 677). . .

is the yolk-sac atrophies the portions of the vitelline veins between it and commencement of the portal vein also atrophy, and the tributaries of the il vein gradually assume their condition in adult life. The vitelline vein, ever, does not disappear for a considerable time, but remains as a free cord ,4) passing out of the umbilicus up to the entrance of the umbilical loop into belly. #

"he following parts of the sinus annularis, or double duodenal ring, undergo phy (see Fig. 677):

1. Right half of lower ventral anastomotic vessel.

2. Right half of lower duodenal ring.

3. Left half of upper duodenal ring.

rhe following parts of the sinus annularis persist:

1. Left half of lower ventral anastomotic vessel.

2. Left half of lower duodenal ring.

3. Middle or dorsal anastomotic vessel.

4. Right upper half of duodenal ring.

5. Upper ventral anastomotic vessel.

These persistent portions, with the exception of the upper ventral anastomotic el, form the greater part of the trunk of the portal vein, the upper ventral stomotic vessel represents a part of the left division of the portal vein.

The portal vein has originally a spiral relation to the duodenal portion of primitive intestinal tube—that is to say, it winds round the left side and sal aspect of the duodenum, and then appears on its right side.

Divisions of the Portal Vein.— These are connected with the upper duodenal ous ring. As previously stated, the veins which convey the blood from this \ to the hepatic sinusoids are known as the vence advehentes, right and lefL.

right division of the portal vein is formed by the right vena advehens, which

ings from the right half of the upper duodenal venous ring, dhe left division firmed by (1) the upper ventral anastomotic vessel, and (2) the left vena ehens

Umbilical Veins.— The two umbilical veins return the blood from the placenta the sinus venosus. They are of small size during the period of the vitelline mlation, but become enlarged as the placenta gradually forms, the two ns unite and form a single trunk within the umbilical cord At the umbi icus 5 trunk enters the body of the embryo, and immediately divides into wo bilical veins, right and left, which traverse the septum transversum and open n the sinus venosus. As they traverse the septum transversum ey are se to the developing liver.


1126


A MANUAL OF ANATOMY


The left umbilical vein enlarges fairly rapidly, that on the right s atrophying more slowly. Just before the 5 mm. stage the left vein effect capillary junction with the left vitelline vein on the caudal aspect of the sept transversum— i.e., on the caudal or visceral surface of the small liver. 1 connection between the umbilical and vitelline veins of the left side enlar very rapidly, thus making the vessel on the visceral aspect of the liver wt is usually referred to as the ‘ left umbilical vein ’; actually, of course, it is a vite umbilical anastomosis, and the real umbilical vein passes up still beside the lb but dwindles rapidly, and cannot be certainly traced after a fairly short inter When the anastomotic vessel collapses, after birth, it makes the ligament teres of the liver.

In this region part of this fibrous cord lies in the abdominal wall ; part below the liver; the first of these parts is the true umbilical vein, w the second is the vitello-umbilical anastomosis.


Fig. 678. —Scheme to show Early Circulation in Liver, and Direct

of Ductus Venosus.

The right umbilical vein also seems to develop some similar anastom with the vitelline system, but owing to the atrophy of the vein the anastom does not become evident.

The anastomosis of the left umbilical vein with the left vitelline vein oc at the level (in this last vessel) of the upper junctional loop with its fellow, as sh in Fig. 677. As already stated, this upper loop becomes embedded in the lb and forms a part of the left portal vein, whence the fact that the ligamen; teres, buried between two lobes of the liver, runs to join the left division of portal vein.

There is possibly some connection between the entrance of the umbi blood at this level and the disappearance of the original vitelline (A in Fig. 677) between this and the next anastomotic loop, the vol of blood from the larger vein prohibiting entrance of vitelline blood it below.

Ductus Venosus. —Blood from the left umbilical vein enters the live; j increasing amount as the placenta grows, and before long there becomes evil a dilatation into a large vessel of the vascular spaces in the liver lying bet\i the point of entrance of the blood and that of its discharge into the infc







DEVELOPMENT OF VASCULAR SYSTEMS


1127


, cava. This vessel is termed the ductus venosus (or ductus Arantii). It nds from the left portal vein, which has been formed from the uppermost line loop and receives (Fig. 678) the vitello-umbilical anastomotic vessel; ,sses upwards and to the right, reaching the terminal part of the right hepatic nage into the inferior vena cava, which becomes dilated to form its terminal

✓ •

After birth, when the placental circulation has ceased, the ductus venosus becomes a fibrous cord, the ligamentum venosum.


minute portion of the lumen he left umbilical vein remains ious within the ligamentum > of the liver. This pervious ion communicates at the liver . the left division of the portal , and at the umbilicus it is lected with the epigastric veins

he abdominal wall. It thus

is a channel of communication yeen the left division of the al vein and the systemic veins tie anterior abdominal wall. In pervious portion the blood can towards the umbilicus. This stomosis between the portal and emic circulations accounts for enlargement of the veins of the irior abdominal wall in cases of

al obstruction within the liver.

2. The cardinal system of veins iprises several vessels on each

, which ultimately drain their

d into the sinus venosus through right and left veins {or ducts) of ier. A general idea of their ribution can be gained from . 679A. A large vessel, the primijugular or anterior cardinal (or cardinal), drains the cranial part the body, beginning in associa1 with the venous drainage of brain, and passing back through cervical region, where it re/es intersegmental veins, includthe subclavian (S). The posterior dinal runs caudo-cranially, being med in association primarily with mesonephros (W) and receiving srsegmental veins. The posterior 1 anterior cardinal veins join to m the ‘duct of Cuvier,’ situated the septum transversum, cranial the liver ('LL and thus


Fig. 679.—Scheme of Main Venous Drainages of Embryo.

SV, sinus venosus; DC, duct of Cuvier; PJ, anterior cardinal or primitive jugular; C, posterior cardinal; UV and VV, umbilical and vitelline veins.


(L), and thus running ctly into the sinus venosus. # . .

rhe anterior cardinal or primitive jugular veins are two m number—right left—and return the blood from the head, neck, and fore-limbs. Each vein >ists of two parts—intracranial and extracranial. The intracranial part gives , directly and indirectly, to the intracranial sinuses, whilst the extracranial ‘ becomes the internal jugular vein. The intracranial part is known as the



1128


A MANUAL OF ANATOMY


principal or primary head vein. This vein at its anterior end is on the inner of the trigeminal ganglion; passing backwards from this point, it lies just al the outer part of the tubo-tympanic recess lateral to the facial ganglion and f nerve, and reaches behind this the outer side of the glosso-pharyngeal and va

Its different relations with the several cranial nerve-roots indicate it has been produced from two venous trunks, connected between the rc these trunks are represented in lower vertebrates by the vena capitis late and vena capitis medialis.

At its anterior end the principal head vein receives on each side the anti cerebral veins, a plexiform set of vessels draining the mid-brain, the back ol fore-brain, and the optic outgrowth. The anterior cerebral veins anastoi


Fig. 679A.— To show Main Trunk Veins in Young Embryo.

with their opposite fellows dorsally between the two small cerebral vesic thus forming the rudiment of the superior sagittal sinus, which is elongated the vesicles grow backwards (Fig. 680).

Between the trigeminal and facial ganglia the principal vein receive middle cerebral vein or plexus, draining the front limb of the pontine flex and anastomosing with the anterior veins.

A plexiform posterior cerebral vein opens into the principal head vein betw the facial and glosso-pharyngeal ganglia; it drains the back of the poni flexure and the myelencephalon. These details are shown in Fig. 680, f scheme.

As the cerebral vesicles grow backwards, the anterior plexus becomes n closely connected with the middle set, and its blood is returned by this set







DEVELOPMENT OF VASCULAR SYSTEMS 1129

asing amount. Ultimately the superficial middle cerebral vein, the sphenotal sinus, and the ophthalmic veins, are the only vessels left of the original isive anterior venous plexus. The cavernous sinus is the persisting anterior

>f the principal head vein (second figure).

he middle cerebral vein, however, has in the meantime formed a secondary ’ding channel with the posterior cerebral vein, this channel lying above the capsule and beside the pontine flexure within the developing cranium, the blood which has already been seen to be derived from the anterior 1 into the middle set is carried back through this new channel, and the lal principal vein in its intermediate part gets smaller and disappears, the 1 from its anterior end (cavernous sinus) now passing up the lower portion e original trunk of the middle cerebral vein to reach the new channel, through h it passes to the hinder part of the posterior vein, along which it runs down -enter the hinder part of its old vessel, and thus leaves the cranium with r agus.


680.— Semi-schematic Figures to show Changes in Venous Drainage of Brain (founded on Streeter’s Figures).


Continuing their growth backwards (third figure), the cerebral vesicles carry elongating longitudinal sinus with them, so that it ultimately comes to open

  • th figure) into the posterior set of veins, from the lower part of which the

al sinus is made. The middle cerebral plexus is covered over by the growing des, but is represented in the great cerebral veins and their tributaries, the ar veins being also remnants of their connections with the anterior venous The straight sinus is a new connection (arising on the dorsal side of the -brain flexure when this closes) between the middle and posterior sets of s. The inferior petrosal sinus represents the secondary re-establishment direct connection between the original and persisting anterior and posterior 1 of the primary head vein, but the new channel is within the cranium, and is

a reappearance of the old vein. .

die extracranial part of the anterior cardinal vein, after the obliteration of vena capitis lateralis, commences at the jugular foramen, whence it extends lad, receiving in its course the cervical inter segmental veins. In the vicinity te sinus venosus it meets the posterior cardinal vein of its own side, with which lites. The venous trunk thus formed is called the duct of Cuvier, of which e are two—right and left. These two ducts pass transversely, one on either


ii3o


A MANUAL OF ANATOMY


side, to the sinus venosus, into which they open. At this stage the sinus venc also receives the vitelline and umbilical veins of each side. The ducts of Cu are in the septum transversum (see pp. 46 and 52).

As the heart descends from the region of the fore-gut, the ducts of Cu become vertical, and are in line with the anterior cardinal veins. When sinus venosus becomes merged into the right atrium, and the heart undergo^ slight rotation from right to left, the left duct of Cuvier is placed dorsal to left atrium before opening into the right atrium.

Each anterior cardinal vein is joined, near its caudal extremity, by corresponding subclavian vein.

Close to the junction the subclavian vein receives the external jugular V This vein is a secondary formation, and is probably derived from a poste auricular vein, being subsequently reinforced by a pre-auricular vein.


F IG . 681.— The Venous Plexus lying between the Two Primitive.Jugui

JUST BEGINNING TO FORM THE LEFT INNOMINATE CONNECTION (19 MM.)

A transverse anastomotic vessel is now formed, called the transverse jug vein. It is developed (Fig. 681) in the ventral plexus connecting the primitive jugulars. It extends from the junction of the left anterior cardinal left subclavian veins to the right anterior cardinal vein at a point a little b< the place where it receives the right subclavian vein. This transverse jug vein, which extends obliquely from left to right, with a downward inclmal gives rise to the left innominate vein. The venous blood from (i) the left of the head and neck and (2) the left fore-limb now passes through the innominate vein into the permanent superior vena cava. The right innomi vein is formed by the short portion of the right anterior cardinal vein w intervenes between the place where it receives the right subclavian vein and place where the transverse jugular vein joins it. The portion of the right ante cardinal vein, which lies immediately below the place where the transverse jug vein joins it, forms the upper or extra-pericardial part of the permanent sup( vena cava —that is to say, the part above the point where the vena azygos o] into it. The lower or intrapericardial part of the superior vena cava is develc






DEVELOPMENT OF VASCULAR SYSTEMS


n 3 J


. the right duct of Cuvier. The permanent superior vena cava therefore isents (i) the lower part of the right anterior cardinal vein, and (2) the

duct of Cuvier.

'he portion of the left anterior cardinal vein immediately below the left unity of the transverse jugular vein forms the upper part of the left superior costal vein, thus accounting for the ending of that vein in the left innominate which, as stated, is formed by the transverse jugular vein.

'he left duct of Cuvier undergoes partial obliteration. Its terminal part, l with the left lateral cornu of the sinus venosus, gives rise to the coronary 5. The portion next the terminal part also persists in the form of a very ite vein, called the oblique vein of left atrium, which lies over the posterior ct of the left auricle. The obliterated portion is represented by the vestigial


bo. 682. — Sectional Plans to illustrate Venous Modifications in Cardinal Systems in the Middle Region of the Abdomen.


of left atrium, which is a small triangular fold of the serous pericardium in t of the root of the left lung.

‘osterior Cardinal Veins. —These are two in number—right and left—and return the blood from the mesonephroi, body-wall, and hind-limbs. They >n either side of the aorta dorsal to the mesonephroi. The caudal end of vein receives the inferior gluteal vein, which is the primitive vein of the -limb. A little above this point it is joined at a later period by the external vein, which has now been developed.

die cephalic end of each posterior cardinal vein joins the corresponding nor cardinal vein, and the trunk so formed is the duct of Cuvier.

Amongst other tributaries, the posterior cardinal veins receive intersegmental s, such as the lumbar and intercostal veins, and veins from the intermediate mass.







1132


A MANUAL OF ANATOMY


The posterior cardinal veins lie on the dorsal side of the mesonephroi, cardinal veins run longitudinally on the inner and ventral sides of the mesonep within which the cardinals and subcardinals are connected by anastomt veins; they run into the cardinals at the two ends of the bodies. A third sy: of veins develops on the dorsal side of the cardinal on each side, forming a pi round the groups of sympathetic ganglion cells as these grow down from posterior root ganglia. As this ‘ periganglionic ’ system enlarges with the gn and extension of the nervous masses, it forms an extensive plexus, joi laterally with the inter segmental veins , ventrally with the cardinal, and wit) subcardinal internal to this. In many animal forms this venous system constil a definite supracardinal vein on each side, with retro-aortic anastomoses, but a development is not found in the human subject, and retro-aortic conned are few and far between; hence it seems convenient to use the term ganglionic as representing the human condition or modification of the supracarc formations.

Progressing with the ganglionic and nervous growth, the perigangli plexus extends forwards and inwards on each side as a juxta-aortic plexi veins, and from this a pre-aortic plexus is quickly formed. The pre-ai extension is seen in the thorax, and is very marked in the abdomen belov level of the superior mesenteric artery; between these two parts the growt the suprarenal and its association with the sympathetic and the formatio the diaphragmatic crura seem to interfere with the formation of the pre-ai plexus. The part of the left renal vein that lies in front of the aorta is made 1 this plexus below the superior mesenteric artery, putting the two subcard] in connection owing to the extensive anastomoses between these and the gny supracardinal vessels. Caudally, the aorta divides into two umbilical arte and the supracardinal plexus is carried down on each side dorsal to these arte extensions from this plexus here on the sacrum appear to be the origin of left common iliac vein in this part.

The sectional plans shown in Fig. 682 will be of use probably in enabling reader to follow the complicated changes going on in these different sets of ves In I are shown the two mesonephric formations in section, beside the mei mesentery. On the left an intersegmental vein (in) is seen opening into posterior cardinal (C), which is situated on the dorsal and lateral side of mesonephros, and is joined by a plexus within that body with the subcarc (SC) in the medial part of the body near the base of the mesentery. On the r side is shown a stage a very little later, in which a plexus of minute veins is surrounding the sympathetic neuroblasts which have descended from the ne crest; this ‘ periganglionic ' plexus is connected with the intersegmental \ and also (although this is not shown) actually with the posterior cardinal, plexus, following the extension of the neuroblasts, shows a rapid ventral extern as seen in II, towards the ventral aspect of the aorta, over which (III) it pa and joins with the plexus of the other side. It is to be noted that this exten is correlated with a marked anastomosis with the subcardinal, as seen in III, in the same figure is shown the evident tendency of the intersegmental vei: transfer its drainage to the plexus—that is, in general terminology, to trar it to the supracardinal vessels. The connection with the subcardinals ii marked that the transaortic plexus appears very soon to be intersubcardi as is suggested in III, and becomes intersubcardinal in actuality before (IV), as the original anastomosis with the plexus begins to atrophy or break This break is favoured by the establishment of longitudinal anastomoses betv the successive ‘ plexus ' units, so that their blood is now carried cranially longitudinally running and definite supracardinal vessel, which only communic with the subcardinals here and there. In the meantime the intersegme veins have come to drain altogether via the ‘ plexus ’ into this longitud vessel, and the posterior cardinal (in this abdominal region) disappears (c) f the scene. These changes are shown in IV. The last figure (V) is a schem illustrate the age-changes described above. The intersegmental veins in f younger stages (below) are joined by a plexus with the subcardinal (SC), bu



DEVELOPMENT OF VASCULAR SYSTEMS


1133


become older (higher) they establish a longitudinal drainage of their own lose their connections with the subcardinal, except, for example, where the renal vein is made.

'he changes just described are of the nature of general changes; their modificai and extensions, as shown in the development of the inferior vena cava azygos systems, remain for description.

humming up these matters from the viewpoint of the respective cardinal it may be said that the posterior cardinal is formed on each side in association the mesonephros, which it drains, and also receives intersegmental veins, he mesonephros degenerates the cardinal vein gets smaller, and disappears pletely in the abdomen. Its intersegmental tributaries have previously . transferred to the supracardinal (periganglionic) system. Changes in the ax will be dealt with later.

die subcardinal is an accessory channel in the inner part of the mesonephros, extent corresponds with this body, and it joins the main cardinal at its smities. It is connected with this vein by a venous plexus throughout its se, and also secondarily with the supracardinal system and its derivatives; of these last is the left renal vein in front of the aorta, which in this way mes practically an intersubcardinal connection.

rhe supracardinal system is not developed so completely in man as in most le other mammals; its early state constitutes a ‘ periganglionic ’ system, but term, it must be understood, is only a descriptive word applicable to the human yo, and indicates its supracardinal arrangements. The veins of this system lorsal to those described above, with which they are connected by free .tomosis. They take over secondarily the intersegmental drainage, allowing posterior cardinals to disappear, and they develop a longitudinal drainageel of their own, so that their contained blood is not (or is only in part) carried the subcardinal; at the upper end, however, this longitudinal vessel opens the subcardinal, as will be seen when treating of the thoracic vessels, rhe compound systems of cardinal veins, as shortly described above, are metrically placed on the right and left sides, in the abdominal and (future) acic parts of the embryo. The development of the suprarenal glands, of liver, and of the diaphragmatic structures altogether breaks the continuity le systems, which can now be said to have thoracic and abdominal developts only indirectly connected. The abdominal development is concerned he formation of the inferior vena cava and its associated vessels, while the

  • os and left superior intercostal systems are produced from the thoracic

dopments; these vessels, therefore, can be considered at once.


Development of the Inferior Vena Cava.

The inferior vena cava, as regards its development, consists of two divisions >wer or postrenal, and upper or prerenal.

These descriptive names are given to the two parts because it is at the level of the left renal vein, which has been seen to be practically intersubcardinal, that the developmental values of the parts of the vein .change ; the ‘ renal' term, therefore, applies to the venous level, and not necessarily to the kidney itself.

Below the level of the left renal vein, the inferior vena cava is formed from the it longitudinal vessel of the supracardinal system, which receives the intermental (lower lumbar) veins of the right side; a similar formation is found ■he left side. The posterior cardinals disappear when the intersegmental veins their terminations, and the subcardinals also atrophy, as the mesonephros ins to move down, only retaining the drainage of the gonad at this level; s the supracardinal alone is left to carry on the drainage of the body-wall, Further changes usually occur on the left side, where the longitudinal vessel supplanted by a deeper longitudinal channel connecting the intersegmental


H34


A MANUAL OF ANATOMY


veins on the transverse processes, deep to the psoas. Thus the more superb vessel disappears; but it occasionally persists as a left inferior vena cava, extend up to the left renal vein (see Fig. 684).

Sometimes the retro-aortic anastomosis, which is a feature of the suf cardinal system in other forms, may make a partial appearance in the hun individual, when one or more lower left lumbar veins will pass behind aorta to empty into the inferior vena cava.

Above the level of the left renal vein the subcardinals on each side lie in fr of the suprarenal glands, round the outer sides of which the posterior cardii course cranially. Before long the right subcardinal establishes a commumcat


Fig. 683.— Cardinal and Subcardinal Veins, etc.

(Frederick T. Lewis, in the American Journal of Anatomy.)

with the veins (hepatic) emerging from the dorsal aspect of the liver; this C( munication is situated in the right-hand part of the common dorsal mesentf This junction, enlarging steadily, provides a new and direct channel by which blood in the right subcardinal can reach the heart, and the left renal, ahead) position, affords a means by which that from the left subcardinal can ' advantage also of the new channel. Thus the prerenal portion of the inte. vena cava is of subcardinal origin from the entrance of the left renal vein to relation with the suprarenal gland, where it receives the suprarenal vein.. Ab this it is formed by the hepatic anastomosis and the common hepatic vein, wi

The supracardinal system-which empties itself fundamentally (w. possible) into the subcardinal—forms the lower part of the main vein, but as s





DEVELOPMENT OF VASCULAR SYSTEMS


ii35


ssible— i.e., where the subcardinal persists—opens into it. Thus the cony of the great vein is effected.

le kidneys, growing cranially, lie among the veins of the supracardinal n, and drain into them. Thus the right renal vein is altogether supra ml in value, and joins the longitudinal supracardinal vessel as this reaches bcardinal ending, thus a very little below the level of the left vein. The snal vein, at its renal end, is of the same value as the whole of the right vein,

s transaortic portion is not represented on the right side; it passes through


Fig. 684. —Schemes to show 1 Formation of Inferior Vena Cava.


ardinals (Sub) are plain; supracardinals (Sup) black; posterior cardinals are not shown, as they are not concerned in the formation.

In A the supracardinal system is establishing its longitudinal vessel on ?ach side, and so communicates with subcardinal. Subcardinals pass aeyond suprarenals (dotted ovals) and there is no connection with the aepatic veins (H). They are joined by a transaortic (dotted) junction, and receive veins (G, G) from the gonads.

In B the supracardinal no longer communicates with subcardinal, except it R; here the renal vein is placed on each side. Subcardinals accordingly iegenerate below entrance of gonad veins. Right subcardinal has now diected a junction with hepatic veins behind liver.

In C any upper continuation of subcardinal above suprarenal is cut off 3 y diaphragm. Final values of parts of I.V.C. are apparent. The ascending supracardinal (X) on left is replaced by the deeper (Y). The junctional part )f left common iliac is an intersupracardinal (periganglionic) formation.


tion of the subcardinal, where this remnant exists to receive the left supraand left spermatic or ovarian veins.

he right and left veins of the gonad drain from the beginning into the 'rdinals, and thus, in the adult, reach the renal level because there is no ordinal remaining below this.

he left suprarenal vein is probably a remnant of the left subcardinal, correcting with the part of the vena cava formed by the subcardinal above the level; the current of blood in it, however, is reversed.

he posterior cardinal vein, having lost its intersegmental branches, disappears the abdomen by the middle of the second month, having taken no part in 'rrnation of the inferior vena cava.













1136


A MANUAL OF ANATOMY


Thoracic Cardinal Formations.

The prolongation of the three cardinal systems into the thorax from abdomen is interrupted first by the rapid enlargement of the suprarenal gla This particularly affects the subcardinals, but these glands still, for a little i discharge some of their blood by small veins into the thoracic parts of the cardinals; soon, however, the extension of the diaphragm, over and be them, cuts them off finally from this way of discharge and leaves them onl) abdominal subcardinals for drainage.

The terminal piece of the posterior cardinal remains on both sides, persisting portion is the part above the entrance of the subcardinal, exten



Fig. 685.— Schemes of Cardinal Systems in the Thorax.

On each side upper part of posterior cardinal (PC) persists. Longituc supracardinal (Sup), connected at first with subcardinal (Sub), only ret ultimately its terminal opening into this; thus this extreme terminal f of subcardinal persists, the rest of subcardinal and of postcardinal appearing below this point. On left side the original symmetry is fur broken up, and retro-aortic junctions cross to right supracardinal.

A is early condition, B the final state. VC, duct of Cuvier; PJ, primi jugular or anterior cardinal.

from this to the duct of Cuvier. The extreme terminal bit of the subcard also persists, joining the posterior cardinal; immediately below this tern section the longitudinal supracardinal vessel joins the subcardinal, and the of the subcardinal disappears. This junction of the two veins corresponds r or less with the entrance of the sixth thoracic intersegmental vein into the of the supracardinal longitudinal vein. These details will be followed r easily, perhaps, with the aid of the diagrams in Fig. 685.

On the right the azygos vein is formed, below the sixth intercostal level, 1 supracardinal elements; at this level a very short ring of subcardinal come and above this it is persistent posterior cardinal.

On the left the conditions are at first symmetrical and similar, but as the innominate vein forms and the intersupracardinal junctions appear behind





DEVELOPMENT OF VASCULAR SYSTEMS


ii37


, the system is broken in variable ways. The termination of the posterior tal is in the left superior intercostal vein, but the terminal piece of this is true jugular (anterior cardinal). The lower hemiazygos is always supralal.

Development of the Lymphatic System.

ie lymphatic system consists of lymphatic vessels and lymphatic glands des. There is also lymphoid or adenoid tissue, as in the thymus body, tioid follicles and villi of the intestinal mucous membrane, lymphatic es of the spleen, palatine tonsils, and pharyngeal tonsil. There are two 5 in the development of the lymphatic system—primary and secondary. irimary stage is concerned in the formation of lymph-sacs, and the secondary consists in the formation of lymphatic vessels and lymph-glands. fmph-Sacs. —There are two pair of lymph-sacs and two single sacs, as vs:

1. Jugular (2).

2. Retro-peritoneal (1).

3. Cisterna chyli (1).

4. Posterior (2).

pinions differ as to the development of these lymph-sacs. The view of nee R. Sabin will be stated first. According to this lady the sacs are oped as sproutings from the endothelial lining of veins, and this constitutes rimary stage in the development of the lymphatic system, lgular Sacs. —The jugular lymph-sacs, right and left, are the first to appear, is situated on the outer side of the lower part of the primitive anterior nal vein, which becomes the internal jugular vein. It is formed from part capillary venous plexus, connected in early life with the anterior cardinal A large part of this plexus disappears, whilst the connection of the inder with the anterior cardinal vein is severed. There thus results a died collection of capillaries, lined with endothelium and in close proximity e outer side of the lower part of the anterior cardinal vein. These capillaries ne dilated, and subsequently join to form the jugular lymph-sac of each side, h is lined with endothelium, and which establishes a fresh connection with ower part of the anterior cardinal vein, where it is joined by the subclavian a valve being formed at the venous junction by a protrusion of part ie lymph-sac at the place of junction. The jugular sac of each side is ected externally with peripheral lymphatic vessels which extend to the , neck, and fore-limb bud of the same side. The caudal end of the left sac mes connected with the thoracic duct, whilst the caudal end of the right becomes connected with the right lymphatic duct. The dorsal part of sac becomes converted into a plexus of lymphatic vessels, from which is of lymph-glands are developed.

tetro-peritoneal Sac. —The retro-peritoneal or pre-aortic lymph-sac is single, is formed from a capillary venous plexus in the root of the mesentery, which ns is connected with the great pre-aortic transverse anastomotic vessel which nds between the two subcardinal veins. The capillary plexus in the root tie mesentery becomes converted into a lymph-sac, without any venous tection, and this constitutes the retro-peritoneal sac, which establishes a munication with the cisterna chyli, and through it with the thoracic duct, ultimately replaced by a plexus of lymphatic vessels, and from this plexus ns of lymphatic glands are developed which lie along the ventral aspect of abdominal aorta. From the retro-peritoneal sac lymphatic vessels pass in the mesentery along the branches of the superior mesenteric artery, and e form another lymphatic plexus, from which the mesenteric lymphatic leal) glands are developed. Subsequently lymphatic (lacteal) vessels enter wall of the small intestine.

’osterior Sacs. —The sciatic lymph-sacs, right and left, are developed from llary venous plexuses in connection with the two primitive iliac veins. On

72


A MANUAL OF ANATOMY


1138

either side the sac extends from near the caudal end of the cisterna chyli alo the outer side of the primitive iliac vein. It ultimately becomes convert into lymphatic glands.

Cisterna Chyli .—The cisterna or receptaculum chyli is a single sac, situat at the caudal end of the thoracic duct. It is developed from, and replaces venous plexus. The thoracic duct connects the cisterna chyli with the 1 jugular lymph-sac, and the cisterna chyli communicates with each poster sac. From each jugular sac a vessel grows caudalwards. On the right si this vessel constitutes the right lymphatic trunk, and on the left side it forms 1 thoracic duct. As the thoracic duct approaches the developing aortic arch divides and gives rise to two thoracic ducts, which embrace that arch and th pass to join separately the cisterna chyli opposite the mesonephroi. Subsequen these two ducts fuse, and one duct is formed.

The thoracic duct is developed from a series of venous capillaries, origina having a connection with veins.

Lymphatic Vessels. —The formation of these vessels, along with that ymph-glands, constitutes the second stage in the development of the lympha


Afferent Lymphatics


Fig. 686.—Diagrammatic Section of Lymphatic Gland (Sharpey, fr

Quain).

system. According to Sabin, the lymphatic vessels are formed from the en thelial lining of the lymph-sacs, whilst the lymph-glands are. developed ft plexuses of lymphatic capillaries. The development of the thoracic duct, as stat takes place from several groups of venous capillaries. It is the largest lympha vessel, and it connects the cisterna chyli with the left jugular sac.

The lymphatics derived from the jugular lymph-sacs pass to the head, ne and fore-limb buds; those from the posterior lymph sacs extend to the hi] limb buds; and those from the retro-peritoneal (mesenteric) lymph-sac en the mesentery, within which lymph-glands (mesenteric) are developed connection with them. From these mesenteric glands, in succession, m lymphatic vessels pass to the intestinal tube.

The other view of the development of the lymphatic system, held by Hu ington amongst others, is that the connection of the lymphatic vessels with venous system is secondary\ and not primary, as Sabin holds. According this other view the lymphatic vessels spring from lymph-spaces, which are forn in the mesoderm (mesenchyme), and are lined with mesothelium. The endothe cells of the lymphatic vessels are derived from this mesothelium, and not fr









DEVELOPMENT OF VASCULAR SYSTEMS


ii39


lous endothelium, according to Sabin, and the vessels establish a connection le venous system at a later period.

nph-Glands. —Some of these are formed in connection with the lymphdiilst others are formed in connection with peripheral lymphatic vessels, are three stages in the development of a lymph-gland. The first stage s in the formation of a plexus of lymphatic capillaries pervaded by con;-tissue septa. The second stage consists in the invasion of these septa od-capillaries, surrounded by lymphocytes. The third stage consists in mation of a lymph-sinus from the original plexus of lymphatic capillaries.

3 essential elements of a lymph-gland are thus threefold—namely: (1) a of lymph-capillaries; (2) blood-capillaries, surrounded by lymphocytes, connective-tissue septa; and (3) a lymph-sinus.

h lymph-gland is connected with several lymphatic vessels. 1 hose which
he gland are known as afferent vessels, and they open into the peripheral

deal part of the lymph-sinus. Those which emerge from the gland are L efferent vessels, and they arise in the central or medullary part of the -sinus. In no case does a lymphatic vessel pass uninterruptedly through >h-gland. The gland is a station in the path of a lymphatic vessel, which 3nts the terminus of that vessel, but not the terminus of the lymph. That after leaving the afferent vessel, flows in succession through the cortical edullary parts of the lymph-sinus, and from the medullary part it flows re efferent vessels. It is, therefore, so far as the lymph is concerned, a f, so to speak, changing carriages at a glandular station. During this s any injurious matter is taken up by the branched cells (phagocytes) of nph-sinus, and the lymph is furnished with a contingent of lymphocytes.

Structure of Lymphatic Vessels.

lymphatic vessel, of large size, consists of three coats-—inner, middle, iter. The internal coat {tunica intima) consists of a longitudinal network stic fibres lined with endothelial cells. The middle coat {tunica media) ts of plain muscular and elastic tissues disposed for the most part transy. The external coat {tunica externa) consists of (1) longitudinal bundles of

tive tissue, and (2) plain muscular and elastic fibres, disposed for the

part longitudinally, lined with endothelium.

mphatic vessels are furnished with bloodvessels and nerves. Most ol are also provided with valves, similar to those of the veins. Each valve ts of two semilunar segments, facing one another, which are foldings of the coat, containing connective and elastic tissues. They project slightly ds each other, and their free edges are directed in the course of the lymfih1. The valves are situated at short intervals, and they serve to prevent of lymph. When a lymphatic vessel becomes distended it presents a d appearance, with constrictions between the projections, these constrictions ponding to the attached margins of the valvular segments, svelopment. —According to Sabin, the lymphatic vessels are developed from Ldothelial lining of the primitive lymph-sacs (see Development of Lymphatic m).

Structure of Lymphatic Glands.

lymphatic gland consists of a capsule, which encloses the glandular sube. The capsule is composed of connective tissue, containing elastic fibres.

ie glandular substance presents two parts—superficial or cortical, and

al or medullary. Each of these parts is permeated by a supporting frarneof trabeculae derived from the capsule. Ihese trabeculae are composed o active tissue, with a few plain muscular fibres. They subdivide the cortex follicles, between which they form incomplete septa. In the medulla the

culae are arranged in a reticular manner. .. ,

be glandular substance is formed by lymphoid or adenoid tissue, wnic sts of retiform tissue, with lymphocytes in its meshes. In the cortex o


1140


A MANUAL OF ANATOMY


the gland this lymphoid tissue is disposed as lymph-follicles, and in the m it forms lymph-cords. In both parts of the gland there are spaces betwe< glandular substance and the supporting trabecular framework. These s which are for the passage of lymph, constitute the lymph-sinus. This si broken up at all parts of the gland by retiform tissue, the meshes of whi partially lined with branched cells of the nature of phagocytes. The glai substance, except the lymph-sinus, is permeated by blood-capillaries.

Lymphatic glands are furnished with bloodvessels, nerves, and lym vessels. The arterioles pass to the glandular substance, being at first enshe by the supporting trabeculae of connective tissue, and subsequently by the re tissue of the glandular substance. The nerves are destined for the plain mu tissue of the trabeculae and bloodvessels.

The lymphatic vessels are of two kinds—afferent and efferent. The a vessels enter the gland over its surface, whilst the efferent vessels emerge definite part of the gland, where there is a slight depression, called the t The afferent vessels convey lymph to the cortical part of the lymph-sinus, the efferent vessels convey lymph from the medullary part of that sinus, much as the medullary part of the gland extends quite to the surface at the where the depression, known as the hilum, exists, the efferent vessels e from the gland through this hilum, which also gives passage to the arterie veins.

Development. —Lymphatic glands are developed partly from the prii lymph-sacs and partly from peripheral lymphatic vessels (see Developm* Lymphatic System).


CHAPTER XIV

THE HEAD AND NECK


BACK OF THE SCALP AND NECK.

andmarks. —The external occipital protuberance can, as a rule, be

out readily enough in the male, and the superior nuchal line,

ill developed, may be felt extending outwards from it. The oid process of the temporal bone can be distinguished without ulty behind the auricle. The occipital artery, with the greater iital nerve on its inner side, lies about inches to the outer side e external occipital protuberance. The occipital lymphatic gland, [ands, may be felt, when enlarged, over the upper part of the izius or semispinalis capitis muscle. The spine of the seventh cal vertebra, or vertebra prominens, can easily be felt, and that le sixth may also be made out. Extending from the external )ital protuberance to the seventh cervical spine there is an elonI depression, called the nuchal furrow, which indicates the position tie ligamentum nuchse. It is possible to feel the strong bifid 3 of the axis by sinking the finger deeply into the upper part of luchal furrow near the occipital bone, but the spines of the third, Hi, and fifth cervical vertebrae lie too deeply for detection. Lymic glands may be felt, when enlarged, along the posterior border le sterno-mastoid muscle.

Jack and Side of the Neck—Fasciae. —The superhcial fascia presents ing worthy of note. The deep fascia closely invests the cervical ion of the trapezius, and is then prolonged over the posterior lgle of the neck to the posterior border of the sterno-mastoid, re it divides to ensheathe that muscle. It will be described in lection with the deep cervical fascia.

Jutaneous Nerves. —The nerves of this region are as follows: the )Ccipital; the greater occipital; the third occipital; the medial iches of the posterior primary rami of the third, fourth, and fifth ical spinal nerves; the lesser occipital; the great auricular; the rior cutaneous nerve of neck; and the descending superficial iches of the cervical plexus—namely, the supraclavicular nerves Fig. 687).

Die suboccipital nerve is the posterior primary ramus of the first ical nerve; it only occasionally supplies the skin on the outer of the greater occipital area.

Fhe greater occipital nerve is the medial branch of the posterior lary ramus of the second cervical nerve. It pierces the upper

1141


1142


A MANUAL OF ANATOMY


part of the semispinalis capitis muscle, and sometimes the trape2 about -J inch from the middle line. It then runs upwards, with inclination outwards, and accompanies the occipital artery to the era integument, lying on the inner side of that vessel. Its branches long, and have an extensive distribution, reaching as far as the vei of the skull. Laterally it communicates with the small occif nerve, and medially with the third occipital.

The third occipital nerve is a small offset from the me branch of the posterior primary ramus of the third cervical ne Having pierced the trapezius, it ascends medial to the gre; occipital nerve, with which it communicates, and has a lim distribution to the occipital integument inside that nerve.

The medial bran< of the posterior prin rami of the third, fou and fifth cervical ne; appear through trapezius close to middle line, and t outwards to supply skin of the back of neck, that of the tl furnishing, as j stated, the third c pital nerve.

The lesser occij nerve is one of the cending superfw branches of the cerv plexus, and arises fi the anterior prim ramus of the sec cervical nerve, so times receiving a bra from that of the third. It appears at the posterior border of the stei mastoid muscle, and ascends along that border to the occipital reg Here it divides into mastoid and occipital branches, which supply skin of the mastoid, outer part of the occipital, and adjacent porl of the parietal regions. It furnishes an auricular branch to the 5 of the upper part of the inner surface of the auricle, and it commi cates with the greater occipital, the posterior branch of the gi auricular, and the posterior auricular branch of the facial, lesser occipital nerve is sometimes double, and in these cases one port of it usually pierces the anterior border of the trapezius.

The great auricular nerve, like the lesser occipital, is one of ascending superficial branches of the cervical plexus, and arises two roots from the anterior primary rami of the second and tl cervical nerves. It turns round the posterior border of the stei


Occ. Front.

G. Occ. N. Third Occ. N. Less. Occ. N.


Fig. 687.—To show the Nerves and Vessels on the Back of Scalp and Neck.












THE HEAD AND-NECK


ii 43


istoid immediately below the lesser occipital nerve, and passes wards and forwards upon that muscle towards the lobule of the ricle, on approaching which it divides into anterior and posterior anches. The posterior branch is distributed to the skin over the istoid region, the skin of the inner surface of the auricle, and sends e or two twigs through the cartilage of the auricle to the skin covery the lower part of the outer surface; and the anterior branch is dis

Auricularis Anterior


Auricularis Superior


Auricularis Posterior


Occipital Belly of Occipito-frontalis

Greater Occipital Nerve Semispinalis Capitis Lesser Occipital Nerve

Splenius Capitis


Levator Scapulae

Great Auricular Nerve

Accessory Nerv e anches from Third and Fourth Cervical Nerves to Trapezius Scalenus Medius


Lateral Supraclavicular Nerve


Trapezius


' Frontal Belly of Occipitofrontalis


Orbicularis Oculi

Levator Labii Superioris Alaeque Nasi

Levator Labii Superioris - Zygomaticus Minor Zygomaticus Major

Masseter Orbicularis Oris Depressor Labii Inferioris _ Depressor Anguli Oris Mentalis

Anterior Belly of Digastric Stemo-hyoid

Superior Belly of Omo-hyoid Sterno-mastoid

Anterior Cutaneous Nerve of the Neck

— Medial Supraclavicular Nerve

— Intermediate Supraclavicular Nerve


Scalenus Anterior

»

Inferior Belly of Omo-hyoid Subclavian Artery (third part)

Fig. 688.—The Right Side of the Head and Neck. The platysma has been removed, and the nerves are shown.


ibuted to the skin over the parotid gland and angle of the jaw. The )sterior branch communicates with the lesser occipital and posterior lricular nerves, and the anterior branch communicates in the parotid and with the facial nerve.

The anterior cutaneous nerve of the neck (transverse cervical irve), like the lesser occipital and great auricular, is a superficial 'anch of the cervical plexus, and arises by two roots from the anterioi










ii 4 4


A MANUAL OF ANATOMY


primary rami of the second and third or third and fourth cervic nerves. It appears at the posterior border of the sterno-mastc close below the great auricular, and turns over that muscle deep the external jugular vein to reach the front of the neck, where it w be afterwards described.

The supraclavicular nerves from the cervical plexus appear at t posterior border of the sterno-mastoid below the accessory, usua] as a single trunk which arises by two roots from the anterior prima rami of the third and fourth cervical nerves or from the fourth alor This trunk, as it descends, divides into three branches—name] medial, intermediate, and lateral —which pass downwards over t clavicle, and will be afterwards referred to.

Deeper Structures.

Ligamentum Nuchse. —This is a strong fibrous band which occupi the median line of the neck. Its superficial fibres are attached superior to the external occipital protuberance, and interiorly to the spi of the seventh cervical vertebra. Its deep fibres are attached the external occipital crest, and to the spines of cervical vertebr from the second to the sixth inclusive. They also extend into t interspinous intervals between the interspinales muscles, where th represent interspinous ligaments.

Muscles—Cervical Portion of the Trapezius — Origin. —fi) T inner third of the superior nuchal line of the occipital bone, and t] external occipital protuberance; and (2) the ligamentum nuchse.

Insertion. —(1) The posterior border of the outer third of ti clavicle; and (2) the inner border of the acromion process of t] scapula.

Nerve-supply. — (1) The accessory nerve (spinal root); ai (2) branches from the cervical plexus, which are derived from t] anterior primary rami of the third and fourth cervical nerves. T] nerves enter the deep surface of the muscle after passing benea its anterior border a little above the clavicle, and they here for a plexiform communication with each other.

Blood-supply .—The superficial branch (superficial cervical arter of the transverse cervical artery ramifies on and gives branches the deep surface of the muscle.

The fibres are directed downwards, forwards, and outwards.

This part of the muscle lies on the semispinalis capitis just belo the occiput, and below this on the splenius and levator scapuke; tl superficial branch of the transverse cervical artery and superfici branch of the ramus descendens (arteria princeps cervicis) of tl occipital artery anastomose deep to it, and its nerves enter it. As approaches its insertion its fibres lie over the supraspinatus, a fati pad being interposed.

Action .—The cervical fibres, acting from their origin, elevate tl outer end of the clavicle and the point of the shoulder. Acting froi


Fig. 689. —Dissection to show Muscles on Back of Neck.

Insertion and Posterior Border of the Sterno-mastoid.—This muscle nserted into (1) the outer surface of the mastoid process of the poral bone, and (2) the superior nuchal line of the occipital bone r about its outer half, or more. The posterior border of the $cle forms the anterior boundary of the posterior triangle of the k, and has the following nerves related to it: (1) the lesser occipital snds along it to the head; (2) the great auricular passes upwards


THE HEAD AND NECK


1145


r insertion they extend the head, and incline the neck towards same side, the face being directed towards the opposite side.

The anterior border of the muscle forms the posterior boundary he posterior triangle of the neck.

)ccasionally a small muscle, called the transversus nuchse, is met with, nding from the external occipital protuberance to the tendon of insertion le sterno-mastoid. It may be fleshy or tendinous.


Cut. Muscles Longiss. Cap. Semispin. Cap.


Splenius Cerv. Levator Scap.


Semisp. Cap. Sterno-mastoid Splenius Cap.












1146


A MANUAL OF ANATOMY


and forwards superficial to it towards the lobule of the auricle; (3) anterior cutaneous nerve of the neck crosses it in a forward directi (4) the accessory appears from behind it, along with the branc of the third and fourth cervical nerves to the trapezius; and (5) supraclavicular branches of the cervical plexus emerge from unt neath it.

Some deep cervical lymph glands are situated along the poste border of the sterno-mastoid muscle. They will be described h (see p. 1199).

The levator scapulae, rhomboids, serratus posticus super splenius, semispinalis capitis, longissimus cervicis, longissimus cap: semispinalis cervicis, intertransversales, and interspinales muscles be found described in connection with the muscles of the back 1 p. 400 et seq.).

Second and Third Parts of the Occipital Artery. —At the mast process this vessel lies very deeply. Having crossed the rectus cap lateralis muscle, it enters the occipital groove on the inner aspeci the mastoid process, where it is covered by the following structu in order from the surface inwards: (1) sterno-mastoid; (2) spier capitis; (3) longissimus capitis; (4) mastoid process; and (5) posterior belly of the digastric. In its backward course the ve rests in succession upon the insertions of the obliquus capitis supe and semispinalis capitis, and it escapes from beneath the musi covering it in the following order: posterior belly of the digast longissimus capitis, splenius capitis, and sterno-mastoid. A emerging from beneath the last-named muscle, it lies for a little the posterior angle close to the apex, and then, frequently pierc the occipital origin of the trapezius, it enters upon the third pari its course. This part ascends along with the greater occipital ne to the occipital region, where it divides into several long tortu branches (Figs. 690 and 691).

Branches. —The branches of the second and third parts are follows: mastoid, meningeal, descending, communicating, muscu and occipital. The mastoid branch passes through the mast foramen when there is one on the outer surface of the mastoid proc and supplies the diploe and mastoid air-cells, as well as the adjac dura mater. The meningeal branches enter the cranial cavity throi the jugular foramen, and take part in the supply of the dura me of the posterior fossa. The descending branch (arteria princeps cervi< arises under cover of the splenius capitis, and at the outer bor of the semispinalis capitis it divides into a superficial and deep brar The superficial branch is distributed to the splenius capitis and trapez and anastomoses in the latter muscle with the superficial brand the transverse cervical artery. The deep branch passes deep to semispinalis capitis, and anastomoses upon the semispinalis cerv. with (1) the deep cervical artery, a branch of the costo-cervical tm and (2) branches of the vertebral artery. The communicating branc enter the suboccipital triangle, where they anastomose with branc


THE HEAD AND NECK


1147


the vertebral artery. The muscular branches supply the contiguous iscles. The occipital branches, which are the terminal branches,

at first two in number, but these soon divide into several long

tuous branches, which supply the occipital belly of the occipitontalis and the integument as high as the vertex. They anastomose


g. 690. — To show Course of Occipital Artery (OA) as a Dotted Line on

the Under Side of Skull.

passes deep to mastoid process and muscles attached to this (digastric, longissimus capitis, sterno-mastoid, and splenius). It is lateral to rectus lateralis (RL), rectus major (R.Mj), superior oblique (SO), and semispinalis capitis (SSC). It emerges between splenius and trapezius (T).

th one another, with the posterior auricular, the posterior branch the superficial temporal, and their fellows of the opposite side.

The occipital venous plexus communicates with the posterior iricular and the posterior branch of the superficial temporal veins, receives the parietal emissary vein, which emerges through the





1148


A MANUAL OF ANATOMY


parietal foramen, and so a communication is established with t] superior sagittal sinus; a communication is also formed with tl sigmoid sinus by means of the mastoid emissary vein through tl mastoid foramen. Sometimes it receives a small occipital emissa\ vein which emerges through an opening at the external occipit protuberance, and then a communication would be established wii the confluence of the sinuses.

Two or three occipital veins leave the occipital plexus. Tl external vessel is known as the posterior external jugular vein. Havii

been reinforced by tributaries from the superficial structures at tl upper part of the back of the neck, the posterior external jugular ve passes on to the sterno-mastoid, where it opens into the extern jugular. The middle occipital vein (inconstant) accompanies tl occipital artery, and usually opens into the internal jugular. Tl internal occipital vein, having in some cases pierced the trapeziu passes beneath the semispinalis capitis, and enters the suboccipit triangle. In this situation it joins the suboccipital plexus, from whi( the deep cervical and vertebral veins emerge.

Occipital Lymph Glands. —These glands are usually two in numbe and he superficial to the occipital portion of the trapezius, or the upp part of the semispinalis capitis. They receive their afferent lymphati from the back part of the scalp, and their efferent lymphatics pass the deep cervical glands.

Deep Cervical Artery. —This vessel is in most cases a branch of tl costo-cervical trunk of the second part of the subclavian. Havii passed backwards between the transverse process of the seveni cervical vertebra and the neck of the first rib, it ascends upon tl semispinalis cervicis, under cover of the semispinalis capitis, towar< the level of the spine of the axis, where it anastomoses with the de( branch of the ramus descendens of the occipital. In its course furnishes a spinal branch, which enters the vertebral canal throu^ the intervertebral foramen for the eighth cervical nerve, and mu cular branches, which anastomose with branches of the vertebr artery.

The deep cervical vein begins within the suboccipital triangle the suboccipital plexus, which receives the internal occipital vei It descends in company with the deep cervical artery to the low' part of the neck, where it passes forwards between the transver: process of the seventh cervical vertebra and the neck of the first ri and ends by joining the vertebral vein just before that vessel terminate in the innominate vein.

In addition to the muscular branches of the occipital and dee cervical arteries, the deep muscles of the back of the neck receh twigs from the second part of the vertebral artery, which travers* the foramina transversaria of the upper six cervical vertebrae. The: twigs pass backwards through the intertransverse spaces, and anas! mose with branches of the ramus descendens of the occipital artei and the deep cervical artery.



THE HEAD AND NECK


1149


Suboccipital Region—Muscles—Rectus Capitis Posterior Major

Origin .—The ridge leading to one of the tubercles in which the ne of the axis ends.

Insertion .—The outer part of the inferior nuchal line of the occipital ne, and the subjacent area.


Nerve-supply .—The posterior primary ramus of the suboccipital rve.

The direction of the fibres is upwards and outwards, in spite of its ime.

Action. —(1) To rotate the face towards the same side; and (2) to tend the head.






















A MANUAL OF ANATOMY


1150

The muscle is pyramidal, and its insertion is largely covered the obliquus capitis superior.

Rectus Capitis Posterior Minor— Origin.— The posterior arch the atlas close to the tubercle.

Insertion. —The inner third of the inferior nuchal line of the occipi bone, and the subjacent area as low as the foramen magnum.

Nerve-supply .—The posterior primary ramus of the suboccipi nerve.

The direction of the fibres is upwards in an expanded manner.

Action. —To extend the head.

The muscle is fan-shaped, and lies deeper than, and medial the rectus capitis posterior major.

Obliquus Capitis Inferior — Origin.- —The outer and upper aspect the spine of the axis.

Insertion. —The lower surface of the transveise process of the at at its back part.

Nerve-supply. —The posterior primary ramus of the suboccipi nerve.

The direction of the fibres is outwards and slightfy upwards.

Action .—To rotate the atlas along with the head, so that the fa looks towards the same side.

The muscle is thick and fleshy. At its origin it is interpos between the rectus capitis posterior major superiorly and the high bundle of the semispinalis cervicis interiorly. The greater occipi nerve winds round its lower border.

Obliquus Capitis Superior — Origin. —The upper surface of the trai verse process of the atlas at its back part.

Insertion .—The occipital bone between the outer parts of i superior and inferior nuchal lines.

Nerve-supply. —The posterior primary ramus of the suboccipi nerve.

The direction of the fibres is upwards and very slightly inwards.

Action .—(1) To extend the head, and (2) to act as a slight late flexor of the head.

The muscle is triangular.

Suboccipital Triangle. —This triangle is situated under cover of 1 upper part of the semispinalis capitis close below the occipital bone.

Boundaries — Supero-medial. —The rectus capitis posterior maj External. —The obliquus capitis superior. Inferior. —The obliqi capitis inferior. The roof is formed by the semispinalis capitis a longissimus capitis, and the floor by half of the posterior arch the atlas and half of the posterior atlanto-occipital membrane. * contents are (1) the third part of the vertebral artery, (2) the si occipital plexus of veins, and (3) the posterior primary ramus of first cervical nerve. The greater occipital nerve turns upwards rou the inferior oblique and crosses the inner part of the triangle deep the semispinalis capitis, and the deep division of the ramus descend* of tde occipital artery runs down near this.


THE HEAD AND NECK


1151


lird Part of the Vertebral Artery. —The vertebral artery, having i through the foramen transversarium of the atlas, enters upon bird part of its course, and takes a winding course backwards


Recti Capitis Posteriores Minores


Rectus Capitis Posterior Major


Tubercle on Posterior Arch of Atlas


Spine of Axis-

Interspinales


,Suboccipital Triangle


Obliquus Capitis Superior


’-.Mastoid Process


Vertebral Artery (Third Part)

Posterior Primary Ramus of Suboccipital Nerve ' Transverse Process of -- Atlas

* Obliquus Capitis Inferior Greater Occipital Nerve


Semispinalis Cervicis (upper two bundles)


Fig. 692.—The Suboccipital Triangle.


inwards. It lies in the vertebrarterial groove of the atlas, the

rior primary ramus of the first cervical nerve being beneath it,

it passes under an arched band of the posterior atlanto-occipital


693.—Atlas seen from Above, to show Position of Vertebral Artery

and Suboccipital Nerve.

hrane, which is sometimes ossified. It thus leaves the suboccipital igle, pierces the dura mater, and enters the cranial cavity through oramen magnum. The third part of the vessel furnishes muscular






1152


A MANUAL OF ANATOMY


branches to the adjacent muscles, which anastomose with the rai descendens of the occipital and the deep cervical of the costo-cerv trunk.

Suboccipital Plexus of Veins. —This plexus is formed by bram which proceed from (i) the vertebral venous plexuses, (2) the adjat muscles, and (3) the occipital periosteum. It receives the inte: occipital vein, and the blood is conveyed away from it by the d cervical vein, already described, and the vertebral vein, which wil afterwards considered.

Posterior Primary Division of the First Cervical or Suboccii Nerve. —This division passes backwards as a single nerve in the ve brarterial groove of the atlas, lying between the bone and the tl part of the vertebral artery. On entering the suboccipital triangl divides into branches which supply the obliqui, recti posteriores, semispinalis capitis muscles. A filament joins the greater occip nerve.

Posterior Primary Rami of the Cervical Spinal Nerves.—

cervical nerves are eight in number, the first being known as the s occipital nerve. Each breaks up into an anterior and a poste primary ramus. The posterior primary ramus of the first or s occipital is single, and has just been described. The posterior prim rami of the lower six arise in the intervertebral foramina, and e soon divides into a lateral and medial branch. The upper two cerv nerves make their exit behind the articular masses, and their poste primary rami cross the vertebral arches behind these; the second div: into medial and lateral branches. The lateral branches of all are tributed to the deep muscles, and do not become cutaneous. medial branch of the posterior primary ramus of the second, whic of large size, constitutes the greater occipital nerve. It winds nr the lower border of the obliquus capitis inferior, and pierces semispinalis capitis, to which it gives branches. Later it r pierce the trapezius to reach its cutaneous distribution, which been already described. The medial branches of the third, fou: and fifth are directed inwards superficially to the semispin cervicis, to which, as well as to the semispinalis capitis, they { branches. Close to the cervical spines they pass backwards me^ to the spinalis capitis (biventer cervicis), and, having pierced splenius and trapezius, they reach the integument, which they sup] The medial branch of the posterior primary ramus of the third, be] piercing the trapezius, gives off a small ascending branch, knowr the third occipital. It passes upwards, lying at first under cove: the trapezius, and then passing through it to reach the occipital inte ment. The medial branches of the posterior primary rami of sixth, seventh, and eighth are directed inwards towards the cerv spines beneath the semispinalis cervicis, and are distributed to adjacent muscles. They do not furnish any branches to the inte ment.



THE HEAD AND NECK


ii53


The Scalp and Temporal Region.

ascise. —The place of the deep fascia beneath the skin may be to be taken by the epicranial aponeurosis of the occipito-frontalis

le. The aponeurosis becomes thin and fascial over the temporal

ns. Where it is thick and aponeurotic it is firmly attached to overlying skin by fibrous processes, between which are small r lobules, so that the subcutaneous laver is firm and somewhat ular in appearance. The vessels and nerves are distributed in this

  • , which loses its fibrous nature in the temporal regions and becomes

lerficial soft fatty layer.

uperficial Nerves and Vessels. —The superficial nerves of the ero-lateral aspect; the greater, small, and third occipital nerves; the mastoid branch of the great auricular , have been described idy. In the fronto-parietal region two sensory nerves are met —namely, the supra-orbital and supratrochlear —both of which lerived from the frontal nerve, which is one of the branches of the

halmic division of the fifth cranial nerve. In the temporal region

the temporal branches of the facial nerve , the auriculo-temporal


1 n

u 6 Uf.

  • Y «r


Skull


Fig. 694.—Diagram of Section through Scalp.


e, and the zygomatico-temporal nerve. Of the arteries of the p, the third part of the occipital artery, in the posterior region, has 1 described. Those of the fronto-parietal region are three in ber—namely, the supra-orbital , supratrochlear , and anterior branch he superficial temporal. The superficial temporal artery ramifies he side of the head in the temporal region.

Qie supra-orbital nerve, which is of large size, leaves the orbit •ugh the supra-orbital foramen. It then ascends, lying at first ) to the upper part of the orbicularis oculi and the frontal belly he occipito-frontalis muscle, but subsequently piercing the latter cle in two branches, medial and lateral. The lateral branch is the er of the two, and its offsets extend as far back as the lambdoid ire. As the supra-orbital nerve passes through the supra-orbital 'h it furnishes one or two twigs to the mucous membrane of the tal sinus and to the diploe of the frontal bone, and after leaving notch it sends downwards branches to the integument of the upper id. After this the nerve supplies the integument of the frontoetal region.

rhe medial and lateral branches of the supra-orbital nerves sometimes leave orbit separately, and each may form a notch or foramen of its own.








A MANUAL OF ANATOMY


1154

The supratrochlear nerve, which is of small size, is medial to supra-orbital nerve. It leaves the orbit close to the medial angi process of the frontal bone, where it lies above the pulley of the s-upe oblique muscle of the eyeball. It then ascends deep to the upper j of the orbicularis oculi and the frontal belly of the occipito-front muscle, and, piercing the former muscle, it has a limited distribui to the frontal integument close to the median line. As the nt leaves the orbit it furnishes twigs to the inner part of the integurr of the upper eyelid.

The supra-orbital artery is a branch of the ophthalmic, and emei from the orbit with the supra-orbital nerve. It is distributed to structures covering the frontal bone, and anastomoses with the su] trochlear branch of the ophthalmic artery and the anterior brand the superficial temporal artery. In the supra-orbital notch it fumis one or two branches to the mucous membrane of the frontal sinus to the diploe of the bone, and after leaving the notch it sends do wards branches to the integument of the upper eyelid (Fig. 698).

The supra-orbital vein passes downwards and inwards to a p( just above the medial angle of the orbit, where it joins the suj trochlear vein. In this manner the angular vein is formed, whic the commencement of the anterior facial vein. The supra-orbital ^ receives tributaries from the frontal region and the upper eyelid, ; in the region of the medial angle of the orbit it communicates with superior ophthalmic vein. It also communicates with the supe ophthalmic vein through the supra-orbital notch, and this commun tion receives the frontal diploic vein, which returns the blood from diploe of the frontal bone and mucous membrane of the frontal sir

The supratrochlear artery (frontal artery), like the supra-orbita a branch of the ophthalmic, and leaves the orbit with the supratroch. nerve. It is distributed to the structures over the frontal bone me* to the supra-orbital artery, with which it anastomoses, as well as v its fellow of the opposite side.

The supratrochlear vein (frontal vein), of large size, passes do wards near the median line, and at a point just above the medial ar of the orbit is joined by the supra-orbital vein, the resultant ve being the angular vein. At the root of the nose it communicates v its fellow of the opposite side by a transverse vessel, called the m arch.

The supra-orbital and supratrochlear veins communicate with e other, and with the tributaries of the anterior branch of the superfi temporal vein.

Occipito-frontalis. —This muscle consists of the following pa (1) two occipital bellies, (2) two frontal bellies, and (3) the epicra aponeurosis.

Each occipital belly arises from (1) the highest nuchal line of occipital bone; and (2) the outer surface of the mastoid process of 1 temporal bone immediately above the insertion of the sterno-mas muscle.



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Insertion .—The epicranial aponeurosis.

Each belly forms a thin, broad sheet, the length of the fasciculi Lg about ij inches. The two bellies, right and left, are separated ards the median line by a portion of the epicranial aponeurosis, ch here dips down between them.

Each frontal belly, right and left, is separated superiorly by a row angular portion, of the epicranial aponeurosis, but interiorly / are in contact. Origin .—(1) The subcutaneous tissue of the


Fig. 695.—To show Occipital Belly of Occipito-frontalis.

)row and root of the nose, where the fibres blend with the upper - of the orbicularis oculi and the corrugator supercilii; and (2) slightly 1 the zygomatic process of the frontal bone, and from the nasal

e.

Insertion ,—The epicranial aponeurosis a little below the level of fronto-parietal suture.

Hie fasciculi are about 3^ inches long, and the innermost fibres riorly are regarded by some as being prolonged downwards upon nasal bone as the procerus muscle.





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1156

Epicranial Aponeurosis. —This is the intermediate tendon of occipito-frontalis muscle. It forms an aponeurotic stratum ben< the superficial fascia, and is connected firmly to the skin by fib processes, which separate the subcutaneous tissue into lobules, deep surface is loosely connected by areolar tissue to the subja* periosteum. Posteriorly it gives insertion to the two occipital be and in the interval between these it dips down to be attached to inner part of the superior nuchal line of the occipital bone and external occipital protuberance. Anteriorly it gives insertion to two frontal bellies. Laterally, below the superior temporal : it is prolonged downwards over the temporal fascia as a deh


Fig. 696. —Shows Frontal Portion of Occipito-frontalis.

expansion, which gives origin to the auricularis superior and auricul anterior muscles. It is connected to the superior temporal line I thickening of the loose areolar tissue between it and the bone.

Nerve-supply .—Each occipital belly is supplied by the poste auricular branch of the facial nerve, and each frontal belly is supp by the temporal branches of the facial nerve.

Action .—The two occipital bellies draw backwards the epicra aponeurosis, and along with it the scalp. The two frontal bellies from above, elevating the eyebrows, and throwing the skin of frontal region into transverse wrinkles. When the occipital and fro' bellies act simultaneously the scalp is drawn backwards, and eyebrows are forcibly raised. In certain cases the frontal bellies 1









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ii57


n the reverse direction, their lower attachment being fixed by other muscles, such as the orbicularis oculi, corrugator supercilii, and crus. When this is done the scalp may be alternately twitched r ard and backward, a simian habit which may be acquired by

tice.

Pericranium. —This is the periosteum of the cranium, and it is sly connected by areolar tissue to the superjacent epicranial leurosis.


Parotid Duct. Buccinator Muscle_

Facial Artery Submental Artery

Lingual Artery Sup. Lar. Art. and Nerve Thyro-hyoid Muscle Superior Thyroid Artery


Inf. Belly of Omo-hyoid

Subclavian Artery (third part)


Transverse Facial Artery


Superficial Temporal Artery

- Maxillary Artery


Posterior Auricular Artery


Occipital Artery


-Stylo-hyoid Muscle


-Post. Belly of Digastric

-Hypoglossal Nerve

-Nervus Descendens

Cervicalis External Carotid Artery


Stemo-mastoid — Trapezius


_Transverse Cervical Artery

-.Suprascapular Artery


Fig. 697. —The Left Side of the Head and Neck. The platysma has been removed.


The temporal branches of the facial nerve pass upwards a little in tt of the auricle, and supply the following muscles: the frontal Y of occipito-frontalis, upper part of the orbicularis oculi, corrusupercilii, auricularis superior and auricularis anterior. They municate with the auriculo-temporal, zygomatico-temporal, and 'a-orbital nerves.

Hie auriculo-temporal nerve is a branch of the mandibular nerve, 'h is the third division of the fifth cranial nerve. It emerges just nd the capsule of the mandibular joint, turns upwards round the of the zygoma, and ascends immediately in front of the auricle in









A MANUAL OF ANATOMY


1158

company with the superficial temporal artery, lying between that, ves and the auricle

Branches.—In this part of its course the nerve furnishes following branches! (1) two branches to the external auditory meat which enter the canal between its osseous and cartilaginous walls, a supply the integument of the meatus, the upper of the two branc. giving an offset to the tympanic membrane; (2) two auricular brand which supply the skin of the tragus and outer aspect of the auri over less than its upper half; and (3) superficial temporal brand which supply the integument above and in front of the auricle, and the temporal region generally.

The zygomatico-temporal nerve (temporal branch of temporo-ma nerve) from the maxillary is of small size, and pierces the tempc fascia about 1 inch above the anterior part of the zygoma, and cl behind the frontal process of the zygomatic bone. Having cc municated with one of the temporal branches of the facial nerve has a limited distribution to the integument of the anterior part the temporal region.

The superficial temporal artery is one of the terminal branches the external carotid artery, from which it arises within the pare gland on a level with the neck of the mandible. Leaving the gla it ascends in front of the auricle in company with the auriculo-tempc nerve, which lies between the vessel and the auricle, and after a cou of about 2 inches it divides into its two terminal branches.

Branches.—These are as follows: (1) transverse facial; (2) articul (3) auricular; (4) middle temporal; (5) zygomatic; and (6) termina namely, anterior and posterior.

The transverse facial artery will be described in connection w the face. It arises within the parotid gland, and in its course furnis glandular branches. The articular branches supply the mandiby joint. The auricular branches supply the outer aspect of the auri' and in part the external auditory meatus. The middle tempc artery pierces the temporal fascia immediately above the zygoma, c then ascends in a groove on the outer surface of the squamous p of the temporal bone deep to the temporalis. It gives branches to temporalis, and anastomoses with the deep temporal branches of maxillary artery. The zygomatic artery passes forwards close above zygoma, where it lies between the two layers of the temporal fas< It is distributed to the outer part of the orbicularis oculi muscle, anterior branch passes forwards and upwards in a tortuous man: and is distributed to the structures covering the frontal bone, wher anastomoses with the supra-orbital and supratrochlear branches 0T ophthalmic artery, and with its fellow of the opposite side, posterior branch takes an arched course upwards and backwa above the auricle, supplying the adjacent structures, and anas mosing with the posterior auricular and occipital arteries, and v its fellow of the opposite side (see Fig. 698).

The arteries of the scalp are peculiar in many ways. In the f


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they are very superficial, lying in the fatty layer of the scalp

deep to the skin; they are thus very liable to injury, and in old le, where their walls are hardening and the superficial fat diminishthey may easily be seen in the temporal region, n the second place they are very tortuous, a condition which is lly associated with arteries supplying movable parts, and in ige this tortuosity increases.

'hirdly, they not only anastomose with one another, as most 'ies do, but they anastomose freely across the middle line, thus lg wonderful vitality to a piece of scalp which has been torn away >st completely.


L. Testut’s ‘ Anatomie Humaine ’).

fourthly, when cut they bleed most profusely, because their walls prevented from collapsing by the dense connective tissue between skin and the epicranium in which they lie. For this reason, too, difficult to pick them up when they have to be tied, fhe superficial temporal vein is formed in front of the auricle by union of an anterior and a posterior branch, the former communing freely with the supra-orbital and supratrochlear veins, and the T with the posterior auricular vein and the occipital venous plexus, ve the zygoma it is joined by the middle temporal vein, which inates in a plexus in the temporal fossa, and pierces the temporalis temporal fascia, receiving in its course the zygomatic vein. The Official temporal vein then descends over the zygoma and enters





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A MANUAL OF ANATOMY


the parotid gland, within which it receives the auricular, articu and transverse facial veins. Finally, it joins the maxillary vein ah the level of the neck of the mandible to form the posterior facial's (temporo-maxillary vein).

Extrinsic Muscles of the Auricle.—These are three in number, follows: (i) auricularis superior; (2) auricularis anterior; and (3) aur: laris posterior.

Auricularis Superior (Attollens Aurem)— Origin. —The lateral par the epicranial aponeurosis and temporal fascia.

Insertion. —The inner or cranial surface of the auricle over convexity corresponding to the fossa of the antihelix on its 01 surface.

Nerve-supply. —The temporal branches of the facial nerve, posterior part of the muscle may be supplied by the posterior aurici branch of the facial nerve.

The muscle is very thin, pale, and fan-shaped, and. its fibres c verge in a downward direction.

Action. —To raise the auricle, though all the auricular muscles vestigial in man and practically functionless.

Auricularis Anterior (Attrahens Aurem)— Origin .—The lateral p of the epicranial aponeurosis in front of the auricularis superior, v which muscle it is continuous. Also from the temporal fascia.

Insertion. —The anterior part of the helix of the auricle.

Nerve-supply. —The temporal branches of the facial nerve.

The muscle is directed backwards.

Action. —To draw forwards the auricle.

Auricularis Posterior (Retrahens Aurem)— Origin. —The upper p of the outer surface of the mastoid process of the temporal bone.

Insertion. —The inner or cranial surface of the auricle over convexity of the concha.

Nerve-supply. —The posterior auricular branch of the facial nerv

The muscle is directed forwards.

Action. —To draw back the auricle.

The auricularis posterior is more distinct than the other two muse and is usually arranged in two bundles.

Behind the ear, in the mastoid region, which is not a part of scalp proper, there are certain structures which have some conned with the scalp. These comprise posterior auricular nerves (branc of the facial and vagus), posterior auricular vessels, and poste auricular lymph glands.

Posterior Auricular Nerve.—This is a branch of the facial ne; immediately after it emerges from the facial canal through the st; mastoid foramen. It passes upwards between the mastoid pro< and the auricle, where it lies deeply in company with the postej auricular artery, and it divides into two branches—auricular ; occipital. The auricular branch supplies the auricularis poste; muscle on its deep aspect, and those intrinsic muscles of the aur which lie on its inner or cranial aspect. It may also send a bra




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yards beneath the auricularis posterior to supply the posterior t of the auricularis superior. The occipital branch passes back■ds, lying deep to the lesser occipital nerve and posterior branch the great auricular, and supplies the corresponding half of the ipital belly of the occipito-frontalis muscle. The posterior auricular ve communicates with the lesser occipital and great auricular ves, and also with the auricular branch of the vagus.

The Auricular Branch of the Vagus Nerve (Nerve of Arnold). —This t branch of superior ganglion of the nerve. Having traversed the stoid canaliculus in the petrous part of the temporal bone, it srges through the tympano-mastoid fissure between the mastoid cess and tympanic plate, and then divides into two branches. One nch takes part in the supply of the inner or cranial surface of the icle, and also supplies the lower and back part of the external litory meatus; and the other branch joins the posterior auricular ve.

Posterior Auricular Artery. —This vessel is one of the two posterior nches of the external carotid artery, the other branch being the ipital artery. Having passed backwards and upwards on the loid process under cover of the parotid gland, it lies deeply between i mastoid process and the auricle in close relation to the posterior icular nerve, and divides into two branches—auricular and occipital, e auricular branch supplies the inner or cranial surface of the auricle i adjacent structures, and it anastomoses with the posterior branch the superficial temporal artery. The occipital branch passes backrds to the occipital belly of the occipito-frontalis muscle, and istomoses with the occipital artery.

The posterior auricular vein is of fairly large size, and returns the od from the lateral portion of the scalp posteriorly and the inner face of the auricle. Its radicles communicate with the occipital xus and with the posterior branch of the superficial temporal vein, e vessel passes downwards and forwards over the upper part of the rno-mastoid muscle, and terminates on this muscle about the level the angle of the mandible by joining the posterior division of the sterior facial vein to form the external jugular vein.

Mastoid Lymph Glands (Posterior Auricular Lymph Glands). These all glands lie close to the insertion of the sterno-mastoid muscle, ey receive their afferent lymphatics from the lateral part of the back the scalp and the back of the auricle, and their efferent lymphatics $s to the upper deep cervical lymph glands.

Temporal Fascia. —This is a strong aponeurosis which covers the nporalis. Superiorly it is attached from before backwards to the nporal border of the zygomatic bone, the superior temporal line of i frontal and parietal bones, and the supramastoid crest. of the nporal bone. Interiorly it divides into two laminae, which aie ached to the outer and inner margins of the upper border of the somatic arch. Between these two laminae there are a small amount adipose tissue, and the zygomatic branch of the superficial temporal


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A MANUAL OF ANATOMY


artery, and the zygomatico-temporal nerve. Superficial to the fasc there are the delicate prolongation of the lateral portion of the e] cranial aponeurosis and the auriculares superior et anterior muscl< with the superficial temporal vessels and auriculo-temporal nen Superiorly the fascia gives origin by its deep surface to superfic: fibres of the temporalis, but it is separated from that muscle towar the zygoma by fat.

The temporalis muscle is described on p. 1302.

Lymphatic Vessels of the Scalp—Frontal Region. —These pass the parotid lymph glands. The anterior lymphatics pass directly the parotid lymph glands, and the posterior lymphatics terminate in t mastoid lymph glands.

The Scalp as a Whole. —Before leaving the scalp it may be w< to review its general structure and to notice that it is made up of fi layers.

(1) The skin is very thick, and nee^6 a firm incision to penetrate:

(2) The subcutaneous tissue binds the skin closely to the epicrani aponeurosis, with which it moves; it contains lobular, granulated f in which are the bloodvessels and nerves as well as the roots of t. hair follicles. On account of the presence of the nerves as well as of t. density of the connective tissue any suppuration in this layer will strictly localized and very painful.

(3) The epicranial aponeurosis is formed by the very thin, flatten tendon of the occipito-frontalis muscle.

(4) The subaponeurotic layer, sometimes known to surgeons as t. ‘ dangerous layer * of the scalp, is composed of very loose connectf tissue, and is little more than a lymph space. The looseness of tj cellular tissue allows the first three layers to move freely over t] skull, and if septic matter reaches it and suppuration follows, t] pus readily spreads all over the space and tends to bag at the mo dependent points in front and behind. The absence of nerves and tl looseness of the tissue account for the little pain which accompani suppuration in this layer.

(5) The periosteum or pericranium covers the skull bones, and continuous with the dura mater at the sutures as long as these a unclosed. For this reason a subpericranial collection of blood pus will be limited to the area of one skull bone, while a subepicrani collection, as has been seen, has no such definition.

Basal Part of the Cranial Cavity.

Dura Mater on the Base of the Skull. —A full and general accoui of the membranes of the brain will be found on p. 1598 ^ se ^-> short description of the dura mater, as it is seen on the base of tl skull after removal of the brain, will be given here.

The dura mater is seen to be continuous with the falx cerebri in t middle line in front. Just outside this it covers the cribriform pla of the ethmoid at the bottom of a well-marked hollow which contai



THE HEAD AND NECK


1163

olfactory bulb. External to this it covers the irregularities of the tal plate of the frontal and the lesser wing of the sphenoid behind . In the middle fossa it lines the so-called ‘ optic groove/ and at

I end of this is carried into the optic foramina. Behind the groove >rms the diaphragma sella, covering the hypophyseal fossa, while

pierced by the internal carotid artery just behind the foramen.

diaphragma sellae shows a central hole for the infundibulum of hypophysis cerebri. The membrane is attached to the clinoid

esses and the interclinoid ligaments, and stretches outwards from
e to line the hollow of the greater wing and upper surfaces of the

•ous bone. It is carried upwards and forwards here to cover the erior orbital fissure and gain the lower aspect of the lesser wing, mall fold of dura mater projects from the edge of the lesser wing he sphenoid, the sphenoidal fold , and a small ‘ lunula ’ overhangs optic foramen. At the upper border of the petrous bone the nbrane projects upwards and inwards as the tentorium cerebelli, ch is a two-layered reflection of the dura mater. Below the torium it lines the posterior fossa, and presents apertures through ch all the nerves which come from the pons and medulla pass to

h their bony foramina. A small fold, the falx cerebelli, projects

he middle line behind. The dura mater becomes continuous with spinal dura at the foramen magnum, but the exact position of this mien is not easily distinguished when the membrane is in position, ng to the smooth, continuous slope formed by it as it passes from basi-occiput over the odontoid process and its ligaments into the tebral canal.

Certain structures lie deep to the dura mater, between it and the y skull— i.e., between the inner layer, which we have been consider, and the outer layer, which covers the bones. These are venous ises, nerves, and arteries. The venous sinuses on the base of the

II are (see p. 1603 et seq. for further details):

The sigmoid, running downwards and then forwards in the posterior >a to reach the jugular foramen.

The inferior petrosal, passing forwards and upwards from the ular foramen to the apex of the petrous bone along its lower edge. The superior petrosal, running forward along the upper edge of the rous bone at the base of the tentorium cerebelli.

The cavernous, placed on the side of the body of the sphenoid ere this joins the greater wing, and formed by the junction of the ) petrosal sinuses; in front it is continuous with the superior ophImic vein and with the spheno-parietal sinus, which lies in the fold lura mater along the lesser wing of the sphenoid.

The circular sinus is a spongy venous network which surrounds

pituitary body and connects the two cavernous sinuses.

The transverse sinus lies under the central basal dura mater, and n the form of a network joining the inferior petrosal sinuses.

The cranial nerves must necessarily pierce the dura mater to ch and pass through the base of the skull, and the situations of the


1164


A MANUAL OF ANATOMY


points of passage through the membranous and bony parts do n always correspond. Those nerves which leave the skull in relati( with the greater wing of the sphenoid pass through the dura mat at points some distance behind their bony foramina, and in the inte vening parts of their courses lie deep to the inner layer of dura mate lying near or in relation with the cavernous sinus. These nerv


Frontal Sinus


Anterior Fossa


Optic Nerve Ophthalmic Artery


Oculo-motor Nerve / •


Trochlear Nerve


Region of Cavum Trigeminale

Trigeminal Nerve


Facial Nerve

Auditory Nerve

G losso-pharyngeal Nerve

Vagus Nerve


Posterior Border c Small WingofSphi


Ant. Intercav., S: Hypophysis C« 


.-Cavernous S -- Abducent N


— Middle Foss


4 - - Basilar Plex


Sup. PetrosE Sinus

Inf. Petrosa] Sinus


" Sigmoid Sin


'•Cerebellar Fossa


Accessory Nerve


Transverse Sinus


Hypoglossal Nerve]


Cerebral Fossa


Spinal]Cord j Confluence of Sinuses Occipital Sinus


Fig. 699. —The Internal Base of the Skull, showing the Cranial Nervi

and Venous Sinuses.

are the oculo-motor, trochlear, trigeminal, and abducent; the oth< cranial nerves pierce the dura mater opposite their bony foramina.

It is not quite correct to say that the cranial nerves ‘ pierce ’ the dura mat at the places where their apertures of exit are seen; they carry out with the a covering from the membrane, so that they could be described rightly 1 evaginating it. The covering layer, however, is so thin in most cases, and so soon lost in the ordinary fibrous sheath of the nerve, that little exceptk is taken to the descriptive expression ‘ piercing.' In the case of the trigemin nerve, however, the evaginated covering of dura mater is better marked, and '















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1165

he whole, looser; it envelops the roots of the nerve and the trigeminal

jlion, and is known as the cavum trigeminale (.Meckel's cave). The cavum jminale, therefore, lies between the dura and the skull. The optic nerve, eover, should not be described as ‘ piercing ’ the membrane, for the eye and lervous stalk are developmentally parts of the brain itself, and the dura er is carried along the nerve to become directly continuous with the sclerotic

of the eye, which represents the same layer.

Some other nerves, such as the superficial petrosals and the nasoiry in a part of its course, lie deep to the dura mater, and will be bribed later.

All the meningeal vessels lie between skull and dura mater, and do pierce the inner membranous layer. The only things which pass Dugh this layer are the cranial nerves and the cerebral vessels; $e last are represented by (a) the internal carotid, which, lying irst between dura and bone with the cavernous sinus, pierces the nbrane medial to the anterior clinoid process to reach the brain;

. ( b ) the vertebral arteries, which pierce the membrane below the 11 and run up through the foramen magnum to reach the brain, tain cerebral veins pierce the dura mater at various points (see p. 8 ) to open into extradural sinuses.

Hie aqueduct of cochlea is described as passing through the dura to reach subarachnoid space, and the endolymphatic duct lies between the membrane the bone.

Cranial Nerves at the Base of the Skull. —The cranial nerves are inged in twelve pairs, and as they leave the cranial cavity they five sheaths from the meninges of the brain.

The olfactory bulb rests upon one half of the cribriform plate of ethmoid bone, with dura mater interposed. Through the fora1a of that plate it receives about twenty olfactory filaments, which

e as the axons of the olfactory cells of the olfactory mucous

[nbrane of the nasal fossa.

The optic nerve passes forwards and outwards from the optic asma to the optic foramen, through which it enters the orbit. It .ccompanied by the ophthalmic artery, which lies below and lateral t. Before reaching the foramen it is crossed by the anterior cerebral ery, and the internal carotid comes through the dura mater just dnd and lateral to it.

The third or oculo-motor nerve pierces the dura mater, which ns the upper and outer wall of the cavernous sinus, a little in front the posterior clinoid process of the sphenoid bone.

The fourth or trochlear nerve, of small size, pierces the dura mater a point a little behind the posterior clinoid process of the sphenoid ie, lateral to the third nerve, and in or just beneath the free margin the tentorium cerebelli. Afterwards it traverses the outer wall of

cavernous sinus.

The fifth or trigeminal nerve consists of two roots—sensory and tor. These two roots pierce the dura mater near the apex of the rous part of the temporal bone below the tentorium, and enter


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A MANUAL OF ANATOMY


a'recess of the dura mater, called the cavurn ingeminate (Meckel's cav where they will be presently described.

The sixth or abducent nerve pierces the dura mater £ inch behi the level of the posterior clinoid process, and near the apex of t petrous bone, where it enters the inferior petrosal sinus. It lies little to the inner side of the fifth nerve.

The seventh or facial nerve, the eighth or auditory nerve, accoi panied by the internal auditory artery, enter the internal meatus.

The ninth or glosso-pharyngeal nerve, the tenth or vagus ner and the eleventh or accessory nerve pass through the middle compa:


Fig. 700.—Showing the Venous Sinuses on the Petrous Bone, and

Relation with the Trigeminal Nerve.

Also shows great superficial petrosal nerve.

ment of the jugular foramen. This foramen is divided into thi compartments—namely, antero-medial, middle, and postero-later The antero-medial compartment gives passage to the inferior petro.j sinus. The middle compartment transmits the glosso-pharyngeal, vagi and accessory nerves, in this order from before backwards. T glosso-pharyngeal nerve pierces the dura mater separately, a receives special sheaths from the dura mater and arachnoid membrai The vagus and accessory nerves pass together through a sin^ aperture in the dura mater, and receive common sheaths from t dura and arachnoid membrane. The postero-lateral compartment trai








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5 the sigmoid sinus, which terminates in the internal jugular vein, the vein is deep to the dura, this part of the foramen cannot be 1 directly when the dura mater is in position.

The twelfth or hypoglossal nerve pierces the dura mater in two dies, which pass through separate apertures. As these bundles 5 through the anterior condylar canal they unite to form one nerve, ween the points of exit of the hypoglossal and the last three nerves jugular tubercle is seen, forming a very useful landmark.

Structures passing through the Foramen Magnum. —(1) The medulla mgata, with its membranes, passes out and becomes the spinal i. (2) The spinal root of the accessory nerve of either side, having mded from the interval between the posterior roots of the cervical lal nerves and the ligamentum denticulatum, enters the cranial ity. It then turns outwards behind the jugular tubercle to the Idle compartment of the jugular foramen, where it meets the rial root of the nerve, with which it becomes closely connected it passes through the foramen. (3) The vertebral artery of each j enters the cranial cavity after having pierced the dura mater. The two anterior spinal branches of the vertebral arteries descend the front of the medulla oblongata, and, inclining inwards towards h other, they unite in passing through the foramen magnum to n the anterior spinal artery, the membrana tectoria, and the apical ment of the odontoid process.

Trigeminal Ganglion (Gasserian Ganglion) (Fig. 700).—The trilinal ganglion occupies the trigeminal impression (Gasserian imssion) on the superior surface of the petrous part of the temporal Le near the apex, where its posterior part lies in a recess of the a mater, called the cavum trigeminale ( Meckel’s cave). It is someit semilunar, being convex in front and concave behind, and measures y \ inch from before backwards. It is associated with the sensory t of the fifth nerve, which, before entering the posterior concave ect of the ganglion, becomes expanded, its fasciculi at the same e becoming separated and assuming a plexiform arrangement, lially the ganglion is intimately related to the back part of the ernous sinus, and by its inner and lower aspect to the internal otid artery in the foramen lacerum, and on this aspect it receives icate filaments from the internal carotid sympathetic plexus. The tor root of the fifth nerve, small in size, lies below the deep surface

he ganglion; but there is no blending of the two sets of fibres, the

tor root passing independently in an outward direction to the imen ovale. The greater superficial petrosal nerve, on its way to foramen lacerum, passes beneath the ganglion, though not in the r um trigeminale.

The ganglion contains cells similar to those of a spinal ganglion, 1 it receives its blood from the middle and accessory meningeal eries. It is important in connection with modern surgery to notice ■t the front part of the ganglion does not lie in the cavum trininale, but has a close investment of dura mater. Hence the front


1168


A MANUAL OF ANATOMY


part may be removed without opening the subarachnoid space allowing cerebro-spinal fluid to escape.

Branches. —The branches of the ganglion arise from its anteri convex aspect, and are known as divisions. They are as follow the first or ophthalmic division; the second or maxillary divisio and the third or mandibular division. The ophthalmic and maxilla nerves are entirely sensory, but the mandibular nerve, being join by the motor root, is both sensory and motor.

The first division of the trigeminal nerve, or the ophthalmic ner\ is the smallest of the three branches of the ganglion. It passes fc wards in the outer wall of the cavernous sinus, where it lies below t] fourth nerve. On approaching the superior orbital fissure it divid into branches in the following order from behind forwards: (i) nas ciliary (nasal), (2) lacrimal, and (3) frontal. All these three branch enter the orbit through the superior orbital fissure. As the ophthaln nerve passes forwards it receives a communicating branch from t' internal carotid sympathetic plexus, and it furnishes the nervus tento> to the tentorium cerebelli. It also communicates with each of t oculo-motor, trochlear, and abducent nerves.

The naso-ciliary nerve, having passed through the orbit, re-ente the skull by running between the orbital plate of the frontal and t' upper surface of the ethmoid. It then lies deep to the dura mater < the cribriform plate near its anterior extremity, and soon disappea by passing down between this bone and the nasal area of the frontal

The second division of the trigeminal nerve, or the maxillary ner (superior maxillary nerve), passes horizontally forwards for a she distance in the lower part of the outer wall of the cavernous sinus, ai it leaves the cranial cavity through the foramen rotundum, whi leads to the pterygo-palatine fossa. Before leaving the cranial cavi it furnishes the delicate meningeal nerve to the dura mater of tl middle fossa.

The third division of the trigeminal nerve, or the mandibular ner (inferior maxillary nerve), is the largest of the three branches of t. ganglion. It passes downwards to the foramen ovale, through whi it leaves the cranial cavity, and so enters the infratemporal foss It is accompanied by the motor root of the fifth nerve, which joi it as it passes through the foramen ovale. The nervus spinosus fre the mandibular nerve is not given off until after the parent trui has issued through the foramen ovale, and it enters the cranial cavi through the foramen spinosum in company with the middle meninge artery. It then divides into two branches, anterior and posterior. T anterior branch supplies the dura mater over the greater wing of t sphenoid bone, and the posterior branch passes through the fissr between petrous and squamous parts of the temporal bone to supp the mucous membrane of the mastoid air-cells.

Greater Superficial Petrosal Nerve. —This nerve is a branch of the gangli of the facial nerve in the facial canal. It enters the middle fossa of the be of the skull through its hiatus, and passes forwards and inwards in a groove


THE HEAD AND NECK


1169


anterior surface of the petrous part of the temporal bone. Having passed sath the trigeminal ganglion embedded in the dura mater, it enters the upper of the foramen lacerum, where it is placed on the outer side of the internal tid artery, and it joins the deep petrosal nerve from the internal carotid pathetic plexus. In this manner the nerve of the pterygoid canal is formed,

h enters the latter canal by its opening on the anterior aspect of the foramen

rum, and so reaches the spheno-palatine ganglion in the pterygo-palatine i. The greater superficial petrosal nerve is accompanied by the superficial osal branch of the middle meningeal artery.

jesser Superficial Petrosal Nerve. —This nerve represents the continuation ugh the tympanic plexus of the tympanic branch (Jacobson's nerve) of the 30-pharyngeal nerve. It is reinforced by a small branch from the ganglion he facial nerve, Avhich joins it as it traverses a small canal in the petrous of the temporal bone beneath the canal for the tensor tympani muscle, nerve enters the middle fossa through a small opening on the lateral side he hiatus for the greater superficial petrosal nerve. It then passes for a 3 forwards and inwards, and leaves the cranial cavity through the canaliculus iminatus (when present), or through the fissure between the petrous temporal the greater wing of the sphenoid, or, it may be, through the foramen ovale, r which it terminates in the otic ganglion.

External Petrosal Nerve. —This nerve, which is inconstant, passes from the pathetic plexus on the middle meningeal artery backwards and outwards

he anterior surface of the petrous part of the temporal bone, and it leaves

cranial cavity through a minute aperture situated within the thin margin tie hiatus for the greater superficial petrosal nerve. It ends in the ganglion re facial nerve.


Interior of the Cavernous Sinus.—The interior of this sinus ia ken up by a network of delicate trabeculae. The outer wall of sinus contains the following rial nerves, in order from above mwards: the oculo-motor, the ihlear, the ophthalmic division

he trigeminal, and the maxilr division of the fifth. These

ves, as they pass forwards, separated from the bloodrent by the endothelial lining the outer wall of the sinus.

J cavity of the sinus is travel by (1) the cavernous portion the internal carotid artery, rounded by a plexus of symhetic filaments; and (2) the Lucent nerve, which lies in >e contact with the outer side of the artery. These structures are ) separated from the blood-current by the endothelial lining of the is.

For the processes and other sinuses of the dura mater see p. 1601. Cavernous Portion of the Internal Carotid Artery.—This part of the irnal carotid artery lies within the cavernous sinus, which occupies carotid groove on the lateral aspect of the body of the sphenoid ie. It is separated from the blood-current by the endothelial

74


Internal Carotid Artery Abducent.Nerve Oculo-motor Nerve Trochlear Nerve Ophthalmic Nerve


Sella Turcica


Maxillary Nerve

Left Sphenoidal Sinus

Fig. 701.—Diagram of the Left Cavernous Venous Sinus and its Outer Wall, showing the Relative Positions of the Contained Structures (Posterior View).



1170


A MANUAL OF ANATOMY


lining of the sinus. The course of the vessel is at first upwan between the lingula of sphenoid and the posterior petrosal process the sphenoid; then forwards as far as the anterior clinoid process the sphenoid; and finally upwards medial to the anterior clinc process. In the latter situation it pierces the dura mater, whi forms the roof of the cavernous sinus, and enters upon the cerebi part of its course.

The vessel is accompanied by the internal carotid sympathe plexus, and the abducent nerve lies in close contact with its out side, all being invested by the endothelial lining of the sinus.


Fig. 702.—Right Internal Carotid put in Position on Base of Skui

and Crossed by Sixth Nerve.

Great superficial petrosal nerve is also seen.

Branches.—These are as follows: hypophysial, to the hypophys cerebri; ganglionic, to the trigeminal ganglion; cavernous, to the w£ of the cavernous sinus, and to the oculo-motor, trochlear, trigemim and abducent nerves; meningeal, to the dura mater of the midd cranial fossa; and the ophthalmic artery. The latter vessel arises fro: the cavernous portion of the internal carotid on the inner side of tl anterior clinoid process, and it enters the orbit, with the optic nerv through the optic foramen, lying at first beneath the nerve, and the on its outer side.

The Medial Part of the Internal Carotid Sympathetic Plexus (Caveri ous Plexus).—This plexus is situated principally on the inner and low< aspects of the bend which the cavernous portion of the internal caroti





THE HEAD AND NECK


1171


•y describes medial to the anterior clinoid process. Its branches as follows; (1) vascular, to the internal carotid artery and its ches; (2) hypophysial, to the hypophysis cerebri; (3) communing, to the oculo-motor, trochlear, ophthalmic division of the tri[nal, and abducent cranial nerves; and (4) the sympathetic root of

iliary ganglion. The last-named branch enters the orbit through

superior orbital fissure.

"he hypophysis cerebri (pituitary body) is a small oval mass which tuated in the hypophysial fossa, or sella turcica, of the sphenoid It lies under cover of a circular fold of the dura mater, called the hragma sellce, in the centre of which is an opening for the passage le infundibulum. Its long measurement extends transversely, and msists of two lobes—anterior and posterior. The anterior lobe is larger of the two, and the posterior lobe is connected with the rior part of the tuber cinereum by means of the infundibulum, rhe infundibulum projects downwards from the anterior part of tuber cinereum to the posterior lobe of the pituitary body. Its sr part is hollow, and contains mnel-shaped diverticulum of the ty of the third ventricle.

tructure. —The anterior lobe consists of ral tubules lined with epithelium, and sted by capillary bloodvessels. The jrior lobe, though developed from the 1, is destitute of nervous elements. It imposed of a reticulum of connective e, which contains branched cells. Bern the two lobes is the middle part.

)evelopment. —The anterior lobe is deped from a diverticulum of the buccal tomatodaeal ectoderm, which is known ie pouch of Rathke. The diverticulum rs upwards, and, when the cranio•yngeal canal of early life becomes closed, connection of the diverticulum with the

al ectoderm is severed. The diverurn later on becomes converted into

lies, which form the anterior lobe, dhe Brior lobe of the pituitary body and the ndibulum, which is connected with it, are sloped as a diverticulum which grows nwards from that part of the diencephalon

h forms the floor of the third ventricle. #

cavity of the diverticulum remains permanent in the upper part of its ndibular portion, but elsewhere it becomes obliterated. The lower part of diverticulum thereafter becomes converted into a reticulum of connective ie with branched cells, which forms the posterior lobe.


Fig. 703. —Diagram of Anteroposterior Section through the Hypophysis.

A, anterior lobe: PT, its pars tuberalis. Pars Interm., pars intermedia. N, neural or posterior lobe. INF, infundibulum. OPT. CH, optic chiasma.


Side of the Neck.

The side of the neck has a quadrilateral outline, the boundaries which are as follows: superior, the lower border of the mandible . a line prolonged from the angle of that bone over the mastoid


1172


A MANUAL OF ANATOMY


process to the inner third of the superior rruchal line of the occipi bone; inferior , the clavicle and one half of the upper border of 1 manubrium sterni; anterior , the middle line of the neck; and posteri the outer border of the trapezius in the neck.

Landmarks.—The body and angle of the mandible can easily felt, and the clavicle, together with the upper border of the manubrii sterni, is conspicuous. A deep depression, called the supraster: fossa, is perceptible above the upper border of the manubrium ster lying between the sternal h'eads of origin of the sterno-mastoid muscl The outline of the sterno-mastoid muscle is readily discernible when 1 head is turned so as to direct the face towards the opposite should The muscle extends in a diagonal direction from the sterno-clavicu joint to the mastoid process and outer half or two-thirds of the super nuchal line of the occipital bone, and it divides the side of the ne into two triangles—anterior and posterior. A small triangular inter may be felt between the sternal and clavicular heads of origin of t sterno-mastoid just above the inner end of the clavicle, in which t common carotid artery and internal jugular vein lie deeply. T external jugular vein crosses the sterno-mastoid muscle in the directi of a line extending from a point just behind the angle of the mandil to a point above the centre of the clavicle, and it is accompanied the superficial cervical glands. The common carotid artery lies unc cover of the anterior border of the sterno-mastoid muscle in the directi of a line drawn from the sterno-clavicular joint to a point midw between the angle of the mandible and the tip of the mastoid proc( of the temporal bone. The vessel extends along this line as high the level of the upper border of the thyroid cartilage, above which is replaced by the external carotid artery. The internal jugular vt is close to the outer side of the common carotid artery, and the vag nerve lies deeply between the two vessels. If deep pressure is ma over the common carotid artery on a level with the cricoid cartila of the larynx, the anterior tubercle of the transverse process of t sixth cervical vertebra may be felt. It is known as the carotid tuber (of Chassaignac.)

The bifurcation of the innominate artery lies behind the upp border of the right sterno-clavicular joint, and the left common carol artery lies behind the left sterno-clavicular joint, while the lower pa of the internal jugular vein on each side is behind the inner end the clavicle. Near the middle line of the neck the anterior jugul vein descends vertically. The spinal root of the accessory ner passes downwards and outwards beneath the anterior border of t sterno-mastoid to pierce the deep part of that muscle at about t junction of the upper fourth and lower three-fourths. The nerve met with fully 1 inch below the tip of the mastoid process, and in t direction of a line let fall vertically from the mastoid tip. It is ve nearly on a level with the body of the hyoid bone. Along the posteri border of the sterno-mastoid some superficial cervical lymph glan may be felt.


THE HEAD AND NECK


ii 73


Important structures occupy the middle line of the neck, and can usually distinguished without difficulty. These are as follows, in sr from above downwards: (1) the body of the hyoid bone, lying

below the mandible, and having the greater horn projecting

kwards and upwards on either side; (2) the thyro-hyoid membrane; the thyroid cartilage, with its laryngeal prominence (pomum imi) in the middle line, leading up to the V-shaped thyroid notch the upper border, and its expanded ala on either side, each of which s behind in a superior and an inferior horn; (4) the crico-thyroid ment; (5) the narrow anterior part of the cricoid cartilage, which icides with the level at which the superior belly of the omo-hyoid


scle crosses the carotid sheath; and (6) the rings of the trachea, ich, however, are covered superiorly by the isthmus of the thyroid nd, and inferiorly by the sterno-hyoid and sterno-thyroid muscles 1 adipose tissue.

The lateral lobes of the thyroid gland may be felt on either side of larynx and trachea as low as about the fifth ring; and in young Idren the thymus extends upwards upon the trachea for some tance above the manubrium sterni.

The greater horn of the hyoid bone is the guide to the lingual artery , hypoglossal nerve for operative purposes, the structures lying just ve the greater horn.





A MANUAL OF ANATOMY


1174

The upper border of the thyroid cartilage is on a level with the di between the bodies of the third and fourth cervical vertebra.

The narrow anterior part of the cricoid cartilage is on a level wi the disc between the bodies of the fifth and sixth cervical vertebrae, which level the pharynx becomes the oesophagus. In this situatior foreign body, when swallowed, is liable to become impacted.

Below the cricoid, in the middle line, one or two rings of the trach may be felt above the thyroid isthmus, and it is here that a hi tracheotomy is performed, an easy operation since the windpipe is


Fig. 705. —Superficial Dissection.


close to the skin. Below the isthmus the trachea rapidly recedes, that a low tracheotomy is often a difficult and sometimes a ve dangerous operation; dangerous because, often in children and son times in the adult, the left innominate vein lies in the suprasterr region above the level of the manubrium sterni, and so in the way the knife. Ignorance of this fact has meant, and may mean aga the loss of a life.

Above the middle third of the clavicle, between the sterno-mash and trapezius muscles, there is a depression known as the greai



THE HEAD AND NECK


ii 75


aclavicular fossa, which indicates the position of the subclavian lgle, with the third part of the subclavian artery and the trunks ie brachial plexus of nerves.

Platysma (Platysma Myoides)— Origin .—The superficial fascia which >rs the clavicular parts of the pectoralis major and deltoid muscles. Insertion. —(1) The outer part of the body of the mandible from symphysis menti to the anterior border of the masseter muscle; (2) the angle of the mouth, where the fibres blend with those of depressor anguli oris and orbicularis oris.

Nerve-supply .—The cervical branch of the facial nerve, which comlicates with branches of the anterior cutaneous nerve of the neck. The fibres are directed upwards and forwards or inwards over the dele and side of the neck.

Action. —(1) To draw the angle of the mouth downwards and outds; (2) to act as a feeble depressor of the mandible; (3) to raise the 1 of the neck and upper pectoral region as far out as the acromion cess, throwing it into obliquely-disposed folds.

The muscle forms an extensive, thin, pale sheet, which is embedded hin the superficial fascia. In the region of the symphysis menti innermost fibres decussate across the middle line with those of the >osite side, the fibres of the right muscle being superficial. The scle covers the external and anterior jugular veins, the superficial nches of the cervical plexus of nerves, the subclavian triangle, and sterno-mastoid, sterno-hyoid, omo-hyoid, and digastric muscles.

The platysma in man is a remnant of a subcutaneous muscular sheet, called panniculus carnosus, which exists in many animals, and by which the twitchof the skin is produced.

Jugular Veins.—The jugular veins are four in number on either e—anterior, external, posterior external, and internal.

The anterior jugular vein begins in the roof of the digastric triangle, Lere it is formed by the union of radicles which communicate with 3 submental vein, and are joined by radicles which have descended >m the structures over the body of the mandible. It descends rtically near the median line, lying at first superficial to the deep rvical fascia, but subsequently entering the suprasternal space. II en describes a bend, and, passing outwards behind the sternoistoid muscle, and in front of the scalenus anterior, it opens to the lower part of the external jugular vein. It may, however, >en into the subclavian vein. It communicates with the external gular vein by one or more tributaries, and usually receives a branch 3 m the facial vein which descends along the anterior border of the erno-mastoid and joins it towards the lower part of the neck, urther, it communicates with its fellow, of the opposite side by a ansverse branch, the jugular arch, which crosses in front of the achea, and lies in the suprasternal space.

The anterior jugular veins are usually asymmetrical, one or other sing of small size. Occasionally there is only one vein, which divides


A MANUAL OF ANATOMY


1176

into two vessels interiorly. The anterior jugular vein is destitute ^ valves.

The external jugular vein commences close behind the angle of tl mandible in the substance of the parotid gland, where it is formed t the union between the posterior division of the posterior facial ve: and the posterior auricular vein. On leaving the parotid gland descends almost vertically to a point above the centre of the clavicl In its course the vessel crosses the sterno-mastoid muscle, lying supe ficial to its sheath, and deep to the superficial fascia containing tl fibres of the platysma. At this level the main part of the anteri<


Fig. 706. —Superficial Veins of Neck.

SF, CF, superficial and common facial. TM, posterior facial or temporo-maxillar PA, posterior auricular. PJ, EJ, AJ, posterior, external, and anterior juguls

cutaneous nerve of -the neck runs forward deep to the vein, and offse of the nerve pass superficial to it. Having crossed the sterno-masto muscle, the vein descends not far from its posterior border, where lies in the roof of the subclavian triangle over the third part of tl subclavian artery. Up to this point the vessel is superficial to tl deep cervical fascia, but it now pierces that fascia and opens into tl subclavian vein.

The course of the external jugular vein is indicated by a line draw from a point close behind the angle of the mandible to a point abo^ the centre of the clavicle. Its tributaries are as follows: (1) poster!




THE HEAD AND NECK


1177


3rnal jugular, which joins it about the middle of the neck; (2) trans;e cervical; (3) suprascapular; and (4) anterior jugular, the latter

e joining it not far from its termination. It also communicates

1 the anterior jugular vein by one or more branches. The vessel rovided with valves, both at its termination and about i\ inches ve this point, and the transverse cervical and suprascapular veins


isterior Auricular Lymph Glands

Occipital Vein

al Lymph Gland

>r Auricular Vein

terior Division of

erior Facial Vein

iperficial Cervical Lymph Glands


osterior External Jugular Vein

mal J ugular Vein


rse Cervical Vein_



P, ,

whi 1 \n\


_Supratrochlear Vein

-Supra-orbital Vein

- Angular Vein


Superficial Temporal Vein Maxillary Vein


Posterior Facial Vein Anterior Facial Vein

Ant. Div. of Posterior Facial Vein

Submandibular Lymph Glands

Common Facial Vein Internal J ugular Vein Lingual Vein

Superior Thyroid Vein


Middle Thyroid Vein


Anterior Jugular Vein

. Suprasternal Lymph Gland


. 1 ■"


Suprascapular Vein and.Supraclavicular; Lymphatic Glands


r. 707. —The Superficial Veins and Superficial Lymph Glands of the

Right Side of the Head and Neck.

The platysma muscle has been removed.


i also furnished with valves where they open into the external

ular vein, or near their orifices.

The external jugular vein is sometimes very small, or even absent, I it may communicate with the cephalic vein by a vessel which sses over the clavicle.

r

Development. —The external jugular vein was formerly regarded as being sloped from the anterior cardinal vein; but according to most authorities anterior cardinal vein gives rise to the internal jugular vein, the external ular being of later development.








A MANUAL OF ANATOMY


1178

The posterior external jugular vein represents the most exter: occipital vein, and is formed by tributaries which issue from the ou part of the occipital plexus, reinforced by veins from the superfic structures at the back of the neck. It usually receives the mast' emissary vein and passes downwards and forwards, joining the exter: jugular vein about the middle of the neck.

The internal jugular vein will be found described on p. 1211.

Superficial Cervical Lymph Glands.— These are about six in numb and they lie upon the sterno-mastoid muscle, along the course of 1 external jugular vein, and deep to the superficial fascia and platysi muscle. They receive their afferent lymphatics from the adjac< superficial structures, the occipital and mastoid lymph glands, a some of those of the parotid and submandibular lymph glands. Tb efferent lymphatics pass to the deep cervical lymph glands.

Deep Cervical Fascia. —The deep cervical fascia is divided ii (1) a superficial investing layer, which completely invests the neck the form of a collar; and (2) deep processes or laminae, which inv the muscles, viscera, and chief bloodvessels and nerves.

Investing Layer. —This layer is attached posteriorly to the li\ mentum nuchae; superiorly to (1) the superior nuchal line of the oc pital bone, (2) the mastoid process of the temporal bone, (3) the zyj matic arch, and (4) the body of the mandible, under cover of 1 platysma, as far forwards as the symphysis menti; and interiorly the clavicle and upper border of the manubrium sterni, being pierc above the centre of the clavicle by the external jugular vein. Ale the middle line of the neck anteriorly it is continuous with the invest] layer of the opposite side.

The investing layer invests the cervical portion of the trapezi and from the anterior border of that muscle it passes forwards 0 1 the posterior triangle of the neck to the posterior border of the sten mastoid. In doing so it furnishes a deep process, which ensheat] the inferior belly of the omo-hyoid muscle. This process also embra^ the intermediate tendon of that muscle, after which it passes dov wards and inwards to be attached to the back of the inner end of 1 clavicle and the first rib. In this manner the horizontal position the inferior belly of the omo-hyoid is accounted for. When the vesting layer of the deep cervical fascia reaches the posterior bore of the sterno-mastoid it splits into two laminae, which ensheathe tl muscle, the superficial lamina being underneath the external jugu vein and platysma. At the anterior border of the sterno-mastoid 1 two laminae reunite, and the fascia passes forwards over the anter triangle of the neck to the median line, where it is continuous with 1 corresponding layer of the opposite side.

Between the upper part of the anterior border of the sterno-masb and the angle of the mandible the investing layer is of considera strength, and draws that border of the muscle forwards and upwar so as to render it convex and keep it over the line of the leading vess< Between the mastoid process and the angle of the mandible the



THE HEAD AND NECK


1179


ting layer is prolonged upwards over the parotid gland as the parotid

ia, which is very dense, and is attached superiorly to the lower

der of the zygomatic arch.

Below the level of the thyroid gland the investing layer divides 0 two laminae, anterior and posterior, both of which are superficial the infrahyoid muscles. At the middle line these laminae are conuous with those of the opposite side, and inferiorly they are attached the anterior and posterior margins of the upper border of the nubrium sterni. Between them there is an interfascial interval, led the suprasternal space (space of Burns). This interval contains

olar tissue, one or more lymphatic glands, the lower portions of the

terior jugular veins, with the jugular arch which here connects im, and the sternal heads of the sterno-mastoid muscles.

Deep Processes or Laminae.— The deep laminae, as stated, invest the iscles, viscera, and chief bloodvessels and nerves. The most imrtant are derived from that lamina of the investing layer which ms the posterior wall of the sheath of the sterno-mastoid muscle, d they are three in number—namely, carotid sheath, pretracheal icia, and prevertebral fascia—all of which have an intimate initial nnection.

The carotid sheath contains in separate compartments (1) the mmon carotid artery and the constituents of the ansa hypoglossi, the internal jugular vein, and (3) the vagus nerve, the latter being ntained within the back part of the septum, which separates the tery from the vein.

The pretracheal fascia, which is at first intimately connected with e anterior wall of the carotid sheath, passes forwards behind the frahyoid muscles, in which situation it splits to ensheathe the yroid gland, trachea, and oesophagus, and then it passes to the sdian line, where it is continuous with the pretracheal fascia of the •posite side. The pretracheal fascia is attached superiorly to the >dy of the hyoid bone, and inferiorly it descends over the trachea Ld bloodvessels into the superior mediastinum of the thorax, where it ends with the fibrous pericardium.

The prevertebral fascia, which is at first intimately connected with e posterior wall of the carotid sheath, passes forwards behind the larynx and oesophagus, and in front of the prevertebral muscles, t the middle line it is continuous with the corresponding fascia of e opposite side; superiorly it is attached to the base of the skull; id inferiorly it descends over the longus cervicis muscle into the isterior mediastinum of the thorax. Along a line corresponding to le inner wall of the carotid sheath the pretracheal fascia furnishes a condary lamina, called the bucco-pharyngeal fascia, which covers ie constrictor muscles of the pharynx and the buccinator muscle, etween the bucco-pharyngeal and prevertebral fasciae there is an terval, called the retro-pharyngeal space, which contains the loosely 'ranged connective tissue uniting the two fasciae. This space extends high as the base of the skull, and inferiorly is continuous with the


ii8o


A MANUAL OF ANATOMY


posterior mediastinum of the thorax. Another process of the pi vertebral fascia passes downwards and outwards in front of t scalenus anterior muscle. After this it invests the third part of t subclavian artery and subclavian vein, together with the nerve-trun of the brachial plexus, and, passing behind the clavicle, it becom continuous with the axillary sheath, which latter blends with t posterior aspect of the clavi-pectoral fascia. In the region of the su clavian triangle there is an interfascial space between this proce of the pretracheal fascia and the investing layer of the deep cervic fascia. This space extends downwards behind the clavicle to the poi where the axillary sheath and clavi-pectoral fascia join. It contai


Stemo- thyroid Sterno-hyoid

Investing Layer of Deep Cervical Fascia Superior Belly of Omo-hyoid Pretracheal Fascia Prevertebral Fascia


Suprasternal Space Trachea

Muscular Compartment

Lateral Lobe of Thyroid Gland


Carotid Sheath


Scalenus Anterior


Scalenus Medius


Levator Scapulae

Semispinalis Capitis


(Esophagus

Descendens hypoglossi ^ Common Carotid Artery Internal Jugular Vein - Vagus Nerve Platysma


Splenius


Sympathetic Trunk

Longus Cervicis - Stemo-mastoid


External Jugular V<


' Vertebral Vessels


Trapezius


Semispinalis Cervicis


Tig. 708. Diagram of a Transverse Section of the Neck at the Lev of the Sixth Cervical Vertebra, showing the Arrangement of ti Deep Cervical Fascia and the Positions of Other Structures.


the inferior belly of the omo-hyoid muscle, the suprascapular ar transverse cervical vessels, the lower part of the external jugular vei and the terminal portion of the anterior jugular vein.

Interfascial Compartments. —It has been stated that the det cervical fascia reaches the median line of the neck anteriorly in thr layers—namely, investing (in two divisions), pretracheal, and pr vertebral. It is therefore evident that there are four interfasci compartments as follows: (1) the suprasternal space (space of Burn! which is situated between the two divisions of the investing layer, ai contains the structures already enumerated; (2) the muscular cor partment, which is situated between the investing layer and the pr tracheal layer, and contains the infrahyoid muscles; (3) the viscer





















THE HEAD AND NECK


1181


partment, which lies between the pretracheal and prevertebra rs, and contains the larynx, trachea, thyroid gland, pharynx, phagus, and carotid sheath, the retro-pharyngeal space being in subdivision of this compartment behind the bucco-pharyngeal ia; and (4) the vertebral compartment, which lies between the vertebral layer and the attachment of the fascia to the ligamentum iae posteriorly, and contains the vertebral column, spinal cord, and vertebral and postvertebral muscles.

rhe suprasternal and muscular compartments are shut off from thoracic cavity. The visceral compartment in front of the trachea mtinuous with the superior mediastinum of the thorax, and behind oesophagus it, along with the retro-pharyngeal space, is continuous 1 the posterior mediastinum.

Parotid Process of the Deep Cervical Fascia. —This process is given a little below the angle of the mandible, and it passes upwards on deep surface of the parotid gland to the skull. Along with the Dtid fascia superficial to the gland it forms a dense sheath which ely invests the glandular substance. The parotid process furnishes aths to the posterior belly of the digastric, styloid, and pterygoid scles, and it also gives an investment to the superficial part of the mandibular gland. Connected with the parotid process there are sral bands, usually called ligaments, which are as follows: (1) sphenoadibular; (2) stylo-mandibular; (3) pterygo-mandibular; and

pterygo-spinous.

The spheno-mandibular ligament will be described in connection h the mandibular joint, of which it is sometimes regarded as an essory medial ligament (see p. 1316).

The stylo-mandibular ligament extends from the styloid process of temporal bone near its tip to the angle and adjacent part of the terior border of the ramus of the mandible, where it is placed ween the masseter and internal pterygoid muscles.

The pterygo-mandibular ligament is a narrow band which extends hi the hamulus of the medial pterygoid plate of the sphenoid bone the posterior extremity of the mylo-hyoid line of the mandible $e to the last molar socket. Anteriorly it gives origin to fibres of buccinator muscle, and posteriorly to fibres of the superior condor muscle of the pharynx.

The pterygo-spinous ligament is a narrow band which extends from harp spine on the posterior border of the lateral pterygoid plate of sphenoid bone, towards its upper part, to the spine process of the lenoid. This ligament is liable to become ossified.

The foregoing description is orthodox and traditional, and every fact stated be demonstrated by a good dissector; but there are some observers who 3rd the whole of these fascial planes as artifacts, and believe that all the irstices between the structures in the neck are filled with loose connective ue which, when it is cleaned from the surrounding parts, collapses into Y definite sheets. If this is the case, it should be possible, by varying the action of the incisions, to produce sheets in any plane. As a matter of fact, > can be done.


Il82


A MANUAL OF ANATOMY


Sterno-mastoid — Origin .—The sternal head, which is narrow ar round, arises from the upper and outer part of the anterior surfa* of the manubrium sterni. It is tendinous in front, and fleshy behin The clavicular head, which is broad and flat, arises from a rough rid| about ij inches long on the upper surface of the clavicle at its inn end.

Insertion .—The outer surface of the mastoid process of the ter poral bone, and the superior nuchal line of the occipital bone ov about its outer half or two-thirds.


Fig. 709. —Showing Sterno-mastoid and the Muscular Floor of

Posterior Triangle.



Nerve-supply .—The accessory nerve, and a branch from the cervic plexus, more particularly from the anterior primary ramus of the secor cervical nerve.

The spinal root of the accessory nerve passes deep to the anteri border of the muscle fully 1 inch below the tip of the mastoid proces and in passing downwards and backwards it pierces the deep part the muscle, giving off as it does so its branches to it.

The muscle is directed upwards, outwards, and backwards.

Action .—To flex the head towards the side on which the muse





THE HEAD AND NECK


1183

aced, the face being turned towards the opposite side. This is position of the head in torticollis or wry-neck, a condition which be due to an organic contraction to the muscle, affecting both s, or, it may be, the sternal head alone. When both muscles act ther from their origin they flex the head towards the thorax, when the head has been already thrown back the sterno-mastoid ls capable of extending it still farther instead of flexing it. It t be remembered, however, that a certain amount of flexion of lead may take place between any of the cervical vertebrae. When muscles act together from their insertion they elevate the upper of the anterior thoracic wall in forced inspiration.

"he sternal and clavicular heads are separated by a triangular Jar interval for a short distance above the sterno-clavicular joint, before their junction the fibres of the clavicular head to a large nt pass behind those of the sternal head, so that overlapping s place. The muscle is surrounded by a strong sheath, which is led by the deep cervical fascia. The platysma covers a large part

, and the external jugular vein, the anterior cutaneous nerve of
and great auricular nerves, and the superficial cervical lymph

ds are related to its superficial surface under cover of the platysma. principal deep relations are as follows: in the lower part of the

it covers the first and second parts of the subclavian artery, the

10-hyoid, sterno-thyroid, omo-hyoid, and scalenus anterior muscles, l the phrenic nerve lying upon the last-named muscle. In this rtion it also covers the anterior jugular vein, and the transverse ical and suprascapular arteries. Higher up it covers the cervical

us of nerves, the levator, scapulae, scalenus medius, and scalenus

erior muscles, and the accessory and the hypoglossal nerves. At insertion it covers the splenius capitis, longissimus capitis, and

erior belly of the digastric muscles, and a portion of the occipital

ry, in this order from the surface downwards. The anterior border he muscle forms the posterior boundary of the anterior triangle of neck, and covers the carotid sheath, with its contents, as high as level of the upper border of the thyroid cartilage ; and above that 1 it covers the external and internal carotid arteries. This border overlaps slightly the lateral lobe of the thyroid gland.. The

erior border forms the anterior boundary of the posterior triangle

he neck, and along it there lie the following structures: the superI cervical lymph glands, the lesser occipital nerve, great auricular, nrior cutaneous nerve of neck, the accessory, and the descending srficial branches of the cervical plexus of nerves, and a portion of external jugular vein.

The sterno-mastoid muscle, from its diagonal position upon the

of the neck, divides the quadrilateral space into two triangles terior and anterior.

Posterior Triangle. —This is the region which lies behind the sterno>toid muscle.

Boundaries — Anterior. —The posterior border of the sterno-mastoid.


A MANUAL OF ANATOMY


1184

Posterior .—The anterior border of the trapezius. Inferior (base).— middle third of the clavicle. The apex is at the superior nuchal of the occipital bone, where the sterno-mastoid and trapezius may n but the apex is usually truncated. The roof is formed by the ; superficial and deep fasciae, and for a short distance interiorly by platysma. The lesser occipital nerve lies in the upper part of roof, and the descending superficial branches of the cervical pi and the external jugular vein lie in the lower part of the roof, floor is formed by the following muscles, in order from above dc wards: (1) small angle of the semispinalis capitis, provided the trapt


is not well developed at the occiput; (2) the splenius capitis; (3) levator scapulae; (4) the scalenus medius and scalenus poster (5) the scalenus anterior; and (6) the first digitation of the sern anterior if the clavicle is depressed.

The posterior triangle is subdivided by the inferior belly of omo-hyoid into a large upper portion, called the occipital trian and a small lower portion, called the subclavian triangle.

Occipital Triangle—Boundaries — Anterior .—The posterior boi of the sterno-mastoid. Posterior .—The anterior border of trapezius. Inferior (base). —The inferior belly of the omo-hy The muscles in its floor are (1) a small angle of the semispinalis caj




THE HEAD AND NECK


1185

instant), (2) splenius capitis, (3) levator scapulae, and (4) scalenus .ius and posterior. The contents are the superficial branches of the ical plexus, the accessory nerve, the branches of the cervical

us to the levator scapulae and trapezius, a small part of the occipital

ry close to the apex, and some superficial cervical lymph glands.

t should be realized that the foregoing gives a picture of the triangle as seen le dissected body. In life and in the undissected part it is little more than tter, the anterior edge of the trapezius being only about \ inch from the srior border of the sterno-mastoid.


Parotid Duct Buccinator Muscle

Facial Artery Submental Artery


Lingual Artery Sup. Lar. Art. and Nerve Thyro-hyoid Muscle Superior Thyroid Artery


.Transverse Facial Artery


, Superficial Temporal Artery

- Maxillary Artery

/_Posterior Auriculat

wma ^ . Artery

Occipital Artery


-Stylo-hyoid Muscle

-Post. Belly of Digastric

-Hypoglossal Nerve

_Descendens Hypogloss'

_External Carotid

Artery


-Sterno-mastoid

.— w Trapezius


_Transverse Cervical Artery

-. Suprascapular Artery


Inf. Belly of Omo-hyoid

Subclavian Artery (third part)


, y 1, An

Fig. 711.—The Left Side of the Head and Neck. The platysma has been removed.


Cervical Plexus. —The cervical plexus lies deep to the upper part

he sterno-mastoid muscle, and immediately in front of the slips

•rigin of the scalenus medius. It is formed by the anterior primary ii of the first three cervical nerves and the greater part of that of fourth, a small branch of the latter descending to join the anterior nary ramus of the fifth, and so taking part in the brachial plexus, h of the anterior primary rami of the first four cervical nerves is nected with the superior cervical ganglion of the sympathetic by 'ey ramus communicans.


75








1186 A MANUAL OF ANATOMY

The anterior primary ramus of the first cervical nerve lies at f in the vertebrarterial groove of the atlas below the vertebral arte It then passes forwards in a groove on the outer surface of the supei articular process of the atlas, having the vertebral artery on its or side. It next emerges between the rectus capitis lateralis mu; (to which it gives a branch) and the rectus capitis anterior, ; descends in front of the root of the lateral mass of the atlas to join ascending branch of the second nerve. From the loop so forr


Vagus


Lesser Occip. N.


N.toTh

Int. La

Ne


Accessory Nerve ..


Ext. Li Nerv


Descent Hvpog Desc. C


Ansa


Ant. Jv


Fig. 712.—Deep Relations of Sterno-mastoid, showing Cervical

Plexus, etc.


branches are given to the rectus capitis anterior and the longus cap muscles, and one or more branches pass to the hypoglossal nerve, destination of their fibres being the ramus descendens cervicalis 2 the nerves to thyro-hyoid and genio-hyoid.

The anterior primary rami of the second, third, and fourth cervi nerves, having emerged between the corresponding intertransversa muscles, form a superficial and a deep part of the plexus, of wh the superficial is altogether cutaneous, while the deep is divided h


Phrenic


Upper Cord of Brachial Plexus








THE HEAD AND NECK


1187


tor and communicating branches. It will also be found that the p plexus consists of an external and an internal set of branches. Superficial Group. —The branches of this group are ascending, nsverse, and descending.

The ascending and transverse branches arise from the second and

d cervical nerves.

The ascending nerves are the lesser occipital and great auricular

p. 1141). The transverse branch is the anterior cutaneous nerve
he neck.

The anterior cutaneous nerve of the neck (superficial cervical nerve)

es by two roots from the anterior primary rami of the second and


Fig. 713. —Scheme of Cervical Plexus. superficial plexus red ; deep plexus black. I., E., medial and^lateral sides.


'rd cervical nerves, and, turning round the posterior border of the Tno-mastoid muscle, it passes forwards superficial to that muscle, ng deep to the platysma and the external jugular vein. Having iched the anterior triangle of the neck, it divides into two branches,

ending and descending, which are distributed to the integument

er the anterior triangle. The offsets of the ascending branch commicate freely with the cervical branch of the facial nerve deep to the itysma.

The descending branches are the medial, intermediate, and lateral 3 raclavicular nerves, and they arise in common from the third and irth cervical nerves. As they descend they form distinct nerves,






n88


A MANUAL OF ANATOMY


which lie on the roof of the subclavian triangle under cover of t platysma. For their distribution see p. 412.

Deep Group. —The nerves of this group are arranged in two sets external and internal.

External Set .—These nerves are muscular. The second ner furnishes a branch to the sterno-mastoid, which communicates in tb muscle with the branch of the accessory nerve. The third and four


Fig. 714. —Superficial Branches of Cervical Plexus.

SO, lesser occipital; GA, greater auricular; TC, anterior cutaneous; DC, descending supraclavicular; XI, accessory nerve.


nerves furnish (a) two branches to the trapezius, which communicc with the accessory nerve deep to the upper part of the muscle formi the subtrapezial plexus; ( b) two branches to the levator scapulae; a (c) branches to the scalenus medius.

Internal Set .—The nerves of this set are communicating a muscular.

The communicating branches are as follows: (1) connecting brand (grey rami communicantes) pass from the superior cervical gangli










THE HEAD AND NECK


1189


the sympathetic; (2) communicating branches pass to the vagus d hypoglossal nerves from the highest loop of the plexus; and two rami communicantes cervicales pass from the second and third rves forwards and downwards, usually superficial, but sometimes ep to the internal jugular vein, and join the descendens hypoglossi, aether or separately, to form the ansa hypoglossi.

The muscular branches are distributed to the rectus capitis lateralis,

tus capitis anterior and longus capitis, upper part of the scalenus

terior, longus cervicis, and the diaphragm. The nerve to the iphragm is the phrenic, which, from its importance, requires a special scription.

The phrenic nerve arises, as a rule, by two roots, the larger of lich is derived from the anterior primary ramus of the fourth cervical rve, and the other from that of the third. In some cases the fifth rvical nerve, which enters into the brachial plexus, furnishes an ditional small root. In the neck the nerve descends in front of the ilenus anterior muscle, which it crosses obliquely downwards and wards, passing deep to the intermediate tendon of the omo-hyoid uscle, the transverse cervical and suprascapular arteries, the anterior gular vein, and, on the left side, the thoracic duct. At the root of e neck the nerve, having left the scalenus anterior, passes behind e terminal part of the subclavian vein, and crosses in front of the ternal mammary artery from without inwards. Having come into ntact with the inner surface of the cupola of the pleura, it disappears kind the inner end of the clavicle, and enters upon the thoracic part its course (see p. 1015).

The right nerve at the root of the neck is superficial to the second irt of the right subclavian artery, with the intervention of the alenus anterior muscle. The left nerve at the root of the neck is iterior and parallel to the first part of the left subclavian artery.

The phrenic nerve is sometimes reinforced towards the root of the ick by a branch from the nerve to the subclavius muscle, and when is takes place the root from the fifth cervical nerve is usually absent, efore leaving the neck the phrenic nerve receives a twig from the iddle or inferior cervical ganglion of the sympathetic.

No branches arise from the phrenic nerve in the neck.

Lower Group of Deep Cervical Lymph Glands (Supraclavicular pmph Glands). —These glands lie in the anterior part of the subclavian iangle, and are related superficially to the intermediate supraclavicular 'rve and deeply to the upper and middle trunks of the brachial plexus. 'iperiorly they are continuous with the upper deep cervical lymph ands. They receive their afferent vessels from the following sources:

1. The back of the neck.

2. The axillary lymph glands.

3. The upper part of the pectoral region.

4. Occasionally the lymphatics along the cephalic vein, which ay ascend over the clavicle.

5- The internal mammary lymph glands.



1190


A MANUAL OF ANATOMY


Their efferent vessels form the subclavian trunk, which, with t jugular trunk, opens into the thoracic, or into the right lymphai duct.

Subclavian or Supraclavicular Triangle. —The subclavian triangle the lower division of the posterior triangle of the neck, and is separate from the upper division or occipital triangle by the inferior belly


Fig. 715. —Common Carotid and Subclavian Arteries exposed by Remow of Sterno-mastoid, Omo-hyoid, and Internal Jugular Vein.

the omo-hyoid muscle. Situated above the middle third of the clavicl* it is of small size until the deep cervical fascia, which ensheathes tt inferior belly of the omo-hyoid, has been divided.

Boundaries — Superior .—The inferior belly of the omo-hyoid muscf Inferior .—The middle third of the clavicle. Anterior .—The clavicuk part of the sterno-mastoid muscle. Roof .—The skin; superficial fasci










THE HEAD AND NECK


1191


platysma muscle; medial, intermediate, and lateral supraclavicular es; a part of the external jugular vein; and the deep cervical fascia, if.—The scalenus medius and posterior muscles, and the serratus

rior.

rhe extent of the triangle is affected by (T) the height to which inferior belly of the omo-hyoid ascends above the clavicle, and the extent of the clavicular attachments of the sterno-mastoid trapezius muscles. The depth of the triangle is influenced by the tion of the shoulder, being greater when the shoulder is raised carried forwards, and less when it is depressed and carried kwards.

Contents. —The contents are: (1) the greater portion of the third t of the subclavian artery; (2) small portions of the transverse


Brachial Plexus Cephalic Vein Musculo-cutaneous Nerve Deltoid


Trapezius

1 Suprascapular Vessels

\ Transverse Cervical Artery

Inferior Belly of Omo-hyoid

Scalenus Anterior / Sterno-mastoid


-Clavicle in section


Subclavius


Axillary Artery - Axillary Vein

Pectoralis Major (cut)


Pec!oralis Minor Lateral Root of Median Nerve


Medial Cutaneous Nerve of Arm

Axillary Vein

Ulnar Nerve


Medial Root of Median Nerve Medial Cutaneous Nerve of Forearm


Fig. 716. —Subclavian and Axillary Regions.


vical artery and vein; (3) the lower portion of the external jugular in; (4) the nerve-trunks of the brachial plexus; and (5) the nerve the subclavius muscle, the suprascapular nerve, and the nerve serratus anterior

Third Part of the Subclavian Artery. —1 his part of the vessel extends >m the outer border of the scalenus anterior muscle to the outer rder of the first rib, where it becomes the axillaiy artery. Its course downwards and outwards, and for the greater part of its extent it s in the subclavian triangle. Its last inch or so, howevei, passes

hind the clavicle and subclavius muscle.

Relations- — Anterior .—The skin; superficial fascia and platysma; edial, intermediate, and lateral supraclavicular nerves; deep cervical >cia; clavicle and subclavius muscle; transverse cervical vessels; prascapular vessels; nerve to the subclavius muscle; and the termina





1192


A MANUAL OF ANATOMY


portion of the external jugular vein. The last-named vessel cro: in front of the artery close to the sterno-mastoid muscle, and in ■ situation is joined by the transverse cervical and suprascapular ve A plexiform arrangement of veins is sometimes met with in from the artery, which may be rendered more complex by a branch ascenc superficial to the clavicle from the cephalic vein. Posterior .—' scalenus medius, the lower nerve-trunk of the brachial plexus in vening. Superior .—The upper and middle nerve-trunks of the brad plexus, the latter being nearest the vessel. Inferior .—The upper s face of the first rib and the subclavian vein, the vein being on a m anterior plane than the artery, and lying behind the clavicle.

It is most important to understand that, though the first rib is spoken o an inferior relation, its surface is so oblique that it is just as much behinc below.

The third part of the subclavian artery does not always give any branch. In very many cases, however, the deep branch of transverse cervical artery arises from it, instead of from the latter arte

which is a branch of the first, p of the subclavian. In these ca the posterior scapular art passes outwards between nerve - trunks of the brad plexus.

The direction of the third p of the artery is indicated b^ line drawn from a point on i posterior border of the ster mastoid muscle, about J ir above the clavicle, to the cen of that bone. The artery may compressed as it passes over 1 first rib, the guide to it at t point being the centre of i clavicle. In order to tie the si clavian artery in the dead bo< after fully depressing the clavi( feel for the outer edge of the scalenus anterior muscle, and follow to its insertion on the first rib. The structure which lies immediat behind the muscle here is the artery; and great care must be taken i to mistake it for the lower trunk of the brachial plexus.

For the manner in which the collateral circulation is carried after ligation of the third part of the subclavian artery, see p. 441.

The subclavian vein, in the region of the subclavian triangle, situated behind the clavicle, where it lies below and anterior to 1 artery. On the upper surface of the first rib it is anterior to the scaler anterior, and it receives the external jugular vein, and in some ca the anterior jugular vein,


Fig. 717.— Plan of Branches of Subclavian Artery.



THE HEAD AND NECK


ii 93


L'he transverse cervical artery lies in the subclavian triangle for Lort distance only, close to where the inferior belly of the omoid passes deep to the sterno-mastoid. It passes outwards behind former muscle into the lower part of the occipital triangle, where ivides into its superficial and deep branches, the former entering trapezius, and the latter passing in front of the levator scapulae, r which it descends along the base of the scapula in front of the nboid muscles.

rhe transverse cervical vein opens into the external jugular vein, •e being a valve at or near its ending.

rhe suprascapular artery is not in the subclavian triangle, but lies ind the clavicle, close to its upper aspect. It will be described in nection with the first part of the subclavian artery (see p. 1243).

The suprascapular vein also lies behind the clavicle, and it opens > the external jugular vein, there being a valve at or near its ending. The external jugular vein will be found described on p. 1176.

Brachial Plexus. —The brachial plexus is situated in the lower part he posterior triangle of the neck, behind the clavicle, and in the >er part of the axilla. Its complex formation is rendered simple arranging it into four stages—namely (1) nerve-roots, (2) nervenks, (3) divisions of nerve-trunks, and (4) nerve-cords.

First Stage .—The nerves which form the plexus are the anterior nary rami of the fifth, sixth, seventh, and eighth cervical, and the ater part of that of the first thoracic. Superiorly the plexus is lforced by a small descending branch from the fourth cervical, ich joins the fifth, and interiorly it is occasionally reinforced by a ,nch from the second thoracic, which joins the first. As regards the t thoracic nerve, the part of it which does not join the plexus, and ich is of small size, enters the first intercostal space to become the t intercostal nerve. The nerves, as thej^ emerge at the side of the k, are placed between the scalenus anterior and scalenus medius, which they give branches.

Second Stage .—The fifth and sixth cervical nerves join at the

er border of the scalenus anterior to form the upper trunk ; the

r enth cervical remains meanwhile single, and forms the middle nk ; and the eighth cervical and greater part of the first thoracic ite between the scalene muscles to form the lower trunk. There ! thus three trunks—upper, middle, and lower.

Third Stage.—A little above the clavicle each of the three trunks ^aks up into anterior and posterior divisions.

Fourth Stage.— The anterior divisions of the upper and middle inks unite to form the lateral cord of the plexus; the anterior dsion of the lower trunk, which is of large size, forms the medial rd; and all three posterior divisions (that of the lower trunk being small size) unite to form the posterior cord. There are thus three rds—lateral, medial, and posterior. As a variety, the anterior /ision of the middle trunk may subdivide into two branches, one tering the lateral cord and the other the medial.


H 94


A MANUAL OF ANATOMY


Branches of the Plexus above the Clavicle. —The branches are c< veniently divided into two groups—supraclavicular, arising above 1 clavicle, and coming from nerve-roots and nerve-trunks; and inf clavicular, arising below the clavicle, and coming from nerve-cords.

Supraclavicular Branches .—These are muscular branches fr< the four cervical nerves to the scalene muscles and longus cervicis.

One root of the phrenic nerve (inconstant) from the front of 1 fifth cervical.

The Nerve to the Rhomboids. —This branch arises from the ba of the fifth cervical, close to or along with the highest root of 1


Iug. 718. —The Brachial Plexus.

\ ellow=spinal nerves and their branches; blue=trunks; red=lateral cord

purple=medial cord; grey=posterior cord.

neive to serratus anterior, and it takes a backward course throu the scalenus medius.

The Nerve to the Serratus Anterior (Nerve of Bell or Posteri Thoracic Nerve). —This branch arises by three roots from the ba of the fifth, sixth, and seventh cervical nerves. The upper two ro( pierce the scalenus medius muscle below the nerve to the rhomboi( either conjointly or separately, whilst the lowest root passes in fro of the scalenus medius, and joins the trunk formed by the oth( neai the first rib. The nerve then courses behind the brachial plex and the first part of the axillary artery to the axillary surface of t serratus anterior, which it supplies.



THE HEAD AND NECK


ii95


he Nerve to the Subclavius. —This small branch arises from the of the upper trunk, its fibres being derived from the fifth cer. It descends in front of the third part of the subclavian artery, passing behind the clavicle, enters the subclavius muscle on leep aspect. This nerve sometimes communicates with the nic nerve.

he Suprascapular Nerve. —This is a large nerve which arises from Dack of the upper trunk, its fibres being derived from the fifth


Fig. 719. —Plan of Triangles of Neck.

sixth cervical. It is directed downwards, outwards, and backds beneath the trapezius and inferior belly of the omo-hyoid to upper border of the scapula, on approaching which it meets the rascapular artery. It is distributed to the supraspinatus and ispinatus muscles and shoulder-joint.

[t will be seen that all the branches of the brachial plexus belong er to the anterior or posterior divisions, even if they come off before >e divisions become separate, and that their distribution gives a clue






1196


A MANUAL OF ANATOMY


to the division to which they belong. The nerves to the scale] medius and posterior, as well as that to the rhomboids, the sup scapular, and to serratus anterior, are, from their distribution, clea dorsal or posterior in their origin; while the nerves to the scale] anterior, longus cervicis, and subclavius are equally clearly anteric

Below the clavicle the lateral and medial cords give off all the antei branches, while the posterior come entirely from the posterior cord.

For the infraclavicular branches of the brachial plexus, see p. 4

Anterior Triangle. —This triangle is situated in front of the ster: mastoid muscle, and its base is directed upwards.

Boundaries — Anterior. —The middle line of the neck—that is say, a line extending from the chin to the upper border of the mai brium sterni. Posterior. —The anterior border of the sterno-mast muscle. Superior. —The lower border of the mandible and a 1 drawn from the angle of that bone to the mastoid process. 1 triangle is covered by the skin, superficial cervical fascia, platysr and deep cervical fascia. Superficial to the deep fascia there the following structures: the anterior jugular vein, the ramificati< of the anterior cutaneous nerve of neck, and the cervical branch of 1 facial nerve.

The anterior triangle is subdivided into three triangles by i superior belly of the omo-hyoid muscle inferiorly, and posterior be of the digastric muscle superiorly. The subdivisions from bel upwards are called muscular, carotid, and submandibular.

The muscular triangle is bounded anteriorly by the middle line the neck; posteriorly by the anterior border of the sterno-mastoid; a superiorly by the superior belly of the omo-hyoid.

The carotid triangle is bounded inferiorly by the superior be of the omo-hyoid; superiorly by the posterior belly of the digast and stylo-hyoid; and posteriorly by the anterior border of the sten mastoid.

The submandibular triangle (submaxillary triangle) is bound

postero-inferiorly by the lower part of the posterior belly of the digasti the stylo-hyoid, and by the body of the hyoid bone: antero-inferio by the mid-line of the neck; and superiorly by one half of the be of the mandible, and a line drawn from the angle of that bone to t sterno-mastoid muscle.

Contents of the Triangles—Muscular Triangle (Fig. 719).—The ai of this triangle is occupied by the sterno-hyoid and sterno-thyn muscles; hence the name muscular triangle. Under cover of th< muscles there are the carotid sheath with its contents, the late lobe of the thyroid gland, the trachea, and the larynx. The oesophag lies behind the trachea, with a slight inclination towards the 1 side at the root of the neck, and the recurrent laryngeal nerve 1 in the groove between the trachea and the oesophagus. The infer thyroid artery has a tortuous course inwards behind the lower p; of the carotid sheath, and the trunk of the sympathetic descer behind both.




THE HEAD AND NECK


1197


arotid Triangle. —This triangle contains the upper part of the non carotid, and the beginnings of the external and internal

id arteries, all of which are overlapped by the anterior border

le sterno-mastoid, when the connective tissue which ensheathes muscle is undisturbed. The common carotid and internal carotid ies, together with the vagus nerve, are contained within the tid sheath, and the descendens hypoglossi lies in front of the th, or within it, being situated in either case in front of the common tid artery. The sterno-mastoid artery and the superior thyroid cross the sheath near the bifurcation of the common carotid


.Transverse Facial Artery


Parotid Duct -Buccinator Muscle Facial Artery -Submental Artery


Lingual Artery — Sup. Lar. Art. and Nerve Thyro-hyoid Muscle _. Superior Thyroid Artery


Inf. Belly of Omo-hyoid-,

Subclavian Artery (third part)


, Superficial Temporal Artery

HPI"' Maxillary Artery

Posterior Auriculav

r Artery

/r _ Occipital Artery

>itW

,,,, . .-. - JIlifL. _Stylo-hyoid Muscle

WyMSm---- Post - Bel, y of Di s astric

!£- _Hypoglossal Nerve

-Descendens Hypoglossi

Jj_External Carotid Artery


-Sterno-mastoid

Trapezius

_Transverse Cervical Artery

_. Suprascapular f\ Artery


^iwii iin^wiu !ii wu M1 1 \w ' An '

Fig. 720.—The Left Side of the Head and Neck. The platysma myoides has been removed.


  • ry, and the carotid body lies behind the vessel about the same

d. The deep cervical lymph glands lie just lateral to the course he internal jugular vein. The origins of the superior thyroid, lingual, ial, and occipital arteries are contained in this triangle, and the ending pharyngeal branch of the external carotid lies deeply between t vessel and the internal carotid. The internal jugular vein in this ingle receives the common facial, lingual, and superior thyroid veins, e hypoglossal nerve lies along the lower border of the posterioi ly of the digastric muscle, and it here gives off, fiom behind wards, the descendens hypoglossi and the nerves to thyio-hyoid









A MANUAL OF ANATOMY


1198


and genio-hyoid, the former passing downwards in front of, or witl the carotid sheath, and the latter passing forwards and downwards an acute angle with the parent trunk. The internal branch of superior laryngeal nerve lies deeply behind the bloodvessels, and external laryngeal branch of that nerve descends parallel and deep the superior thyroid artery, and passes deep to the upper end of posterior border of the sterno-thyroid muscle. The vagus nerve within the carotid sheath, and the sympathetic trunk is behind The accessory nerve lies deeply, its course being downwards and ba wards beneath the sterno-mastoid, the deep portion of which usual! pierces about an inch below the angle of the mandible.

Digastric Triangle.—This triangle is divided into two parts, antei and posterior, by the stylo-mandibular ligament. The anterior p contains the superficial part of the submandibular gland, the antei facial vein being superficial to it, and the facial artery being embed( in its upper and back part. In this triangle the facial artery gives its ascending palatine, tonsillar, glandular, and submental brand The muscles in the floor of the anterior part of the triangle are mylo-hyoid and a part of the hyo-glossus. The superficial part of submandibular gland is superficial to the mylo-hyoid muscle, a conceals the mylo-hyoid nerve and submental artery, which are direct contact with the muscle. The hypoglossal nerve lies upon t] part of the hyo-glossus muscle which appears in the anterior part the triangle, but it soon disappears beneath the posterior free bon of the mylo-hyoid muscle. It is important to notice that it lies para to and just above the greater horn of the hyoid bone, which forms important structure in the floor of the triangle, and shows a little the insertion of the thyro-hyoid muscle below it.

The anterior jugular vein and the anterior cutaneous nerve of 1 neck have been already described (see pp. /1173 and 1187). 1 cervical branch of the facial nerve will be found described on p. 12

Submandibular Lymph Glands (Submaxillary Lymphatic Glands) These glands lie upon the superficial surface of the submandibu salivary gland, under cover of the deep cervical fascia. They forn chain beneath the corresponding half of the base of the mandit which extends from near the angle of the bone to near the origin of 1 anterior belly of the digastric muscle. The central gland of the chi is closely related to the facial artery as that vessel is about to asce


over the base of the mandible, from the following sources:

1. The front of the scalp.

2. The side of the nose.

3. A few from the lower eyelid.

4. The lower part of the cheek.

5. Half of the upper lip.

6. The lateral part of the lower lip

7. The anterior third of the lat eral border of the tongue.


They receive their afferent vess


8.


9 10.


11.

12.


The subjacent portion of floor of the mouth.

Half of the upper gum.

The lateral part of the lo^ gum.

The facial lymph glands.

The submandibular and si lingual salivary glands.


THE HEAD AND NECK


1199


Their efferent vessels pass to the upper deep cervical lymph glands, ch are on a level with the upper border of the thyroid cartilage of larynx.

The submental lymph glands lie beneath the chin, and are two or

e in number. They receive their afferent lymphatics from the tip

he tongue, the front of the floor of the mouth, and the inner part the lower lip; and their efferent lymphatics pass to the subidibular lymphatic glands. It must be borne in mind that these Lphatic vessels, like those elsewhere in the body, frequently comnicate across the middle line.

The prelaryngeal lymph glands, when present, are situated in front the crico-thyroid ligament, and are one or two in number. They give their afferent lymphatics from the interior of the larynx, dw the rima glottidis, and from the adjacent part of the thyroid nd. Their efferent lymphatics pass to the inferior deep cervical lph glands. The upper part of the larynx drains into the superior p cervical lymph glands along a course accompanying that of the >erior laryngeal vessels.

The para- and pretracheal lymph glands lie in front and at the sides the trachea, from which, as well as from the adjacent part of the a*oid gland, they receive their afferent lymphatics. Their efferent iphatics pass to the inferior deep cervical lymph glands. Occasionally a few lymph glands are met with along the course the anterior jugular vein.

Deep Cervical Lymph Glands. —These glands lie deep to the sternostoid muscle, and are very numerous. They are arranged in two tups, superior and inferior.

The superior deep cervical lymph glands lie along the internal

ular vein above the level of the upper border of the thyroid cartilage,

ey receive their afferent lymphatics from the cranial cavity, the ernal maxillary glands, some of the parotid and submandibular nph glands, the root of the tongue, the upper part of the thyroid nd, the upper part of the larynx, and the lower part of the pharynx, eir efferent lymphatics pass to the inferior deep cervical lymph nds. One large gland of this group is very constant, and lies close the angle of the mandible. It drains the dorsum and sides of the igue, but not the tip as a rule.

The inferior deep cervical lymph glands lie along the lower part of j internal jugular vein, and extend outwards and backwards deep to

1 sterno-mastoid as far as its posterior border. These lymph glands J continuous inferiorly with the deep cervical lymph glands lying the subclavian triangle, and, through these, with the axillary glands, ey receive their afferent lymphatics from the superior deep cervical nph glands, the upper superficial cervical lymph glands, the lower rt of the thyroid gland and larynx, and the cervical portions of the ichea and oesophagus. Their efferent lymphatics unite to form a ^gle vessel, called the jugular trunk, which opens on the left side into

2 thoracic duct, and on the right side into the right lymphatic duct.


1200


A MANUAL OF ANATOMY


Infrahyoid Muscles. —These are the omo-hyoid, sterno-hyoi sterno-thyroid, and thyro-hyoid.

Omo-hyoid. —This muscle consists of two bellies, superior (anteric and inferior (posterior), and an intermediate tendon. Origin .—I means of the inferior belly from (i) the upper border of the scapu close to the inner side of the suprascapular notch, and (2) the supr scapular ligament, which bridges over the suprascapular notch.

Insertion .—By means of the superior belly into the outer third the lower border of the body of the hyoid bone immediately later to the insertion of the sterno-hyoid muscle.

Nerve-supply .—The superior belly is supplied by the ramus desce dens hypoglossi, and the posterior belly derives its branches from t] ansa hypoglossi.


Greater Horn


Lesser Horn


Omo-hyoid (Sup. Belly)


1


Fig. 721.—The Hyoid Bone, showing its Muscular Attachments.

The inferior belly is contained in the posterior triangle of the nec and separates the occipital from the subclavian triangle. Its course forwards and slightly upwards, and it passes deep to the stern mastoid muscle, where its fibres terminate in the intermediate tendo It is ensheathed by a deep process of the deep cervical fascia as th fascia crosses the posterior triangle, and this process is attached to t back of the inner end of the clavicle and the first rib, which explai the almost horizontal position occupied by the inferior belly.

The superior belly proceeds from the intermediate tendon, ai passes upwards and slightly inwards to the body of the hyoid bor As it emerges from beneath the anterior border of the sterno-mastc muscle the superior belly crosses the carotid sheath on a level wi the narrow anterior part of the cricoid cartilage, and in the anteri triangle of the neck it forms the separation between the muscular ai carotid triangles.




THE HEAD AND NECK


1201


rno-hyoid — Origin. —(i) The posterior surface of the manubrium at its upper and outer part; (2) the posterior sterno-clavicular jnt; and, sometimes, (3) the posterior surface of the clavicle at Ler end.

sertion. —The inner two-thirds of the lower border of the body of roid bone, extending from the middle line to the insertion of the or belly of the omo-hyoid. irve-supply. —The ansa hypoglossi.

ie muscle is flat and ribbon-like, and rests upon the sternod and thyro-hyoid.

irno-thyroid — Origin. —(r) The posterior surface of the manusterni at its upper and outer part below the origin of the sterno; and (2) the posterior surface of the first costal cartilage. sertion. —The oblique line on the -outer surface of the lamina of Lyroid cartilage.

irve-supply. —The ansa hypoglossi. The nerves enter this and st muscle quite at the lower part of the neck, ie muscle is broader, but shorter, than the sterno-hyoid underwhich it lies. Within the thorax the right muscle lies in front 3 innominate artery, and the left in front of the left common d artery and left innominate vein. In the neck each muscle upon the carotid sheath and the corresponding right or left lobe 5 thyroid gland.

ie sterno-hyoid muscles as they leave the thorax are separated 1 interval, in which situation the sterno-thyroid muscles lie in contact. As the muscles ascend the sterno-hyoids converge, but erno-thyroids diverge.

tyro-hyoid — Origin. —The oblique line on the outer surface of tmina of the thyroid cartilage.

\sertion. —(1) The outer half of the lower border of the body of yoid bone; and (2) the basal half of the greater horn of that

erve-supply. —A special branch of the hypoglossal, though originlerived from the first and second cervical nerves. The nerve 3 the surface of the muscle close to its posterior border, ie muscle is quadrilateral. Its superficial surface supports the ior belly of the omo-hyoid and the sterno-hyoid muscles, and its surface is related to the lamina of the thyroid cartilage, the -hyoid membrane, the internal branch of the superior laryngeal

, and the superior laryngeal artery.

e nerves which supply the infrahyoid group of muscles are derived from 'st, second, and third cervicals through the hypoglossal and ansa hypo ction of the Infrahyoid Muscles — Omo-hyoid. —(1) lo depress yoid bone; and (2) to render tense the deep cervical fascia in the part of the neck.

erno-hyoid. —To depress the hyoid bone, erno-thyroid. —To depress the thyroid cartilage.


76



1202


A MANUAL OF ANATOMY


Thyro-hyoid.— (i) To depress the hyoid bone; and (2) to ele the thyroid cartilage, as in the production of high notes, or in glutition.

Structures in the Median Line of the Neck. —The median line of neck is divisible into two regions, suprahyoid and infrahyoid.

Suprahyoid Region. —The innermost fibres of the two platy muscles decussate at the median line for a short distance below chin. On either side of the median line, under cover of the platy< is the anterior belly of the digastric muscle. The anterior bellic


Posterior Belly of Digastric— and Stylo-hyoid Hyo-glossus Muscle and Hypoglossal Nerve


Ster. Head of St.-mas. -Crico-thyroid Muscle -

Cricoid Cartilage Lat. Lobe of Thyroid Gland

Trapezius

Clavicular Head of Stemo-mastoid Brachial Plexus


Subclavian Artery (third part)

Clavicle


Anterior 'Belly of Diga: jf Mylo-hyoid


Body of Hyoid Bone _ Superior Belly of Omo ' - Stemo-hyoid


Thyro-hyoid


Thyroid Cartilage Sterno-thyroid Superior Belly of Omo Crico-thyroid Ligamen


Stemo-hyoid


Isthmus of Thyr Gland


■s Inferior Thyroid y of Veins

Cla. Head of St.-i


,T\T

-\r Sterno-thyroid


Sternal Head of Sternomastoid


Sterno-thyroid


Sterno-hyoid


Fig. 722.—Dissection of the Front of the Neck.

The area bounded on either side by the anterior belly of the digastric a below by the body of the hyoid bone is the submental triangle.


opposite sides are near each other at the chin, but as they des< with an inclination outwards they diverge from each other, and 1 between them a triangular interval sometimes called the subm< triangle. The base of this triangle is formed by the body of the h bone, and each lateral boundary is constructed by the anterior 1 of the digastric, the apex being placed at the chin. The area oi triangle is occupied by the anterior portions of the mylo-hyoid mus which meet at the median line in a tendinous raphe, and super! to these muscles there are the submental lymph glands.


















THE HEAD AND NECK


1203


Epiglottis


Greater Horn of Hyoid Bone~

Lesser Horn of Hyoid Bone Body of Hyoid Bone-"

Thyro-hyoid Membrane -Levator (Mandril® ) Thyroid® Muscle / Thyroid Cartilage - Crico-thyroid Ligament. Pyramidal LobeCricoid Cartilage'

Right Lobe of Thyroid Gland Isthmus


Trachea


lubmental Lymph Glands. —These glands, usually two in number,

1 the submental triangle beneath the chin and above the body of hyoid bone, one being on either side of the median line. Each d receives its afferent vessels from (1) the medial portions of the

r lip and lower gum; (2) the tip of the tongue and adjacent portion

le floor of the mouth; (3) the skin of the chin; and (4) sometimes upper lip. Their efferent vessels pass to (1) the submandibular ph glands, and (2) the ilo-omo-hyoid lymph gland, of the superior deep cer 1 lymph glands, infrahyoid Region. —The re from the hyoid bone downis to the suprasternal notch the upper border of the Lubrium sterni is of conrable importance in conion with bronchocele or re, laryngotomy, and traDtomy.

The body of the hyoid bone

r well-marked structure, lg with the greater horn on er side of it. Below the id bone there is the thyroid membrane, which passes /ards within the lower borof the hyoid bone. The t structure is the thyroid kilage, the upper border of ch has a well - marked iian notch, whilst its two form by their union the minent laryngeal prominence mum Adami).

Succeeding the thyroid carti 2 there is a narrow interval, which is occupied by the crico-thyroid iment, and immediately below this is the narrow anterior part of

cricoid cartilage. The crico-thyroid ligament is only exposed close the median line, being elsewhere covered by the two crico-thyroid scles. The exposed part of the ligament is crossed by the cricovoid arterial arch, which is situated midway between the thyroid 1 cricoid cartilages, and lying upon the ligament there may be i or two prelaryngeal lymphatic glands. Laryngotomy may be formed in the crico-thyroid region, and the crico-thyroid arterial h has to be borne in mind.

Succeeding the cricoid cartilage is the trachea, which, as it cends, inclines backwards, and therefore becomes somewhat


Right Bronchus^ Eparterial Bronchus, Hyparterial Bronchus.^'


Si'- ; .

err::.?*,

iCZZZv

.

^ ".."..-A


Left Bronchus

Fig. 723. —The Hyoid Bone, Larynx Trachea, Bronchi, and Thyroid Gland (Anterior View).












1204


A MANUAL OF ANATOMY


inaccessible; at the suprasternal notch it may be i£ inches fr the surface. The thyroid gland is intimately related to it superioi Each lobe closely embraces it laterally as low as about the fifth ri and the isthmus lies in front of the second and third rings as a n but its position is liable to variation. Crossing the upper border of isthmus there is one of the branches of the superior thyroid arte known as the artery of the isthmus.

There is nothing of any importance in front of the trachea ab< the isthmus of the thyroid gland. Below the isthmus there is a m or less copious plexus of veins, called the inferior thyroid plexus, fr which the right and left inferior thyroid veins descend. OccasI ally a small artery, called the arteria thyroidea ima, ascends direc in front of this part of the trachea in the median line to reach i


\c



% \


\ \ \ » / / / / / —V-A-A-/ / /


phrenic ru-^ scalenus anterior'--., thyro-cervical trunk—-.

sub'elcw^ ay— scalenus medius—

vertebral vn.-vertebral ay.-


-vagus n. 'omo-hyoid

—brachial plexus

-I 5 - 1 rib

sympathetic trunk

Z n _d r jb


zura—"

oesophagus

long, cap. and long cer. disc, between 1st and 2nd thoracic vtb.


\2 n - d thoracic tr pr '"'I s - thoracic spinous pr


Fig. 724.—Section through Lower Part of Neck.


isthmus of the thyroid gland. The innominate, and even the rig common carotid, artery and the left innominate vein sometirr encroach upon the front of the trachea towards the root of the nec The latter is a particularly important arrangement to remember, a: occurs more frequently in women and children. In early life t upper part of the thymus covers the front of the trachea. The foi going structures are covered by the sterno-thyroid and sterno-hyc muscles in the following manner: the two sterno-thyroid muscles a in contact with each other for a short distance above the manubriri sterni, so as to cover the trachea, but the two sterno-hyoid muse! are here separated by an interval; superiorly the two sterno-thyre muscles diverge, and the two sterno-hyoid muscles come very near together.






THE HEAD AND NECK


1205


he operation performed upon the trachea is tracheotomy, rding as it is performed above or below the isthmus of the thyroid 1 , it is spoken of as the high or the low operation. In the high ition there is no anatomical obstacle, unless it be a close attach: of the isthmus of the thyroid gland to the tracheal rings which vers. In the low operation the following obstacles are present: he trachea is here less accessible, because it recedes from the ,ce; (2) the inferior thyroid plexus of veins might prove trouble


.Ansa


- Ant. Jug. V. Vagus


N. toThyro-hyoid

Int. Laryngeal Nerve


Ext. Laryngeal Nerve

Descendens Hypoglossi Desc. Cerv.


sser Occip. N. •


Upper Cord of rachial Plexus


cessory Nerve..


Phrenic

725.— Deep Nerves in the Neck in Relation with Carotid Sheath.


e; (3) an arteria thyroidea ima may be present; (4) the innominate right common carotid arteries and the left innominate vein may endangered; and (5) in young children the thymus would be in the

Fhe Ramus Descendens Hypoglossi (Descendens Cervicis Nerve).

ramus descendens arises from the hypoglossal nerve as the latter ks round the occipital artery, its fibres being derived from the municating branches which the hypoglossal receives from the loop





1206


A MANUAL OF ANATOMY


between the first and second cervical nerves. The nerve, whicl long, passes downwards and slightly forwards, lying upon, or witl the carotid sheath, and in either case directly over the line of common carotid artery. Before reaching the centre of the necl furnishes a branch to the superior belly of the omo-hyoid mus Lower down it is joined by a branch which is formed by the unior the two rami communicantes cervicales from the anterior primary r; of the second and third cervical nerves. These two rami, howe^ sometimes join it separately. In this manner a loop is formed usu; about the level of the cricoid cartilage, which is called the ansa hy


H.G.


Fig. 726.— Scheme of the Hypoglossal Nerve, showing its Connections with Cervical Spinal Nerves.

Sy., twig from sympathetic; Pn., communicating with vagus; ic, 2c, 3c, fi second, and third cervical; C.H., communicans hypoglossi; C.C., c< municantes cervicalis; D.C., descendens hypoglossi; A.B.O.H., to ante belly of omo-hyoid; A.C., ansa hypoglossi; S.H., to sterno-hyoid; S.T. sterno-thyroid; P.B.O.H., to inferior belly of omo-hyoid; T.H., to th] hyoid; G.H., to genio-hyoid; G.H.G., to genio-glossus; H.G., to hyo-gloss S.G., to stylo-glossus.

glossi. The convexity of the loop is directed downwards, and fr it branches are given off to (1) the sterno-hyoid, (2) the sterno-thyrc and (3) the inferior belly of the omo-hyoid muscles.

The fibres of the ramus descendens hyo-glossi are of spinal, not hypoglos; origin.

For the rami communicantes cervicales, see Cervical Plexus (p. ii£

The Nerve to Thyro-hyoid. —This nerve, which is composed of spf fibres derived from the loop between the first and second cervi nerves, arises from the hypoglossal at the lower border of the poster belly of the digastric. It passes forwards and downwards, formi


THE HEAD AND NECK


1207


ute angle with the parent trunk, and enters the thyro-hyoid

le on its superficial surface.

irotid Sheath. —The carotid sheath, already described on p. 1179, ived from the posterior lamina of the sheath of the sterno-mastoid le, and is intimately connected anteriorly with the pretracheal , and posteriorly with the prevertebral layer, of the deep cervical i The interior of the sheath is divided into three compartments— •, inner, and posterior. The outer and inner compartments are •ated from each other by a septum, the inner compartment containhe common carotid artery and, it may be, the ramus descendens glossi, and the outer compartment the internal jugular vein. The rior compartment is situated within the back part of the septum, contains the vagus nerve. The ramus descendens hypoglossi may pon the sheath, or within it, and the trunk of the sympathetic mds behind, and in intimate relation with it.

tie foregoing is the usual account of this sheath, but there are some anaits who believe that not only it, but many other fascial planes are hardly


Fig. 727.—Scheme of Section through Carotid Sheath showing

Contents and Certain Relations.


mizable in the living or in the undisturbed dead body In any case, there > reason to believe that the carotid has more or less of a sheath than any r artery of its own size elsewhere.

[Jommon Carotid Arteries— The right common carotid artery arises 1 the innominate artery behind the upper border of the right sternoicular joint, and the left common carotid aitery arises from the er surface of the arch of the aorta, in close proximity to the origin he innominate artery. The vessel of the right side is therefore rely cervical, whilst that of the left side is partly thoracic and part y

The thoracic part of the left common carotid artery has alieady n described in connection with the thorax (see p. 1039)In the neck the common carotid artery of each side extends from back of the corresponding sterno-clavicular joint to the level o upper border of the thyroid cartilage of the larynx, which corrends to the disc between the bodies of the third and fourth cervica tebrse. At this level the vessel divides into the external and interna



1208


A MANUAL OF ANATOMY


Fig. 728. —The Aorta in


1. Arch of the Aorta

2. Aortic Isthmus

3. Aortic Spindle

4. Descending Aorta

5. Coronary Arteries (from

Ascending Aorta)

6. Innominate Artery

7. Left Common Carotid

8. Left Subclavian

9. Right Common Carotid


the Thorax, and the Head and Neck.

10. Right Subclavian

11. External Carotid

12. Internal Carotid

13. Maxillary

14. Superficial Temporal

15. Vertebral

16. Internal Mammary

17. Thyro-cervical Trunk

18. Inferior Thyroid

19. Transverse Cervical


Principal Arteries of i


20. Suprascapular

21. Superior Thyroid

22. Lingual

23. Facial

24. Occipital

25. Posterior Auricular

26. Ascending Pharyngea

27. Transverse Facial

28. Posterior Intercostals

29. Ligamentum Arteriosum







THE HEAD AND NECK


1209


rotid arteries. The place of bifurcation is sometimes opposite the dy of the hyoid bone, and, more rarely, on a level with the cricoid rtilage of the larynx. The vessel is about 3J inches long, and its urse is upwards and outwards in the direction of a line drawn from 3 sterno-clavicular joint to a point midway between the angle of 3 mandible and the mastoid process of the temporal bone. This e, as high as the level of the upper border of the thyroid cartilage, Dresents the course of the common carotid artery. At the root of e neck the two common carotid arteries are not very far apart, and e trachea lies in the intervening space. As the two vessels ascend ey become more divergent, on account of the projection of the right d left lobes of the thyroid gland and the thyroid cartilage.

The artery, along with the internal jugular vein and vagus nerve, d, perhaps, the ramus descendens hypoglossi, is contained within e carotid sheath, already described. Opposite the cricoid cartilage is crossed by the superior belly of the omo-hyoid muscle. Below is level it lies deeply in the region of the muscular triangle, being Lder cover of the sterno-hyoid and sterno-thyroid muscles, in addition the platysma and the anterior border of the sterno-mastoid. Above is level it is situated in the carotid triangle, where it is more super:ially placed, its only muscular coverings being the platysma and the iterior border of the sterno-mastoid.

Relations — Anterior .—The skin; superficial fascia and platysma; vesting layer of the deep cervical fascia; anterior border of the erno-mastoid; sterno-hyoid; sterno-thyroid; superior belly of the no-hyoid; and the anterior wall of the carotid sheath. Three veins oss the artery from without inwards: (1) the anterior jugular vein osses it immediately above the clavicle, superficial to the sternoA>id and sterno-thyroid muscles; (2) the middle thyroid vein just jlow the level of the cricoid cartilage; and (3) the superior thyroid jin near its bifurcation. The sterno-mastoid branch of the superior lyroid artery, which is of small size, passes obliquely downwards id outwards in front of the carotid sheath in the carotid triangle, tie ramus descendens hypoglossi descends in front of the carotid Leath to form the ansa hypoglossi.

Posterior .—The posterior wall of the carotid sheath; the cervical ansverse processes as high as the level of the fourth; the longus irvicis, scalenus anterior, and part of the longus capitis muscles; ie sympathetic trunk, which is intimately related to the posterior all of the carotid sheath; the recurrent laryngeal nerve; and the iferior thyroid artery, both of which latter structures pass inwards id upwards behind the lower part of the sheath.

Lateral .—The internal jugular vein and the vagus nerve, the latter ing between the artery and the vein, on a plane posterior to both, t the lower part of the neck, on the right side, the internal jugular ein leaves the common carotid artery, making a slight interval in hich the right vagus nerve appears as it is about to pass in front F the first part of the right subclavian artery. On the left side,


12 IO


A MANUAL OF ANATOMY


however, the internal jugular vein is very closely related to the commo carotid artery, and even overlaps it.

Medial .—From below upwards (i) the trachea and oesophagu: with the recurrent laryngeal nerve and the inferior thyroid arter lying in the intervening groove; (2) the corresponding lobe of th thyroid gland, upon which the vessel impresses a groove, and by whic it is usually overlapped; and (3) the larynx and pharynx.


Accessory Part of Parotid Gland

Parotid Gland ! _ ., ,

Parotid Gland


Transverse Facial Artery i


Superficial Temporal Artery Maxillary Artery


Mental Branch of Inferior Dental | Artery


Facial Artery Lingual Artery


Inferior Thyroid Artery_


__ Posterior Auricula Artery


\Occipital Artery


Greater Occipital Nerve

Internal Carotid Artery


External Carotid Artery.I Superior Laryngeal Artery , Superior Thyroid Artery

Vagus Nerve ( Internal Jugular Vein l C ommon Carotid Artery V

Superior Belly of Omo-hyoid __ Ascending Cervical Artery _.J


Deep Cervical " Lymph Glands


Phrenic Nerve


! \

Subclavian Artery (first part) \


Scalenus Anterior Muscle

Transverse Cervict Artery


\ Suprascapular Artery Thyro-cervical Trunk


Fig. 729.—Deep Dissection of the Left Side of the Neck

(after Spalteholz).


The common carotid artery, as a rule, gives off no branch. Th superior thyroid artery, however, may arise from it superiorly, and i some cases the ascending pharyngeal artery.

Surgery—Compression. —The part of the vessel most favourabl situated for compression lies in front of the tubercle of the transvers process of the sixth cervical vertebra, this tubercle, known as th carotid tubercle, being on a level with the cricoid cartilage of the larynx Ligation. —The part of the vessel most favourably placed fo ligation is situated on a level with the cricoid cartilage just abov the point where it is crossed by the anterior belly of the omo-hyoi'












THE HEAD AND NECK


1211


,cle. The structures to be avoided in the operation are: (i) the us descendens hypoglossi upon, or it may be within, the sheath; the internal jugular vein and vagus nerve, both of which are lin the sheath, and upon the outer side of the artery; and (3) the ipathetic trunk, which lies behind and in close contact with the ith. The small sterno-mastoid branch of the superior thyroid

ry will probably be cut, as it passes obliquely downwards and

wards over the sheath in the carotid triangle. Ligation of the

ry below the level of the cricoid cartilage is attended with diffi
y, the vessel being here covered by the sterno-hyoid and sternoroid muscles, in addition to the platysma and sterno-mastoid.

the left side the internal jugular vein is an additional difficulty. Collateral Circulation after Ligation. —(1) Cross anastomoses take

e freely between the external and internal carotid arteries of

losite sides. (2) The inferior thyroid artery of the side operated ►n anastomoses freely with the superior thyroid of the same side, ch is a branch of the external carotid. (3) The deep cervical nch of the superior intercostal, which latter is a branch of the Dnd part of the subclavian artery on the right side, and of the t part on the left side, anastomoses with the descending branch the occipital, which is a branch of the external carotid. (4) The tebral artery undergoes much enlargement.

Carotid Body.— This small body is situated behind the common otid artery close to its bifurcation. It is composed of a few lobules ted by connective tissue, and it receives minute twigs from the acent part of the common carotid artery. The lobules consist groups of polyhedral cells permeated by blood-capillaries and apathetic nerve-filaments. Some of the cellular constituents are omaffin cells, similar to those which are met with in the medulla the suprarenal gland and in the sympathetic ganglia. These cells derived from the contiguous ganglia of the sympathetic system, e carotid body of each side is similar to the glomus coccygeum 1 organs of Zuckerkandl.

The carotid body is developed in part from the sympathetic system, and in

t from the lymphatic system. # _ , ,, , ,

Development.— The common carotid arteries are developed from the parts of ventral aortae which are situated between the third and fourth aortic arches.

Internal Jugular Vein. —The internal jugular vein is the continuon of the intracranial sigmoid sinus. It begins in the posteroeral compartment of the jugular foramen, and ends behind the ler end of the clavicle by joining the subclavian to form the j nn o~ nate vein. At its beginning it has a slight dilatation, called the berior bulb. The vein descends vertically, lying at first on the outer e of the internal carotid, and then on the outer side of the common ~otid artery, the vagus nerve being interposed in each case, and being enclosed within the carotid sheath. The relations of the ssel for the most part correspond to those of the artenes which 1

companies.


1212


A MANUAL OF ANATOMY


Tributaries.—These are as follows:


Pharyngeal. Superior thyroid. Middle thyroid.


Inferior petrosal sinus.

Common facial.

Lingual.

A small vein accompanying the occipital artery may occasional open into it.

Hypoglossal Nerve

Second Cervical Nerve / Occipital Artery


Accessory

Nerve


Lesser Occipital Nerve


Great Auricular Nerve


R am i Communicantes ( Cervicales \


Fourth Cervical Nerve


Descending Branch of Fourth Cervical Nerve


Supraclavicular Nerves


External Jugular

vd " (ci '° /if

Nerve to Subclavius jdjP®®


Subclavian Vein


Vagus Nerve

Nerve to Thyro-hyoid Muscl


Terminal Branches M Hypoglossal Ner


Internal Laryngea Nerve


External Larynge; Nerve

— Ramus Descenden Hypoglossi

-Nerve to Superior I

of Omo-hyoid Ansa Hypoglossi



Anterior J ugular V

- -. Internal Jugular V


v //i/lfJM


Fig. 730. —Deep Dissection of the Right Side of the Neck (after

Hirschfeld and Leveill£).

1, upper part of sterno-mastoid; 2, trapezius; 3, tendon of omo-hyoid.


The inferior petrosal sinus leaves the cranial cavity through th antero-medial compartment of the jugular foramen, and opens int the internal jugular vein close to the base of the skull.

Development. —The internal jugular vein is developed from the anteric cardinal vein.

The vagus nerve in the neck will be found described on p. 1327.

External Carotid Artery.—The external carotid artery is one c the terminal branches of the common carotid, the other being th internal carotid artery. In spite of its name, it is, at its origin, th medial of the two vessels, and it lies anterior to, and nearer the media









THE HEAD AND NECK


1213


than, the internal carotid. It extends from a point on a level 1 the upper border of the thyroid cartilage to one immediately ind the neck of the mandible, where it divides in the substance of parotid gland into the superficial temporal and maxillary arteries, s about 2J inches in length, and its direction is at first upwards forwards as far as the angle of the mandible, and then upwards backwards. At first the artery lies in the carotid triangle, and is iparatively superficial. As it leaves this triangle it is more deeply

ed, being crossed by the posterior belly of the digastric and styloid muscles, and the hypoglossal nerve. Then the vessel is eroded in the substance of the parotid gland, where it is crossed from

ind forwards by the facial nerve.

Relations.— Antero--lateral. —The skin; superficial fasciaplatysma; p fascia; anterior border of the sterno-mastoid; the lingual and imon facial veins; the hypoglossal nerve (all the foregoing being grior relations, whilst the artery lies in the carotid triangle); the terior belly of the digastric and stylo-hyoid muscles; the greater t of the parotid gland; the posterior facial vein; and the facial ve. Deep or Postero-medial. —(1) The stylo-pharyngeus muscle,

so-pharyngeal nerve, and styloid process of the temporal bone,

of which lie between the vessel and the internal carotid (the latter g lying on a plane behind the external carotid); and (2) a small tion of the parotid gland. The pharynx and hyoid bone; the erior laryngeal nerve; a portion of the parotid gland; and the terior border of the ramus of the mandible.

The external carotid artery has no vein in the sense of a companion sel, but the posterior facial vein descends superficially to it in the otid gland to near the angle of the mandible, beyond which point artery has no vein.

The course of the vessel may be indicated by a line drawn from side of the cricoid cartilage of the larynx to the tragus of the icle.

Development. —The external carotid artery is, for a short portion of its rse, the persistent part of the ventral aorta above the level of the third aortic 1. In the rest of its extent it is formed from enlarged side-branches of the inal stem.

Branches.—These are arranged in four sets ending, and terminal—and are as follows:

Anterior. Posterior. Ascending.

'erior thyroid. Occipital. Ascending

glial. Posterior auricular. pharyngeal.

ial.

Superior Thyroid Artery.—This vessel arises in the carotid tiiangle m the front part of the external carotid close to its oiigin. It

es an arched course forwards and downwards, passing undei covei

the infrahyoid muscles. On reaching the apex of the corresponding >e of the thyroid gland it breaks up into its terminal branches,


—anterior, posterior,

Terminal.

Superficial temporal. Maxillary.


1214


A MANUAL OF ANATOMY


which enter the lobe on its superficial aspect, and anastomose free within it with branches of the inferior thyroid artery, and in the isthm with its fellow of the opposite side.

Branches:

Infrahyoid. Crico-thyroid

Sterno-mastoid. Glandular.

Superior laryngeal. Muscular.

The infrahyoid artery passes inwards on the thyro-hyoid membrar deep to the thyro-hyoid muscle, and close to the lower border of i


Fig. 731. —Dissection of Carotid Triangle.

hyoid bone. It anastomoses at the middle line with its fellow of t opposite side, and with the suprahyoid branch of the lingual arte: of the same side. The sterno-mastoid branch passes obliquely downwar. and outwards, lying superficial to the carotid sheath, to enter the de< surface of the muscle from which it takes its name. It is liable to cut in tying the common carotid artery. The superior laryngeal arte accompanies the internal laryngeal nerve, and, passing deep to tj outer border of the thyro-hyoid muscle, pierces the thyro-hycl membrane, to be distributed to the interior of the larynx. The cril thyroid branch passes transversely inwards upon the crico-thyrC ligament, and anastomoses with its fellow of the opposite side to foil


Hypoglossal


Digastric Post. Belly

Comm. Facial V.


N. Desc. Hypog. Sup. Laryng. N. Inf. Constrict.


. Laryng. N. >uter div.)

Sup. Thyr. V.

Omo-hyoid

Sterno-hyoid





THE HEAD AND NECK


1


1215


crico-thyroid arch. The glandular branches are distributed to the responding lobe of the thyroid gland. They anastomose freely h branches of the inferior thyroid of the same side, and with branches the fellow of the opposite side to a less extent. One very constant .nch, known as the artery of the isthmus, courses along the upper -der of the isthmus, and anastomoses with its fellow of the opposite e. The muscular branches are distributed to the infrahyoid muscles. The superior thyroid vein issues from the upper part of the corremding lobe of the thyroid gland, and crosses in front of the common otid artery near its bifurcation to open into the internal jugular n. Its tributaries for the most part correspond to the branches the artery.

Lingual Artery. —The lingual artery arises from the front part of i external carotid a little above the origin of the superior thyroid d opposite the greater horn of the hyoid bone. From its comcated course it is convenient to divide the artery into three parts.


Dorsum of Tongue

Sublingual Gland (turned >

UP) !


Stylo-glossus Muscle N Lingual Nerve

x


Submandibular Ganglion

Submandibular Gland (deep part)

^Facial Artery


Mandible . (in section)


Genio-glossus Muscle , (

Genio-hyoid Muscle ! Sublingual Artery Arteria Profunda Linguae


_Lingual Artery

_Sup. Thy. Artery

. Ext. Car. Artery

\ \ Vena Comitans Hypoglossi

t Hypoglossal Nerve

Submandibular Duct


Fig. 732.—Deep Dissection of the Left Submandibular Region.


First Part. —The first part of the vessel ascends for a little, and en, bending sharply, descends to the greater horn of the hyoid bone, issing deep to the posterior belly of the digastric and stylo-hyoid uscles. So far the vessel lies in the carotid triangle, and the bend tiich it describes is crossed by the hypoglossal nerve. It is for the ost part comparatively superficial.

Second Part. —The second part passes horizontally forwards along ie upper border of the hyoid bone deep to the hyo-glossus, the hypoossal nerve and its vena comitans being superficial to that muscle, eep to it is the middle constrictor. At the anterior border of the ^o-glossus it enters upon the third part of its course.

Third Part.— Near the anterior border of the hyo-glossus muscle ie lingual artery describes another sharp bend in an upward direction, id ascends almost vertically to the under surface of the tongue,

sting upon the genio-glossus, and being under cover of the anterior

irder of the hyo-glossus. Having reached the tongue, the artery




1216


A MANUAL OF ANATOMY


passes forwards on its under surface in a tortuous manner under th name of arteria profunda linguae.

Branches:

1. Suprahyoid. 3. Sublingual.

2. Rami dorsales linguae. 4. Arteria profunda linguae.

The suprahyoid artery arises from the lingual at the posterior horde of the hyo-glossus, and passes along the upper border of the hyof bone.

The rami dorsalis linguce arise under cover of the hyo-glossn muscle, which they pierce, and so reach the posterior third of th


Superficial Temporal \

Occipital

Maxillary

Posterior Auricular


Transverse Facial


Supraorbital

Supratrochlear


Angular

Lateral Nasal

Superior Labial Inferior Labial


Submental Submandibular Gland


Internal Carotid '


External Carotid


Lingual

Suoerior Thyroid


Fig. 733. —The Arteries of the Right Side of the Head (after

L. Testut’s ‘ Anatomie Humaine ’)•

dorsum of the tongue. They are distributed to the mucous membran and substance of the tongue, the tonsil, and the soft palate.

The sublingual artery arises close to the anterior border of th hyo-glossus muscle. It supplies the sublingual gland, the adjacen muscles, and the mucous membrane of the floor of the mouth. On of the lateral branches anastomoses at the median line with a com sponding branch of the opposite artery, and another of them is know as the artery of the frenulum linguce.

The arteria profunda linguce [ranine artery) is the terminal pai of the lingual. It passes forwards on the under surface of the tongu< lying immediately lateral to the insertion of the genio-glossus, betwee







THE HEAD AND NECK


1217

id the longitudinalis linguae inferior. It is more or less embedded le substance of the tongue, and its course is tortuous in adaptation tie mobility of the organ to which it is so intimately related. ToIs the tip of the tongue the vessel is very superficially placed, close by the side of the frenulum linguae, and it anastomoses l its fellow of the opposite side near the tip. Elsewhere the cross domoses are remarkable for their absence, and if one lingual artery led with fine injection hardly any crosses the mid-line of the tongue pt at the tip. The arteria profunda linguae furnishes branches y to the substance of the tongue. Its close relation to the frenulum rae is to be carefully noted in connection with the operation for f of tongue-tied children.

rhe lingual veins are as follows: (1) the vena comitans hypoglossi ine vein), which is of large size, commences under the tip of the pe, and passes backwards, in company with the hypoglossal nerve,

rficial to the hyo-glossus muscle, receiving tributaries from the

ounding structures; (2) two vence comitantes accompanying the ral artery; and (3) the dorsal lingual veins, which originate in a us beneath the mucous membrane over the posterior third of the .n. These three sets of veins may join into a common trunk, called lingual vein, which opens into the internal jugular vein, or they r terminate independently in that vein.

jingual Lymph Glands.—These glands, which are of small size, pon the outer surfaces of the genio-glossus and hyo-glossus muscles, g the vena comitans hypoglossi. They are really small glandions lying in the course of the lymphatic vessels of the tongue hese pass to join the deep cervical lymph glands.

Facial Artery.—The facial artery arises from the front part of external carotid in the carotid triangle immediately above the nal artery, or sometimes in common with that vessel. It passes ards and forwards deep to the hypoglossal nerve, the posterior 7 of the digastric and the stylo-hyoid muscles, into the submanilar triangle. It then becomes embedded in a groove on the upper back part of the submandibular gland, its general course being ^ards with many curves. From this groove it describes a sharp i upwards over the base of the mandible in front of the masseter cle. The vessel then enters upon the facial part of its course, for scription of which see p. 1278.

Branches. —Four branches arise from the cervical part of the facial ry:

1. Ascending palatine. 3. Glandular.

2. Tonsillar. 4. Submental.

rhe ascending palatine artery passes upwards between the stylosus and stylo-pharyngeus muscles, and then over the upper ler of the superior constrictor of the pharynx along with the levator ti muscle. It is distributed to the soft palate, tonsil, and auditory The tonsillar artery passes upwards between the stylo-glossus

77


1218


A MANUAL OF ANATOMY


and medial pterygoid muscles, and, after piercing the superior c< strictor muscle, it is distributed to the tonsil and the posterior p of the side of the tongue. The glandular branches axe distributed the submandibular gland. The submental artery arises from i facial just below the mandible, and passes forwards superficial the mylo-hyoid muscle. It gives branches to the submandibular gla and mylo-hyoid muscle, some of the branches piercing that mus to reach the sublingual gland and anastomose with the subling artery.

The cervical part of the anterior facial vein passes downwai and backwards superficial to the submandibular gland. Hav: received tributaries corresponding to the branches of the cervical p of the artery, it unites with the anterior division of the posterior fac vein to form the common facial vein, which opens into the inter: jugular opposite the body of the hyoid bone.

Occipital Artery. —The occipital artery arises from the poster aspect of the external carotid opposite the facial artery. It pas

at first upwards and sligh


UATERfll

J>IC,


r rvi T. CAROT.


MX 1.


NJ.X 11


occ i P.

ARTERV.


Fig. 734.—Plan of Course of Occipital Artery in Neck.


backwards beneath the poster belly of the digastric and sty hyoid muscles, and the hy] glossal nerve, having hool round it, passes forwards sup ficial to it. Having reached level of the interval between 1 transverse process of the at and the mastoid process, ' artery changes its course, a passes backwards to occupy occipital groove on the in: aspect of the mastoid proc( where it is in touch with rectus capitis lateralis. In t backward course it crosses


internal carotid artery, internal jugular vein, and vagus, accessc and hypoglossal nerves. As it lies in the occipital groove the ve< is very deeply placed, being covered by the following structui (1) the origin of the posterior belly of the digastric; (2) the lon$ simus capitis; (3) the splenius capitis; and (4) the sterno-mastc After escaping from beneath the splenius capitis, the vessel takes upward course superficial to the semispinalis capitis to the occip: region, where it ramifies in a tortuous manner along with the branc of the greater occipital nerve.

Branches. — Muscular; meningeal; mastoid; descending; s Occipital.

The muscular branches are distributed to the adjacent muse one of them, the sterno-mastoid branch, crosses the hypoglossal ne: and enters the deep surface of the sterno-mastoid muscle in comps



THE HEAD AND NECK


1219


the accessory nerve. The meningeal branch accompanies the internal lar vein, and enters the cranial cavity through the jugular foramen apply the dura mater of the posterior fossa. The mastoid branch es through the mastoid foramen when present, and supplies the cent dura mater. The descending and the occipital [terminal) Lches have been already described (see p. 1146).

Tie description of the occipital veins will be found on p. 1147. tosterior Auricular Artery. —This vessel arises from the posterior ct of the external carotid a little above the origin of the occipital ry, and above the posterior belly of the digastric. It passes ards and slightly backwards under cover of the lower part of the tid gland, and behind the styloid process of the temporal bone, g crossed by the facial nerve. Having reached the groove between back of the auricle and the mastoid process, where it meets the erior auricular nerve, it divides into two branches, auricular and aital.

branches. —These are as follows: muscular; glandular; stylotoid; auricular; and occipital.

rhe muscular branches supply the adjacent muscles. The glandular ches are distributed to the lower part of the parotid gland. The -mastoid artery enters the facial canal through the stylo-mastoid men. It is distributed to the tympanic cavity and the mastoid

ells, and anastomoses with the tympanic branch of the first part

ae maxillary artery. With this latter branch it forms a ring at the lmference of the tympanic membrane on its inner aspect. Within facial canal the stylo-mastoid artery anastomoses with the super1 petrosal branch of the middle meningeal artery, which branch rs the canal through the hiatus for greater superficial petrosal r e. The auricular branch passes upwards deep to the auricularis erior muscle, and furnishes branches to the inner aspect of the

le, some of which reach the outer surface by piercing the cartilage

by turning round its margin. The auricular branch anastomoses l the posterior branch of the superficial temporal artery. The 'ntal branch passes backwards over the mastoid process to the pital region, and anastomoses with the occipital artery, rhe posterior auricular vein, of fairly large size, often unites with posterior division of the posterior facial vein near the angle of inferior maxilla, and by this union the external jugular vein is led. The arrangement, however, is very variable.

Ascending Pharyngeal Artery. —This long, slender vessel arises from beginning of the deep surface of the external carotid. It runs ically upwards towards the base of the skull, lying very deeply 1 the longus capitis muscle, and between the internal carotid ry, in front of which it has passed, and the pharynx, branches :

1. Pharyngeal. 3. Prevertebral.

2. Palatine. 4. Inferior tympanic.

5. Meningeal.


1220


A MANUAL OF ANATOMY


The pharyngeal branches are distributed to the pharynx. TJ palatine branch passes over the superior constrictor muscle of t] pharynx, and is distributed to the soft palate, auditory tube, and tons The prevertebral branches supply the prevertebral muscles. T] inferior tympanic artery passes with the tympanic branch of the gloss pharyngeal nerve through the tympanic canaliculus in the petro part of the temporal bone, and so reaches the tympanic cavity, to t] inner wall of which it is distributed. The meningeal branches are t' terminal branches of the ascending pharyngeal, and are three in numbe One passes through the foramen lacerum, a second through the jugul foramen, and a third through the anterior condylar canal, to be d: tributed to the dura mater in the vicinity of these foramina.

The descending pharyngeal vein accompanies the ascending phary

geal artery.

For the superficial temporal and maxillary branches of the extern carotid artery, see pp. 1158 and 1304.

The internal carotid artery will be found described on p. 1323.

Thyroid Gland. —The thyroid gland is situated on either side the upper part of the trachea and larynx, and a small portion of it li in front of the upper part of the trachea. Its size is subject to mu variation; its weight is rather more than 1 ounce; and it is larger the female than in the male. It consists of right and left lobes and; isthmus.

Each lobe is conical and about 2 inches long, the rounded ba being directed downwards. It extends from the middle of the lami: of the thyroid cartilage to about the level of the fifth ring of the trache Its superficial surface , which looks forwards and outwards, is somewb convex, and is covered by the sterno-thyroid, sterno-hyoid, and superi belly of the omo-hyoid muscles. It is also overlapped by the anted border of the sterno-mastoid. Its deep surface is concave in adaptati to the trachea and larynx. The anterior border is thin, and towar its lower part is connected with that of the opposite lateral lobe means of the isthmus. The posterior border is thick, and is in conta with the pharynx and oesophagus, and has the parathyroid glan embedded in it. Each lobe overlaps the corresponding common carol artery, enclosed in the carotid sheath, and is frequently grooved by tb vessel. Interiorly it overlaps the recurrent laryngeal nerve and infer] thyroid artery. The apex of each lobe rests upon the inferior constrict muscle of the pharynx, and the superior thyroid artery enters it sup< ficially and deeply4

The isthmus is inconstant as regards size and position. Its dep ranges from J to 1 inch, and its breadth is about \ inch. It conne^ the lower parts of the anterior borders of the lateral lobes, but dc not reach quite so low as their bases. .It lies in front of the trach< usually upon the second and third rings, and fits closely to the rir upon which it rests. Along its upper border there is a branch of t superior thyroid artery, known as the artery of the isthmus, which an. tomoses with its fellow of the opposite side. From its lower bore


THE HEAD AND NECK


1221


?ral veins issue, which take part in the inferior thyroid plexus of is in front of the trachea.

In some cases an additional lobe is present, called the pyramidal !. It forms a long pyramid, which is attached by its base to the ier border of the isthmus, usually at its junction with the left lobe, apex is attached to the body of the hyoid bone by a fibrous band, ch sometimes contains muscular fibres, known as the levator glandulcz oidce muscle. It is seldom quite median in position.


erior Belly of Digastricand Stylo-hyoid lyo-glossus Muscle and’ Hypoglossal Nerve


Head of Sterno-mastoid Crico-thyroid Muscle Cricoid Cartilage t Lobe of Thyroid Body


Trapezius vicular Head of

7 / 7 ,


sterno-mastoid Brachial Plexus


Subclavian Artery (third part)

Clavicle


Anterior Belly of Digastric L Mylo-hyoid


Body of Hyoid Bone

Superior Belly of Omo-hyoid Sterno-hyoid

K ljnimr- Thyro-hyoid

USSr - Laryngeal Prominence "m sterno-thyroid


Superior Belly of Omo-hyoid Crico-thyroid Membrane

Sterno-hyoid


Isthmus of Thyroid Gland


Inferior Thyroid Plexus of Veins — - Cla. Head'd St.-mas. Sterno-thyroid

Sternal Head of Sternomastoid


Fig. 735

he area bounded below by the


Sterno-thyroid


Sterno-hyoid

—Dissection of the Front of the Neck.

on either side by the anterior belly of the digastric and body of the hyoid bone is the submental triangle.


The thyroid gland is invested by a fibrous sheath which is derived u the pretracheal layer of the deep cervical fascia.

When a portion or portions of the pyramidal lobe, or of the right or lobes, become detached, the isolated masses are known as accessory roids.

Blood-supply—Arteries. —The thyroid gland is very vascular. The • sries on either side are (i) the superior thyroid, which is a branch of external carotid; and (2) the inferior thyroid, which is a branch of thyro-cervical trunk of the first part of the subclavian. Occasion7 there is a third thyroid artery, called the arteria thyroidea ima, ich is derived from the innominate artery, or from the arch of the




















1222


A MANUAL OF ANATOMY


aorta, and is distributed to the isthmus, its position being in fro of the trachea at the median line, or close to it.

The veins are superior, middle, and inferior. The superior ai middle thyroid veins open into the internal jugular. The inferi thyroid veins, right and left, issue from a plexus of veins in front the trachea below the isthmus. The left vein opens into the 1 < innominate vein, whilst the right may open into the left innomina vein, into the angle of junction of the right and left innominate veil or into the lower part of the right innominate vein.

Nerves. —These are derived from the sympathetic plexuses whi accompany the superior and inferior thyroid arteries.

Lymphatics. —The lymphatic vessels the thyroid body are disposed in t groups —ascending and descending. T ascending lymphatics form three sets median and two lateral, right and le The median ascending lymphatics retn lymph from the upper part of the isthmi and pass to the prelaryngeal lym glands. The lateral ascending lymphat on either side accompany the super thyroid artery, and pass to the infer deep cervical lymph glands on a level wi the cricoid cartilage of the larynx. T descending lymphatics also form three st The median descending lymphatics retr lymph from the lower part of the isthm and pass to the pretracheal lymph glam The lateral descending lymphatics on eitl side accompany the inferior thyroid artery, and pass to the pa: tracheal lymph glands, which lie in the groove between the tract and oesophagus, the efferents of which terminate in the inferior de cervical lymph glands.

Structure. —The thyroid gland has an external capsule of dense connect tissue which sends trabeculae into the interior, thereby dividing it into irregu lobules. These lobules are composed of groups of closed vesicles, which ; connected together by areolar tissue. The vesicles are oval or spherical, a each is lined with a single layer of columnar or cubical epithelium. They cont; a yellowish viscid, albuminous fluid called colloid and are surrounded by n works of capillary bloodvessels.

Development. —The thyroid body is developed from the entoderm of 1 ventral wall of the pharyngeal portion of the primitive gut.

The first indication of the median thyroid is an evagination of the vent pharyngeal entoderm immediately behind the tuberculnm impar. This evagu tion is called the median thyroid diverticulum. It forms a thick-walled epithe. vesicle embedded in mesoderm, which soon becomes solid. As the vesicle grc its distal end becomes bilobed. Superiorly it retains for a little time its co munication with the ventral wall of the pharynx behind the tuberculum im] by a hollow pedicle, which constitutes the thyro-glossal duct (canal of H This duct usually disappears, its superior orifice being represented on the dorsi of the adult, tongue by the blind recess, called the foramen ccecum. In very r;


Fig. 736. — Section of the Thyroid Gland, showing the Vesicles and their Epithelial Lining.

The colloid is indicated.




THE HEAD AND NECK


1223


the lingual portion of the duct may persist for a short distance, in which the foramen caecum leads to the lumen of a short tube, known as the ductus %lis.

tie median thyroid, as stated, gives rise to the isthmus and lobes of the thyroid gland.

tie median bud almost from its beginning is in contact with the pericardial and the two ventral aortae arising from the truncus arteriosus; it extends these vessels. It lies in loose mesoderm ventral to the condensations e second and third visceral arches. As the head grows forward and the irdium assumes in consequence a more caudal position, the thyroid bud h has separated from its lingual attachment) remains in contact with the irdium and the vessels; thus it moves caudally with reference to the pharynloor above it, and as a result of its lateral extension at the same time along vessels, comes into relation with the ventral angle of the fourth lateral 1 (P- 77 )■ Becoming attached to this, its farther caudal dislocation is

>ed, save perhaps in the middle line, where some of its cells may still follow Dericardium in its retrogression. The main part of the bud, however, ins in its fixed position, and forms the lobes and isthmus, he ventral bud from the fourth pouch is sometimes termed the lateral id bud, being supposed to contribute to the formation of each lobe. It is •ally believed, however, that it does not do so, but remains as a small elial mass in the lobe; under some circumstances it appears to show a

ncy to thyroid vacuolization.

□nnective tissue derived from this mesodermic investment now invades the mass, and it is broken up into numerous solid epithelial cords, which

omose freely, and so give rise to an intricate reticulum, the meshes of which

ccupied by connective tissue and bloodvessels of mesodermic origin. The epithelial cords of the reticulum become hollow, and the lumina so produced )roken up at intervals by constrictions into closed vesicles , which contain olloid material.

he pyramidal lobe of the thyroid gland sometimes met with in connection the isthmus of the adult thyroid is developed from the median bud. he epithelial cells of the vesicles of the adult thyroid are derived from the lerm of the pharyngeal part of the fore-gut.

Parathyroid Glands. —The parathyroids are four in number, and are tiged in pairs. The upper pair are related to the dorsal borders ie lobes of the thyroid gland, and the lower pair are placed behind ower ends of the lobes. They are difficult to distinguish with the id eye, but the best way to find them is to follow the anastomosis reen the superior and inferior thyroid arteries. They are developed ^aginations of the entoderm of the third and fourth visceral pouches ther side. The parathyroids present no traces of closed vesicles he colloid material.

ccessory Thyroid Glands. —These glands are sometimes met in the neighhood of the hyoid bone, and are known as the suprahyoid and prehyoid !S. They are developed as buds or evaginations of the thyroglossal duct, they consist of thyroid tissue.


The Trachea and (Esophagus.

trachea. —The trachea extends from the cricoid cartilage of the nx to about the level of the disc between the bodies of the fourth fifth thoracic vertebrae, where it divides into the two bronchi, t and left. Its average length is about inches, and its width


1224


A MANUAL OF ANATOMY


about i inch. Anteriorly and laterally it is cylindrical and fi but posteriorly it is flattened and membranous, so that it does press upon the oesophagus, in front of which it lies. It occupie medial position, and its direction is downwards with an inclinat backwards. It is divisible into two parts, cervical and thoracic.

For the trachea in the thorax, see p. 1085.

The cervical part of the trachea extends from the cricoid cartil to the level of the upper border of the manubrium sterni, and it measr about 2 \ inches in length. It is freely movable, and is surroun<

by areolar tissue, which c


Epiglottis


Greater Horn of Hyoid Bone Lesser Horn of Hyoid Bone_

Body of Hyoid Bone —


Thyro-hyoid Membrane —

Levator Glandulae \ Thyroidm Muscle/

Thyroid Cartilage - Crico-thyroid Ligament Pyramidal Lobe f Cricoid Cartilage Right Lobe of Thyroid Gland _

Isthmus

Right Bronchus Eparterial Bronchus


Hyparterial Bronchus.._ f


Trachea


tains many elastic fibres, ; is somewhat loosely arrange Relations — A nterior. —' isthmus of the thyroid gli lies directly upon the sect and third rings as a rule, first ring usually lying expo between its upper border 1 the cricoid cartilage. Su] ficial to the first ring, on left of the median line, th may be the lower part of pyramidal lobe of the thyi gland. Below the isthmus the inferior thyroid plexus veins, from which the ri and left inferior thyroid v( pass downwards one on eit side of the median line. ' arteria thyroidea ima may cend to the isthmus of thyroid gland, lying in fr of the trachea at the med line, or slightly to the right it. The anterior jugular ve:


Fig.


Left Bronchus

737 .-The Hyoid Bone, Larynx, r ig ht and J eft - are a " teri “ Trachea, Bronchi, and Thyroid Gland it, and just above the ma (Anterior View). brium sterni it is crossed by

communicating branch wh passes between these two veins. In children under two years age the cervical portion of the thymus forms an important ante] relation. Close to the upper border of the manubrium sterni innominate artery may encroach slightly upon it. The pretract layer of the deep cervical fascia forms an anterior relation, as \ as the superficial layer of that fascia, which is here usually descril as dividing to form the suprasternal space above the supraster notch. Another, and perhaps more common-sense, description is say that in front of the trachea is a layer of cellular tissue c











THE HEAD AND NECK


1225


Lateral Thyrohyoid Ligament

Upper Border of Thyroid Cartilage


Epiglottis


— Cartilago Triticea

_Corniculate Cartilage

-Arytenoid Cartilage

f_i.__Cricoid Cartilage

ft 3

Vfj--Right Lobe of Thyroid Body


)us with that in which the thyroid gland is embedded, and that tissue increases in thickness from before backward as the lea recedes from the surface on approaching the thorax. Other rior relations are the anterior jugular veins, along with one or two )h glands, and in some cases the left innominate vein. The sternod and sterno-thyroid muscles cover it in the following manner: derno-hyoid muscles are separated by an interval below, but they 3 nearly into contact above; and the sterno-thyroid muscles are intact below, but diverge above. Between the muscles of opposite 1 there is a very narinterval, along which trachea is free from cular covering. lateral .—The trachea fiosely embraced on sr side by the lobes he thyroid gland as as about the level of fifth ring, and lateral this is the carotid .th with its contents, common carotid artery g nearest the lobe.

Posterior .—The trachea n front of the cesogus, which projects a e to its left side tods the root of the neck, ween the two there is groove, in which the irrent laryngeal nerve inferior laryngeal

ry ascend. For a reflce to the high and

operations of tracheny, see p. 1174.

Blood-supply. —The ar- , ,,

es of the cervical part of the trachea are derived from the m or thyroid of each side, which is a branch of the thyro-cervica nk

The veins terminate in the inferior thyroid plexus and inferioi

roid veins. . , , ,

The lymphatics pass to the inferior deep cervical lymph glands

Pretracheal Lymph Glands. —These glands lie upon the front of e deal part of the trachea, below the isthmus of the thyroid gland, fir afferent vessels are derived from the front of the trachea, an lower part of the isthmus of the thyroid gland. Their efferent sels pass to the inferior deep cervical lymph glands. The lymphatic


Fig. 7^8.—The Epiglottis, Larynx, Trachea, Bronchi, and Thyroid Gland (Posterior View).





1226


A MANUAL OF ANATOMY


vessels of the cervical part of the trachea pass to the pretrache; inferior thyroid, and inferior deep cervical lymph glands.

Nerve-supply.— The nerves are derived from the vagus, recurre: laryngeal, and sympathetic.


Structure. —The trachea is composed of about twenty so-called rings hyaline cartilage, which are incomplete posteriorly. They serve to keep t tube permanently open for the transmission of air, and are embedded in fibro tissue, which also connects together their contiguous borders. They are hon shoe shaped, and each forms rather more than two-thirds of a circle, being fl externally and convex internally. The deficient portions of the rings are plac posteriorly, and here each ring ends in two round extremities. The inters between these extremities are bridged over by fibrous tissue continuous wi that which connects the borders of the rings and in which they are embedde

In some cases a ring m;


Ciliated Epithelium Basement Membrane


Mucosa


_ Elastic Fibres


Submucosa, with Mucous Glands


Hyaline Cartilage of Ring


Fibrous Investment


Fig. 739. —Longitudinal Section of the

Trachea.


end in a bifurcated e tremity, or it may jc one of the adjacent rin^ The lowest ring is dee and its lower border pr jects backwards so as form a ridge betwe the openings of the t\ bronchi.

In the posterior w< of the trachea within t fibrous layer there is continuous layer of u: striped muscular tissu the fibres of which e tend transversely betwe* the ends of the rings which they are attache In the intervals betwe< the extremities of ti rings they are attach* to the fibrous coat. The fibres serve to approj mate the ends of t] rings, and so diminish t] calibre of the tube.


The submucous coat consists of loosely-arranged areolar tissue, and contai] the larger bloodvessels and nerves, together with the mucous glands.

The mucous coat consists of areolar and elastic tissues, and a large amoui of lymphoid or adenoid tissue. It contains the ramifications of the arteri and nerves, as well as the lymphatics. Superficial to the mucosa there is well-marked basement membrane which supports the epithelium. The dee portion of the mucosa consists principally of elastic fibres. On the poster! wall these elastic fibres are very numerous, and are arranged in longitudin bundles which give rise to elevations of the mucosa.

The epithelium is of the stratified columnar ciliated variety.

The wall of the trachea contains many mucous glands. Some of these a situated in the submucous coat. Others, which are of large size, lie on t posterior wall, where they are very superficial, many of them appearing li small grains superficial to the fibrous layer. Others are contained within t. fibrous layer. The ducts of these glands have to pass through the muscula elastic, and mucous walls of the tube.

Development. —The trachea is developed from the lower part of the laryng























THE HEAD AND NECK


1227


ial tube from the ventral aspect of the fore-gut superiorly, the upper part is diverticulum giving rise to the larynx.

Esophagus.—The oesophagus is that part of the alimentary canal h extends from the pharynx to the stomach. In the neck it ns on a level with the lower border of the cricoid cartilage, and on a level with the upper border of the manubrium sterni. It >mpressed from before backwards and between the trachea and the vertebral mn covered by the longus cervicis cles. At first it occupies the median but as it descends it inclines slightly ie left side, so as to be partly visible on left side of the trachea, delations— Anterior. —The trachea; the

erior parts of the lobes of the thyroid

y ; the recurrent laryngeal nerves; and inferior thyroid arteries. Posterior. —The ebral column and the longus cervicis icles covered by the prevertebral cellular ie. Lateral. —On either side there is the )tid sheath with its contents. The right left recurrent laryngeal nerves are inately related to the oesophagus, and md on each side in the groove between nd the trachea.

The cervical part of the oesophagus reres its blood-supply from the inferior roid arteries, which accompany the corDonding recurrent laryngeal nerves.

Paratracheal Lymph Glands (Inferior rroid Lymph Glands).—These glands lie the groove between the cervical parts of trachea and oesophagus, along the course the inferior thyroid artery and recurrent ^ngeal nerve. Their afferent vessels are ived from (1) the lower part of the lobe p IG —schematic View

the thyroid body, and (2) the adja- of CEsophagus.

it parts of the trachea and oesophagus.

eir efferent vessels pass to the inferior deep cervical lymph glands. For a description of the oesophagus in the thoiax, including its

ucture and development, see p. 1087. .

Suprahyoid Region—Muscles—Digastric. The digastric muscle isists of two bellies, posterior and anterior. Origin. The posterior ly arises from the mastoid notch on the inner aspect of the mastoid ft of the temporal bone; and the anterior belly arises from the distric fossa on the inner surface of the base of the mandible close to

"symphysis.

Insertion. —The two bellies end upon an intermediate tendon,










1228


A MANUAL OF ANATOMY


about 2 inches long, which is inserted by means of a broad fibr band into the anterior surface of the body of the hyoid bone at outer part, and the adjacent portion of the greater horn.

Nerve-supply .—The posterior belly is supplied by the facial nei and the anterior belly by the mylo-hyoid branch of the inferior den a branch of the mandibular nerve.

The posterior belly is directed downwards and forwards, and anterior belly downwards and slightly outwards.

Action .—To elevate the hyoid bone, as in the act of deglutiti and to depress the mandible.

Relations. —The posterior belly is at first deeply placed, be overhung by the mastoid process, and lying under cover of the Ion simus capitis, splenius capitis, and sterno-mastoid muscles. It is ; overlapped by the lower part of the parotid gland. It crosses external and internal carotid arteries, internal jugular vein, ;

hypoglossal nerve, stylo-hyoid muscle above it, and the hy glossal nerve below it a short distance. i intermediate tendon embraced by the fibres the stylo-hyoid mus This tendon crosses hypoglossal nerve, ; forms two sides of a angle, known as the angle of Lesser, the b of which is directed wards, and is formed the hypoglossal nerve. In the area of this triangle is a portion the hyo-glossus muscle, and deep to this is the lingual artery. 1 anterior belly, which is shorter than the posterior, is covered the integument, platysma, and deep cervical fascia. It rests u{ the mylo-hyoid muscle, and forms part of the floor of the digasl triangle. Its inner border is connected with that of its fellow b] fascial expansion.

The posterior belly of the digastric, along with the stylo-hyoid muscle, the stapedius muscle, is associated with the posterior end of the second vise or hyoid arch. The nerve of this arch is the facial nerve, and this explains nerve-supply of the posterior belly.

The anterior belly is associated with the anterior or medial end of the ) visceral or mandibular arch. The nerve of this arch is the mandibular from trigeminal nerve, thus accounting for the nerve-supply of the anterior belly Stylo-hyoid — Origin .—The posterior and outer aspect of the sty! process of the temporal bone near its base.

Insertion .—The anterior surface of the hyoid bone at the junct of the body and greater horn.


5TVIOHVOIP


Fig. 741. —Plan of Main Deep Relations of Digastric in Anterior Triangle.





THE HEAD AND NECK


1229


erv e-supply. —The facial nerve.

he muscle is directed downwards and forwards.

ction. _To draw the hyoid bone upwards and backwards.

he muscle lies close above the posterior belly of the digastric, before taking insertion, it usually splits into two bundles, which ■ace the intermediate tendon of the digastric. It is morphological delamination of the same sheet as the posterior belly of the di•ic, which explains its nerve-supply.

[ylo-hyoid — Origin. — The mylo-hyoid line of the mandible. nsertion— The posterior fibres are inserted into the anterior surface .e body of the hyoid bone; and the principal part of the muscle is ted into a central fibrous raphe, which extends from the symphysis ti on its deep and lower aspect to the body of the hyoid bone.


Mandible


Raph


)-hyoid Muscle - Lingual Nerve

Deep Part of nandibular Gland Post. Belly of Digastric Hypoglossal Nerve Stylo-hyoid


Body of Hyoid Bone


e


Infrahyoid Muscles


Fig. 74 2.—The Mylo-hyoid Region. Anterior belly of digastric removed.


Nerve-supply. —The mylo-hyoid branch of the inferior dental nerve, ch is a branch of the mandibular nerve.

The muscle is directed downwards and f01 wards.

Action.— To raise the floor of the mouth, and, in doing so, to ss the tongue against the hard palate, as in the first stage of the of deglutition; to elevate the hyoid bone, and diaw it forwards,

L to depress the mandible. .

The two mylo-hyoid muscles form a muscular floor for the buccal

ity, which is known as the diaphragma oris. >

Relations —Superficial or Inferior .—The anterior belly of the ditric; the superficial part of the submandibular gland, lodging a 'tion of the facial artery; and the mylo-hyoid nerve and submenta mch of the facial artery.



1230


A MANUAL OF ANATOMY


Posterior Border .—Passing deep to the posterior free border of muscle there are the following structures, in order from above do wards: (i) the lingual nerve; (2) a portion of the submandibular gla and (3) the hypoglossal nerve and its vena comitans.

Deep or Superior. —The hyo-glossus muscle, external to which the lingual nerve, the submandibular ganglion, the deep part of the s mandibular gland and the submandibular duct, the hypoglossal ne and its vena comitans. In front of the hyo-glossus is the genio-h} muscle, and between it and the hyo-glossus is a portion of the gei glossus, with the sublingual gland resting upon it.

Genio-hyoid— Origin. —The inferior genial tubercle of the mand close to the symphysis on its deep aspect.

insertion .—The inner two-thirds of the anterior surface of body of the hyoid bone over its upper part. At its insertion the mu is divided externally into two laminae, anterior and posterior, former of which extends farthest out upon the hyoid bone. The ini most fibres of origin of the hyo-glossus pass inwards between tl two laminae.

N erv e-supply. —The hypoglossal nerve, the branch of which is garded as being composed of spinal fibres.

The muscle is directed downwards and slightly backwards.

Action. —To elevate the hyoid bone and draw it forwards, and depress the mandible.

The muscle is in intimate contact with its fellow of the oppo side at the median line. Its inferior or superficial surface is cove by the mylo-hyoid, and its superior or deep surface is related to lower or posterior border of the genio-glossus.

Genio-glossus— Origin. —The upper genial tubercle of the mand close to the symphysis on its deep aspect.

Insertion. —The under surface of the tongue close to the med line, and extending from near the tip to the root; very slightly i the inner part of the anterior surface of the body of the hyoid b close to its upper margin; and slightly into the side of the phary where the fibres blend with those of the middle constrictor muscle.

N erv e-supply. —The hypoglossal nerve, the branches of which er the outer surface of the muscle.

The upper or anterior fibres arch upwards and forwards, and lower downwards and backwards, whilst the intervening fibres spr out in a fan-like manner.

Action. —The entire glossal fibres depress the tongue at the med line, and, along with those of the opposite side, they give rise to antero-posterior groove on the dorsum of the organ; the postei glossal fibres draw forwards the tongue, causing its tip to be protru< from the mouth; the anterior glossal fibres retract the tip of the ton] when it has been protruded from the mouth; and the lower or postei (hyal) fibres elevate the hyoid bone, and draw it forwards.

The muscle is fan-shaped. The medial surface is closely app] to that of its fellow of the opposite side. The lateral surface is rela


THE HEAD AND NECK


1231


ie longitudinalis inferior muscle, the arteria profundae linguae, the glossus and stylo-glossus muscles, and the sublingual gland. The rior border is covered by the buccal mucous membrane, and the r or posterior border by the genio-hyoid muscle, lyo-glossus— Origin. —The greater horn of the hyoid bone over its •e length; the anterior surface of the body of the bone over about uter half; and the lesser horn (inconstant). The innermost fibres rigin from the hyoid bone lie between the two laminae of the geniod muscle.


Tip of Styloid Process of Temporal Done


Fig. 743. —The Extrinsic Muscles of the Tongue. The longitudinalis inferior is an intrinsic muscle.


Insertion —The posterior half of the under surface of the tongue se to its lateral border, the fibres being situated medial to those of ! stylo-glossus, and both sets of fibres being intimately intermixed

h each other and with the intrinsic lingual muscles.

Nerve-supply .—The hypoglossal nerve, the branches of which enter

i superficial surface. , .. , .

The muscle is for the most part directed upwards, but its anterior

res have a slight inclination forwards.

Action .—To depress the side of the tongue, and, along with its low, to render the dorsum of the organ convex; and to assist m

xacting the protruded tongue.

The hyo-glossus is a flat, four-sided muscle.


1232


A MANUAL OF ANATOMY


Relations — Superficial. —The mylo-hyoid muscle; the intermedi tendon of the digastric, and stylo-hyoid muscle; the lingual nerve, w the submandibular ganglion lying a little below it; the deep part of submandibular gland, and the submandibular duct; the hypoglos nerve; and the vena comitans hypoglossi. Posterior Border .—The : lowing structures pass deep to this border in order from above do\ wards: the glosso-pharyngeal nerve; the stylo-hyoid ligament; and lingual artery. Deep .—The posterior part of the genio-glossus; a port of the middle constrictor muscle of the pharynx; the lingual arte the lower end of the stylo-hyoid ligament; and the glosso-pharyng nerve.

The fibres of the hyo-glossus which arise from the lesser horn the hyoid bone are separated from the rest of the muscle by th< fibres of the genio-glossus which take insertion into the side of i


Hyo-glossus Glosso-pharyngeal N.

Lingual N.-\ _

Hyo-glossus-_

Submandibular Duct-A - __

Vena Comitans Hypoglossi—\_ Al

Hypoglossal N.---X — ^


- -Longitudinalislnfi Stylo-glossus


Sublingual Gland Ant. Facial V. and Fat - Deep Submandibular G 1 • Sup. Submandibular Giant ' Mylo-hyoid

-/- Stylo-hyoid

~ —/Digastric

Hyoid Bone

\ ' Stylo-hyoid Lig.


Lingual ArteryA 'Middle Constrictor

Fig. 744.—Coronal Section through Submandibular Region.


pharynx, and they are vestigial remains of the chondro-glossus monkeys. These fibres, however, are inconstant.

Stylo-glossus — Origin .—The front of the styloid process of t temporal bone near its tip; and the upper extremity of the sty. mandibular ligament.

Insertion .—The under surface of the tongue close to its latei border. The fibres extend as far forwards as the tip, and are situat lateral to the fibres of the hyo-glossus, both sets of fibres being in mately intermixed with each other, and with longitudinalis inferi muscle.

Nerve-supply .—The hypoglossal nerve.

The muscle is directed downwards, forwards, and inwards.

Action. —(1) To draw the tongue backwards; and (2) to elevate t root of the tongue.

Stylo-hyoid Ligament. —This is a narrow fibrous cord which attached superiorly to the tip of the styloid process, and interiorly





THE HEAD AND NECK


1233


lesser horn of the hyoid bone. Its direction is downwards and ards, superficial to the glosso-pharyngeal nerve and deep to the rnal carotid artery, and its lower extremity is covered by the glossus muscle. It is liable to become ossified more or less pletely.

rhe ligament represents the usually unossified skeletal part of the nd visceral arch, and ossification in it, when it occurs, corresponds le epihyal bone of lower mammals, so well seen in the ruminants, lubmandibular Gland (Submaxillary Gland).—This gland is situated he anterior part of the digastric triangle. It consists of a large jrficial part and a small deep part. The superficial part superiorly ipies the submandibular fossa on the inner surface of the body of mandible, and inferiorly it is covered by skin, superficial fascia, platysma, and ) fascia. The anterior facial vein deds superficial to it. Its deep surface 3 anteriorly upon the mylo-hyoid muscle,

1 the intervention of the mylo-hyoid ^e and submental branch of the facial ry; and posteriorly upon the hyo-glossus, slightly upon the posterior belly of the istric and stylo-hyoid muscles. The jrficial part is grooved at its upper and £ part by the facial artery, which lies >edded in the gland. Posteriorly the jrficial part is related to the cervical ion of the parotid gland, from which s separated by the stylo-mandibular ment. The deep part of the gland is of .11 size, and is continuous with the superficial part at the posterior ier of the mylo-hyoid muscle. It lies under cover of that muscle n the hyo-glossus, and is related to the sublingual gland.

Ihe submandibular duct (Wharton’s duct) emerges from the deep set of the superficial part of the gland close to the posterior border he mylo-hyoid muscle. It is about 2 inches in length, and passes ards upon the hyo-glossus muscle, lying beneath the deep part of gland. In this situation it has the submandibular ganglion and ual nerve above it, and the hypoglossal nerve below it. After dng the hyo-glossus muscle, the duct lies superficial to the geniossus, and, passing slightly upwards, it is crossed from above down'ds by the lingual nerve. Having passed just below the mucous nbrane of the floor of the mouth on the inner side of the sublingual id, the duct opens upon the floor of the mouth by a minute orifice, ch is situated on the summit of a papilla lying close to the side of frenulum linguae.

The submandibular gland corresponds to the posterior half of the ly of the mandible, and sometimes reaches down below the level of hyoid bone.


Lumen of Alveolus


Crescents of Gianuzzi


Fig. 745.—Section of the Submandibular Gland of a Dog.


78




A MANUAL OF ANATOMY


1234

Blood-supply.—The gland derives its blood chiefly from the cerv part of the facial artery.

Nerve-supply.—The nerves are derived from the submandibi ganglion, and through this from the chorda tympani, the lingual, < the sympathetic plexus on the facial artery.

Lymphatics.—These pass to the submandibular lymph glands, < thence to the superficial and deep cervical lymph glands.

Structure. —The submandibular gland is a muco-serous gland, and its gen structure is similar to that of the parotid gland. The essential difference tween the two has reference to the alveoli or acini, and the nature of t secretion. The cells of the parotid alveoli are serous or albuminous. The 1 mandibular alveoli contain around the lumen mucous cells filled with gran mucigen, which is discharged as mucus. They, however, also contain s< albuminous cells, known as the marginal cells, which are situated externa


Parotid Duct


the mucous cells, but within the membrana propria of the alveolus. Th cells usually form groups which, from their crescentic arrangement, are knc as the crescents of Gianuzzi.

Development. —The submandibular gland is developed as a solid outgro of the buccal epithelium. This outgrowth undergoes ramifications, and fl subsequently become hollow. The outgrowth takes place from the floor of sulcus between the tongue and the mandibular arch, far back in its lateral p at the beginning of the second month. The lingual nerve passes to the ton below the floor of the sulcus in front of the outgrowth. The submandibular d is gradually produced from before backwards by the closing off of the lov part of the sulcus, so that it really corresponds with the original floor of groove. Thus it possesses a lumen from its earliest stages, while the glan< still solid, and the lingual nerve has to pass below it.

Sublingual Gland.—This is the smallest of the salivary glands, '< resembles an almond in shape. It measures about i\ inches in len£ and is situated beneath the mucous membrane of the floor of mouth, where it gives rise to a mucous fold, called the plica sublingua





THE HEAD AND NECK


1235


iriorly it rests upon the mylo-hyoid muscle, and is here related to deep part of the submandibular gland, the submandibular duct, L the lingual nerve. Laterally it occupies the sublingual fossa on inner surface of the body of the mandible above the mylo-hyoid and medially it is in contact with the genio-glossus muscle. Its dial extremity comes into contact with its fellow of the opposite 3 over the anterior border of the genio-glossus muscle.

The sublingual ducts (ducts of Rivini) vary in number from ten to

nty. A few of them open into the submandibular duct, but the

jority open in a linear manner upon the summit of the plica sub;ualis.

Blood-supply.—The gland receives its blood from the sublingual rich of the lingual artery.

Nerve-supply.—The nerves are derived from the chorda tympani 1 lingual nerves, and the sympathetic plexus on the facial artery, means of a branch of the submandibular ganglion, which is con:ted to the sublingual gland by the lingual nerve.

Structure. —-The sublingual gland is a mucous gland, and its general structure imilar to that of the parotid and submandibular glands, but the lobules are re loosely arranged. The cells of the sublingual alveoli are for the most part cous cells, but there are also serous or albuminous cells.

Development.— The sublingual gland is developed as a number of outgrowths 21 the buccal epithelium. These undergo ramifications, and subsequently

ome hollow.


Scalene Muscles and Subclavian Artery.

Scalene Muscles.—The scalene muscles 5 three.

Scalenus Anterior (Scalenus Anticus)—

igin .—By four short tapering tendons )m the anterior tubercles of the transrse processes of the third, fourth, fifth, d sixth cervical vertebrae.

Insertion .—The scalene tubercle of the st rib.

Nerve-supply .—The anterior primary mi of the fifth and sixth cervical nerves.

The muscle is directed downwards, itwards, and forwards.

Action .—To fix the first rib in ordinary spiration, and to elevate it in forced spiration; and to bend the neck to one le.

Chief Relations — Anterior. —The irenic nerve, which crosses the muscle diquely downwards and inwards; the ternal jugular vein, which lies in front of its origin; the subclavian iin close to its insertion; the thoracic or the right lymphatic duct;


Anterior.



A MANUAL OF ANATOMY


1236

the transverse cervical and suprascapular arteries; and the omo-hy muscle. Posterior. —The scalenus medius, with the intervention of second part of the subclavian artery, the nerve-roots of the bract plexus, and the cupola of the pleura. Medial. —The ascending cervi artery and the origin of the longus capitis.

Scalenus Medius — Origin. —By six short tapering tendons from posterior tubercles of the transverse processes of the lower six cervi vertebrae.

Insertion. —The upper surface of the first rib from the groove the subclavian artery backwards to the tubercle. Sometimes a i fibres are inserted into the suprapleural membrane (Sibson’s fasc over the cupola of the pleura. When distinct they are called 1 scalenus pleuralis.

Nerve-supply. —The anterior primary rami of cervical nerves fr the third to the eighth inclusive.

The muscle is directed downwards and outwards.

Action. —(1) To fix the first rib in ordinary inspiration, and (2) bend the neck to one side.

Relations — Anterior.— The cervical plexus, the nerve-roots of 1 brachial plexus, except the first thoracic, and the second and th parts of the subclavian artery. Posterior. —The levator scapulae a scalenus posterior muscles.

The scalenus medius is pierced by the following nerves: the nei to the rhomboids, which passes in a backward direction; and the up] and middle roots of the nerve to serratus anterior. These two roi usually emerge from the muscle as a single cord, and the lower or th root of the nerve descends in front of the scalenus medius, and jo the foregoing cord about the level of the first rib.

Scalenus Posterior (Scalenus Posticus) — Origin. —By two or th short tendons from the posterior tubercles of the transverse proces of the lower two or three cervical vertebrae.

Insertion. —The upper part of the outer surface of the second in front of the insertion of the highest slip of the serratus poster superior, and behind the origin of a portion of the first and the seco digitations of the serratus anterior.

Nerve-supply. —The anterior primary rami of the sixth, seven and eighth cervical nerves, the branches of which pass through 1 scalenus medius.

The muscle is directed downwards and outwards.

Action. —To elevate the second rib, and to extend the neck.

The scalenus posterior is the vestige of an important extensor muscle of neck in pronograde mammals, in which it is attached to several ribs. In orthograde position, however, with its balanced head, the need for it has ( appeared.

Relations — Anterior. —The scalenus medius. Posterior. —The lov two tendons of origin of the levator scapulae. The scalenus poster is intimately connected with the scalenus medius, of which it is pn tically a part.



THE HEAD AND NECK


1237


Subclavian Artery.—The right subclavian vessel arises from the )minate artery behind the right sterno-clavicular joint on a level 1 its upper part, and the left subclavian vessel arises from the >er aspect of the arch of the aorta towards its back part. On each the artery ends at the outer border of the first rib by becoming axillary artery. In its course the vessel is crossed superficially the scalenus anterior muscle, which divides it into three parts.


Rectus Capitis Anterior


Rectus Capitis Lateralis -

Basilar Part of Occipital Bone


Longus Capitis


Scalenus Posterior


Vertebral Artery (third part)


Scalenus Anterior. Scalenus Medius .


Longus Cervicis(upper oblique part) _Vertebral Artery (second part)


_Longus Cervicis (vertical part)


Vertebral Artery (first part)

HP. Longus Cervicis (lower oblique part)


Scalene Tubercle

Fig. 748. — The Right Prevertebral Muscles. The vertebral artery is also shown.


The first part extends from the origin of the vessel to the inner

der of the scalenus anterior; the second part lies behind that muscle;

I the third part extends from the outer border of the muscle to the ter border of the first rib. The. total length of the vessel on the ht side is about 3 inches, and on the left about 4 i inches. The ery describes an arch in front of the apex of the corresponding lg and pleura, and the height to which it rises above the clavicle

ibout inch.

First Part of the Right Subclavian Artery.—This part extends from i bifurcation of the innominate artery behind the light sterno








Fig. 749.—Right Subclavian Artery in situ: Jugular and Subclavia

Veins Removed.

ficially. The internal jugular and vertebral veins cross it from abc downwards close to the scalenus anterior, the latter vessel being belli the former, and the anterior jugular vein crosses it from within 0 wards, but superficial to the sterno-hyoid and sterno-thyroid muse] The vagus and its cervical cardiac branches, the cervical card branches of the sympathetic, and the nerve-loop known as the ai


1238


A MANUAL OF ANATOMY


clavicular joint, on a level with its upper part, to the inner border the scalenus anterior muscle. Its direction is upwards and out war and it lies very deeply.

Relations— Anterior .—The skin, superficial fascia and platysr deep cervical fascia, clavicular origin of the sterno-mastoid, and ster hyoid and sterno-thyroid muscles. Three veins are related to it sup







THE HEAD AND NECK


1239


. 750.—The Aorta in the Thorax, and the Principal Arteries of the

Head and Neck.


t. Arch of the Aorta Aortic Isthmus l- Aortic Spindle p Descending Aorta 5. Coronary Arteries (from Ascending Aorta)

5 . Innominate Artery 7 • Left Common Carotid 3 . Left Subclavian ?• Right Common Carotid


10. Right Subclavian

11. External Carotid

12. Internal Carotid

13. Maxillary

14. Superficial Temporal

15. Vertebral

16. Internal Mammary

17. Thyro-cervical Trunk

18. Inferior Thyroid

19. Transverse Cervical


20. Suprascapular

21. Superior Thyroid

22. Lingual

23. Facial

24. Occipital

25. Posterior Auricular

26. Ascending Pharyngeal

27. Transverse Facial

28. Posterior Iutercostals

29. Ligamentum Arteriosum







1240


A MANUAL OF ANATOMY


subclavia also cross it superficially. Posterior .—The recurrent lan geal nerve, sympathetic trunk, fat, longus cervicis muscle, first thora vertebra, cupola of the pleura, and apex of the lung. Inferior .—1 recurrent laryngeal nerve, part of the ansa subclavia, and the pleura

The right subclavian and right internal jugular veins unite in fr< of this part of the vessel to form the right innominate vein.

First Part of the Left Subclavian Artery.—This part extends fr< the upper aspect of the arch of the aorta, towards its back part, the inner border of the scalenus anterior muscle. It is therefore plac at first in the thoracic cavity. Its course is almost vertical until reaches the root of the neck, where it curves sharply outwards upon 1 cupola of the pleura, and so reaches the scalenus anterior. The re tions of the intrathoracic portion have been described in connect] with the thorax (see p. 1040).

Cervical Relations— Anterior .—The skin, superficial fascia a platysma, deep cervical fascia, clavicular origin of the sterno-masto sterno-hyoid, and sterno-thyroid muscles, and the thoracic duct whi arches over it. The left internal jugular and subclavian veins un

in front of it to form the left innomim vein, and the left vertebral vein descer in front of it under cover of the left interi jugular vein. Posterior .—The sympathe trunk with the inferior cervical ganglk fat, and the left longus cervicis muse Right. —The trachea, oesophagus, left : current laryngeal nerve, and thoracic du The varieties in origin of the subclavi artery have been described in connecti with the arch of the aorta (see p. 1040 seq.).

Second Part of the Subclavian Artery.

This portion of the vessel is situated behi the scalenus anterior muscle. It lies abo \ inch above the clavicle, and forms t highest part of the arch described by t vessel.

Relations— Anterior. — Its only din anterior relation is the scalenus anteri< Posterior .—The pleura. Superior. —T nerve-roots of the brachial plexus. 1 ferior .—The pleura.

In some cases the second part of the vessel passes through the scalenus ariter and in rare cases it passes in front of the muscle.


Fig. 751. —Left Subclavian Vessels and Terminal Piece of Thoracic Duct.


For the third part of the subclavian artery see p. 1191.


Development. —The right subclavian artery as far as the origin of the inter] mammary artery is developed from the fourth right aortic arch.

The left subclavian artery is developed from the seventh left, segmen arterv.





THE HEAD AND NECK


1241


Branches of the subclavian artery are the vertebral, internal nmary, thyro-cervical trunk, and superior intercostal. The first

e arise from the first part of the artery towards its termination, and

last arises from the second part on the right side, and from the

part on the left side.

Vertebral Artery. —This, the first branch on the right side, arises n the upper and back part of the artery about an inch from its ^n, and on the left side from the vessel just after it enters the root he neck. It passes for a short distance upwards, backwards, and htly outwards, and disappears from view by entering the foramen isversarium in the sixth cervical vertebra as a rule. It then ascends tically through the successive foramina transversaria above that of sixth vertebra, passing outwards between the axis and atlas, ving traversed the foramen transversarium of the atlas, it passes kwards and inwards, lying in vertebrarterial groove on the )er surface of the posterior arch the atlas behind the superior icular process, pierces the dura ter and arachnoid, and having ched the side of the spinal d, it turns upwards and forrds in the subarachnoid space,

I enters the cranial cavity ough the foramen magnum, gradually inclines from the eral to the ventral aspect of

medulla, and at the lower

rder of the pons it joins its low to form the basilar artery.

On account of its complicated arse, the vertebral artery is dded into four parts—namely, first or cervical, second or costoms verse, third or suboccipital, and fourth or intercranial.

The first part extends from the origin of the vessel to the foramen insversarium in the transverse process of the sixth cervical vertebra, lies between the scalenus anterior and longus cervicis muscles, ving the internal jugular and vertebral veins in front of it, being assed by the inferior thyroid artery, and having the sympathetic ank and the transverse process of the seventh cervical vertebra hind it. The vessel of the left side has the thoracic duct as an .ditional anterior relation.

The first part gives off no branches. . . .

The second part traverses the foramina transversaria ol the cervical

rtebrae from, as a rule, the sixth upwards. It is surrounded by t e
rtebral venous plexus, and by the vertebral plexus of the s}/mpaetic, and it lies in front of the cervical spinal neives as these emerge

3m the intervertebral foramina.





1242


A MANUAL OF ANATOMY


Branches.—These are as follows: spinal and muscular. T spinal branches enter the vertebral canal through the interverteb: foramina. The muscular branches supply the deep muscles of t neck, and anastomose with the deep cervical, ascending cervical, a occipital arteries.

For the third or suboccipital, and the fourth or intracranial, pai of the vertebral artery, see p. 1151.

Varieties. —(1) The left vertebral artery not uncommonly arises from the ai of the aorta between the origins of the left common carotid and left subclavi arteries. (2) The vessel may pass the foramen transversarium of the sh cervical vertebra, and may enter that of the fifth, or even that of the four (3) The vessel has been found in rare cases to enter the foramen transversarii of the seventh cervical vertebra.

Development. —The vertebral artery is developed from (1) the seventh cervi< somatic artery, and (2) the longitudinal anastomotic chain which connects f seven cervical somatic arteries.

Internal Mammary Artery.—This vessel, so named in contr

distinction to the external mammary, or lateral thoracic, a branch of t second part of the axillary artery, arises from the lower aspect of t' first part of the subclavian very nearly opposite the thyro-cervic trunk. Its course is downwards, forwards, and slightly inwards, ai it disappears behind the sternal end of the clavicle and first cost cartilage. For its subsequent course and relations, see p. 999.

Relations of Cervical Part— Anterior .—The clavicular part of tl sterno-mastoid, and the internal jugular and subclavian veins. Tl phrenic nerve crosses the vessel superficially from without inward Posterior .—The pleura.

No branches arise from this part of the vessel.

Thyro-cervical Trunk (Thyroid Axis).—This is a short trunk whi<; springs from the front of the first part of the subclavian artery clo to the inner border of the scalenus anterior muscle. It almost imm diately divides into three diverging branches—inferior thyroi transverse cervical, and suprascapular.

The inferior thyroid artery passes upwards and inwards in a tc tuous manner in front of the vertebral artery, and behind the carot sheath and sympathetic trunk, the middle cervical ganglion of whit often rests upon it. Having reached the lower part of the lobe of tl thyroid body, the artery breaks up into its terminal branches, whi< enter the lobe on its deep aspect, and ramify in it, anastomosing wi the superior thyroid and with its fellow of the opposite side of tl isthmus. As the vessel ascends it is intimately related to the recurre: laryngeal nerve, which usually lies behind it.

Branches.—These are as follows: muscular, ascending cervic; inferior laryngeal, tracheal, and oesophageal.

The muscular branches supply the scalenus anterior, longus cervic:: the infrahyoid muscles, and inferior constrictor of the pharynx. Tl ascending cervical artery arises from the inferior thyroid as it pass inwards behind the carotid sheath. It ascends in front of the trait verse processes of the cervical vertebrae, lying between the scalenj



THE HEAD AND NECK


1243


rior and longus capitis, and having the phrenic nerve on its outer and the sympathetic trunk just medial to it. It anastomoses branches of the vertebral, occipital, and ascending pharyngeal ries. It may furnish some spinal branches which enter the vertebral il through the intervertebral foramina to be distributed in a manner lar to the other spinal arteries. The inferior laryngeal artery impanies the recurrent laryngeal nerve to the larynx. The tracheal oesophageal branches are distributed as their names suggest, rhe transverse cervical artery passes transversely outwards in t of the scalenus anterior and phrenic nerve, and behind the icular part of the sterno-mastoid, lying a little above the clavicle, also above the suprascapular artery. It then enters the subdan triangle, which it soon leaves by passing deep to the inferior y of the omo-hyoid. It then passes in front of, or between, the ^e-trunks of the brachial plexus to the deep surface of the trapezius $cle. Having reached the anterior border of the levator scapulae, ivides into its two terminal branches—superficial and deep.

The superficial branch [superficial cervical artery) passes superficial the levator scapulae, and is distributed to the trapezius, levator pulae, splenius, and the adjacent lymph glands. The deep branch sterior scapular artery) passes backwards in front of the levator pulae to the superior angle of the scapula. It then descends along base of the bone, under cover of the rhomboid muscles, as far as inferior angle, where it anastomoses with the circumflex scapular 1 subscapular arteries. The artery gives branches to the adjacent iscles, and anterior and posterior branches to the scapula, which

e part in the scapular anastomoses proper (see p. 438).

The deep branch of the transverse cervical is frequently a branch the third part of the subclavian, in which cases there is no transverse vical artery, the superficial branch of the latter artery taking its ice and arising from the thyro-cervical trunk (see p. 1192).

The suprascapular artery passes downwards and outwards in front the scalenus anterior and phrenic nerve, and behind the clavicular rt of the sterno-mastoid. Having reached the back of the clavicle, courses outwards behind that bone, passing in front of the third rt of the subclavian artery and the trunks of the brachial plexus, then passes to the upper border of the scapula in company with the prascapular nerve. For the further course of the vessel and for the

ipular anastomoses of arteries see p. 441.

Branches in the neck are muscular, suprasternal, and nutrient, le muscular branches supply the sterno-mastoid and subclavius. le suprasternal branch descends over the inner end of the clavicle to pply the integument over the manubrium sterni. The nutrient tery of the clavicle is directed outwards, and enters the nutrient

ramen of that bone. It is often double.

Superior Intercostal Artery. —This vessel arises from the second irt of the subclavian on the right side, and from the first part on le left side, in each case from the posterior aspect of the paient


i 2 4 4


A MANUAL OF ANATOMY


trunk. On the right side it is therefore behind the scalenus anter and on the left side close to the inner border of that muscle. ' vessel at first passes backwards and upwards for a short distance, ; then descends in front of the neck of the first rib. At the postei extremity of the first intercostal space it furnishes the first postei intercostal artery to that space, and then descends in front of neck of the second rib to become the second posterior intercom artery. The superior intercostal artery therefore furnishes the fi and second posterior intercostal arteries for the first and second inf costal spaces, their distribution being similar to that of the succeed posterior (aortic) intercostal arteries. Besides these two brand: the vessel gives off the deep cervical artery. This branch, which homologous with the posterior branch of a posterior intercostal arte arises from the superior intercostal before it descends in front of 1 neck of the first rib.

The superior intercostal artery and the deep cervical art< are often described as terminal branches of a common trunk origin. This trunk is called the costo-cervical trunk; in 1 description adopted here this trunk is looked on as part of f superior intercostal itself.

It passes backwards between the transverse process of the sever cervical vertebra and the neck of the first rib, and then ascends betwe the semispinalis capitis and semispinalis cervicis muscles to about f level of the axis. In this situation it anastomoses with the de division of the descending branch of the occipital artery. The de cervical in its course gives off muscular branches which anastomc with branches of the vertebral and ascending cervical arteries, also furnishes a spinal branch which enters the vertebral canal throu the intervertebral foramen between the seventh cervical and fii thoracic vertebrae.

The superior intercostal artery on each side is developed from the anast< motic loop between the upper two or three thoracic somatic arteries.

Subclavian Vein. —This vessel, which is the direct continuation the axillary vein, extends from the outer border of the first rib to t back of the inner end of the clavicle, where it unites with the intern jugular to form the innominate vein. It lies in front of, and on lower plane than, the subclavian artery, and it passes in front of t scalenus anterior muscle and phrenic nerve. In rare cases the ve has been met with passing behind the scalenus anterior. Its princip tributary is the external jugular vein (sometimes also the anteri jugular). The external jugular vein joins it close to the outer bord of the sterno-mastoid.

The thoracic duct opens at the angle of junction of the left su clavian and left internal jugular veins, and the right lymphatic du opens into the angle of junction of the corresponding veins on t] right side. The duct often opens in two or more parts.

Vertebral Vein. —This vein begins in the suboccipital veno


THE HEAD AND NECK


1245


ms within the suboccipital triangle. It passes through the foramen lsversarium in the atlas, and accompanies the vertebral artery nigh the succeeding foramina transversaria as low as the sixth, ning a plexus around the vessel. This plexus is ultimately replaced a single vein, which emerges through the foramen transversarium he sixth cervical vertebra (sometimes the seventh). It then descends ront of the first part of the subclavian artery under cover of the irnal jugular vein, and opens into the back part of the innominate 1, the opening being provided with a single or double valve.

The chief tributaries of the vertebral vein are as follows: muscular, lal, anterior vertebral, and deep cervical. It also, as a rule, dves the first intercostal vein.

No vein accompanies the ceral part of the internal mamry artery. The inferior thyroid a, which does not accompany corresponding artery, is found cribed in connection with the Toid gland on p. 1222.

The transverse cervical and irascapular veins return the od from the parts supplied by i corresponding arteries, and tributaries of the lower part the external jugular vein.

The deep cervical vein starts the suboccipital venous plexus

Tin the suboccipital triangle. ^ 0

descends in company with the Fk, 753-^*^^™ V*™ 'P cervical artery, and passes . , ,, ,•

  • J xr Anterior jugular frequently opens di

rectly into subclavian vein. Vertebral vein," which receives superior intercostal, opens into beginning of innominate.


INNOM,


wards between the transverse •cess of the seventh cervical tebra and the neck of the first to terminate in the vertebral


rhe anterior vertebral vein begins in a plexus in front of the uppei ical transverse processes. It descends in company with the nding cervical branch of the inferior thyroid artery receiving cular tributaries in its descent, and it opens into the lower part

Jollateral^irculation after Ligature of the Third Part of the Subian Artery.— (i) The suprascapular and the deep branch of the sverse cervical, both branches of the thyro-cervical trunk fiom part of the subclavian, take part in the scapular anastomoses and stomose freely with branches of the first and t rr par s 0 e lary artery. (2) The internal mammary from the first part of subclavian anastomoses with the lateral thoracic from the second

of the axillary.



1246


A MANUAL OF ANATOMY


Collateral Circulation after Occlusion of the First Part of Subclavian Artery. —(1) The vertebral artery of one side anastomc with that of the opposite side. (2) The internal mammary anas moses with the inferior epigastric from the external iliac, and w the posterior intercostal arteries. (3) The inferior thyroid anas moses with the superior thyroid from the external carotid. (4) 1 superior intercostal anastomoses with the third posterior intercosi (5) The deep cervical of the superior intercostal anastomoses with deep division of the descending branch of the occipital from the exter carotid. (6) The scapular branches of the thyro-cervical trr anastomose with branches of the axillary artery. (7) The thora branches of the axillary artery anastomose with the posterior ini costals.

Cervical Part of the Thoracic Duct (Fig. 751). — This part of 1 thoracic duct occupies the root of the neck on the left side, and ] upon the side of the oesophagus, between it and the left subclav: arteries. In this position it ascends to about the level of the sevei cervical vertebra, and then it describes a curve and passes outwar forwards, and downwards in contact with the cupola of the left pleu It then inclines inwards, and, after receiving the left jugular and si clavian trunks, ends in the angle of junction of the internal jugu and subclavian veins of the left side. The terminal orifice of the di is guarded by a valve composed of two segments, which are so direcl as to effectually prevent the reflux of chyle and the flow of blood ii it. The duct crosses the left vertebral artery, passing either in frc of or behind the vertebral vein. In half the cases the duct is dou' for some distance before it enters the internal jugular, and one brar may open into the subclavian vein. Occasionally three or m< openings have been found, and this multiple opening is of surgi importance, for if one branch is cut in an operation on the root of i neck, it is an even chance that there may be another to carry t chyle to the blood-stream. It is important to notice that the di passes behind the vagus and in front of the phrenic nerves.

Right Lymphatic Duct. —The position of this duct corresponds that of the thoracic duct on the left side. It is about inch in lengi and is formed by the union of the right subclavian trunk and rig jugular trunk. Besides returning lymph from the right side of t head and neck and the right upper limb, it receives the lympha vessels from the right side of the heart, the right lung, the upp part of the right half of the thoracic wall, and some of those from t antero-superior surface of the liver. It ends in the angle of juncti of the internal jugular and subclavian veins of the corresponding sic its orifice being guarded by a double valve.

Cervical Portion of the Lung. —The apex of the lung projects in the root of the neck as high as the neck of the first rib. It is cover by the cupola of the pleura, on the inner and anterior aspects of whi the subclavian artery arches outwards. The cupola of the pleura covered by the suprapleural membrane (Sibson’s fascia), which exten


THE HEAD AND NECK


1247


im the medial border of the first rib to the front of the transverse Dcess of the seventh cervical vertebra. This membrane is probably rived from the adjacent scalene muscles, and it may contain some iscular fibres.


The Contents of the Orbit.

The following structures are found in the orbit:

Orbital Fascia. —The periosteum of the orbit is continuous posteriorly th the dura mater through the superior orbital fissure, and constitutes 0 orbital fascia. Anteriorly it becomes continuous with the periinium of the frontal bone, and the periosteum of the maxilla and gomatic bones. Along the supra-orbital and infra-orbital margins 0 superior and inferior palpebral fascia0 blend with it. The orbital >cia is loosely attached to the bony walls of the orbit, and forms a 0ath for the contents of the cavity, which is incomplete in front. Lacrimal Gland. —This gland lies at the anterior and outer part the orbit superiorly, where it occupies the lacrimal fossa on the ler side of the zygomatic process of the frontal bone. It is discaped. Its upper surface is convex, and its under surface is conve in adaptation to the eyeball. The anterior part of the gland is rtly cut off by the outer edge of the levator palpebrae superioris, d is known as the palpebral portion , the chief part being known the orbital portion . The ducts, which issue from both portions, 0 about twelve in number, and they open in a row into the outer part the superior conjunctival fornix.

Blood-supply. —The lacrimal artery.

Nerve-supply. —The lacrimal nerve and sympathetic filaments.

The structure of the gland is something like to that of the parotid. Development. —The lacrimal gland, like the tarsal and ciliary glands, is /eloped as solid epithelial cords from the conjunctiva. These epithelial 'ds spring from the upper and outer part of the conjunctiva, where it is rented from the inner surface of the upper eyelid on to the front of the eyeball, e solid cords grow into the neighbouring mesoderm, and give off lateral proses. Cords and processes, at first solid, soon become hollow, and so give 3 to the alveoli, or acini, and ducts of the lacrimal gland.

In reptiles the ducts open all round the fornix of the conjunctiva, but in unmals only the upper and outer ones persist.

Muscles.— These are the levator palpebrae superioris, rectus superior,

tus inferior, rectus medialis, rectus lateralis, obliquus superior, and

liquus inferior.

Levator Palpebrae Superioris — Origin. —The under surface of the of of the orbit above, in front of, and medial to the optic foramen. Insertion. —By a broad membranous expansion, which divides into ree tendinous laminae. The middle lamina, which is the chief serf ion, and consists largely of involuntary muscular fibres, is attached the upper margin of the superior tarsus. The upper or superficial yer, which is fibrous, passes in front of the superior tarsus, lying tween it and the palpebral fibres of the orbicularis oculi. Its fibres


1248


A MANUAL OF ANATOMY


pierce the superior palpebral fascia, and, having passed between bundles of the palpebral portion of the orbicularis oculi, they attached to the skin of the upper eyelid. The lower or deep layer , wl is also fibrous, is attached to the conjunctiva along the superior for


Supra-orbital Nerve (in two divisions)


Supratrochlear Nerve Infratrochlear Nerve S™


Olfactory Bulb


Naso-ciliary Nerve


Optic Nerve-


Frontal Nerve on Levator Palpebrae Superioris

Lacrimal Nerve passing along Rectus Lateralis


Ophthalmic Artery’-'

Oculo-motor Nerve"*

Trochlear Nerve'

Abducent Nerve-'

Motor Root of Trigeminal Nerve

Fig. 754. —Dissection of the Orbit from above (Hirschfeld and Leveil


Maxillary Nerve Ophthalmic Nerve 7 Mandibular Nerve '-Trigeminal Ganglion

'•Sensory Root of Trigeminal Nerve


The outer and inner margins of the broad membranous expans are attached to the outer and inner margins of the orbit close to lateral and medial palpebral ligaments, and at the inner angle a < is attached to the pulley of the obliquus superior.

Nerve-supply .—The 1 per division of the th cranial nerve, the brai from which enters the d< or ocular surface of muscle near its ori£ having pierced the rec superior.

Action .—To raise upper eyelid. The mus is the antagonist of superior palpebral fibres the orbicularis oculi.

The levator palpebrse is a delamination of the rectus superior, to whicl is so closely attached that, even when it is paralyzed, the upper lid may raised a little by looking upwards.

Relations. — Superiorly , the frontal nerve and the supra-orbi artery. Inferiorly , the rectus superior and the conjunctiva.


WHICH MOVE THE EYEBALL.














THE HEAD AND NECK


1249

Recti Muscles Rectus Superior— Origin. —The upper part of the rnmon tendinous ring in relation to the optic foramen.

Insertion. By a thin expanded tendon into the upper surface of e sclera about three or four lines from the margin of the cornea. Nerve-supply.-' The upper division of the oculo-motor nerve, the anch from which enters the deep or ocular surface of the muscle ar its origin.

The muscle is flattened from above downwards, and its direction forwards and slightly outwards.

The actions of the muscles of the eyeball are considered together tp- 1251 Relations.' Superiorly , the levator palpebrae superioris, which is e narrower of the two muscles. Inferiorly , the tendon of the obliquus penor, the eyeball, and the soft fat of the orbit.

Rectus Medialis (Internal Rectus)— Origin. —The inner part of the mmon tendinous ring in relation to the optic foramen, the origin

ing wide.

Insertion. By a thin expanded tendon into the inner surface of e sclera about three or four lines from the margin of the cornea. Nerve-supply. —The lower division of the oculo-motor nerve, the anch from which enters the deep or ocular surface of the muscle.

The muscle is flattened from within outwards, and its borders are perior and inferior. Its direction is almost straight forwards.

Relations.—Above the upper border of the muscle is the obliquus perior, and between the two the naso-ciliary nerve and the anterior id posterior ethmoidal vessels pass.

Rectus Inferior— Origin. —The lower part of the common tendinous ig in relation to the optic foramen.

Insertion. —By a thin expanded tendon into the lower surface the sclera about three or four lines from the margin of the rnea.

Nerve-supply. —The lower division of the oculo-motor nerve, the anch from which enters the deep or ocular surface of the muscle.

The muscle is flattened from above downwards, and its direction forwards and slightly outwards.

Relations— Inferior. —A part of the obliquus inferior.

Rectus Lateralis (External Rectus)— Origin. —This muscle arises bv [0 heads. y

Inferior Head.—(1) The lower part of the common tendinous ring relation to the optic foramen, where it is near the rectus inferior; d (2) the prominent spine on the lower margin of the superior orbital sure near its inner end.

Superior Head.—The outer portion of the upper part of the common idinous ring in relation to the optic foramen, where it is above 2 superior orbital fissure, external to the optic foramen, and near - rectus superior. The two heads are connected by a tendinous nd which arches over the superior orbital fissure, and gives origin some of the fibres of the inferior head of the muscle.


79



1250


A MANUAL OF ANATOMY


Insertion. —The outer surface of the sclera from three to four li from the margin of the cornea.

Nerve-supply. —The abducent nerve, the branches of which en the deep or ocular surface of the muscle.

The muscle is flattened from without inwards, and its directioi forwards and outwards.

Action. —To abduct the eyeball, so as to direct the cornea outwai

Relations.—The following structures pass between the two he of the muscle in order from above downwards: (i) the upper divis of the oculo-motor nerve; (2) the naso-ciliary nerve; (3) the hr division of the oculo-motor nerve; (4) the abducent nerve; and (5) superior ophthalmic vein or veins.

Common Tendinous Ring of the Recti Muscles.—This tendon ta the form of a fibrous ring, which is attached to the upper, inner, ; lower margins of the optic foramen. It then crosses transvers the inner portion of the superior orbital fissure to a prominent sp on the lower margin of that fissure near its inner end. From 1 spine it recrosses the superior orbital fissure in a vertical direct near its centre, and finally reaches the upper part of the optic foram This latter portion gives origin to some fibres of the inferior head the rectus lateralis. The upper part of the ring is sometimes knc as the tendon of Lockwood , and gives origin from within outwa to part of the rectus medialis, the rectus superior, and the supei head of the rectus laterals. The lower part is also sometimes ca]

the ligament of Zinn y which gives ori from within outwards to part of the rec medialis, the rectus inferior, and the infei head of the rectus lateralis.

Obliqui Muscles — Obliquus Superio: Origin. —The wall of the orbit directly front of the upper and inner part of optic foramen, close to the recti superio] medialis.

Insertion. —By an expanded tendon i the upper and outer aspect of the sc] just beyond the outer border of the supe: rectus, and midway between the margir the cornea and the entrance of the oj nerve.

The muscle is situated at the upper 1 inner part of the orbit, internal to levator palpebrae superioris. It is directed forwards towards inner angle of the orbit, on approaching which it ends in a sr round tendon. This tendon passes through a fibro-cartilagin pulley close to the medial angular process of the frontal bone, then changes its direction, and passes downwards, outwards, ; backwards beneath the tendon of the rectus superior to reach insertion just lateral to that tendon.


Fig. 756.—The Superior Oblique Muscle.




THE HEAD AND NECK


1251

The fibro-cartilaginous pulley or trochlea is attached by fibrous

sue to the trochlear fossa on the orbital plate of the frontal bone

)se to the medial angular process. It is lined with synovial membrane lubricate the tendon and facilitate its movement at this abrupt ange in its course. The tendon receives a fibrous investment from e outer margin of the pulley.

Nerve-supply.—The trochlear nerve, which enters the muscle on

superficial or orbital surface near its origin.

Relations— Superior. —The roof of the orbit and the rectus superior. ferior. —The upper border of the rectus medialis, having the nasoiary nerve and the anterior and posterior ethmoidal vessels between em. Lateraf^—-The levator palpebrae superioris.

Obliquus Snpemr — Origin. —A small depression at the anterior and tier part of the floor of the orbit immediately lateral to the upper >ening of the lacrimal canal.

Insertion. —The outer surface of the sclera under cover of the rectus teralis, and slightly posterior to the level of the insertion of the iliquus superior.

Nerve-supply— The lower division of the oculo-motor nerve, the anch of which is long and enters the posterior border of the muscle. The muscle at first passes outwards and backwards upon the floor the orbit beneath the rectus inferior, and then it turns upwards itween the sclera and the rectus lateralis, where its tendon expands lore its insertion.

Relations. —Towards the eyeball the muscle is related to the ctus inferior and the sclera, and towards the orbit to the floor of e cavity and the rectus lateralis. The borders of the muscle are Lterior and posterior, the latter, as stated, receiving the nerve ppiy Movements of the Eyeball. —The movements of the eyeball con>t of rotation round a point situated just behind the centre of its hero-posterior axis. When the eyeball rotates round its vertical

is, horizontal or lateral movements take place, and the cornea

directed outwards or inwards according to the muscle which acts. ie rectus lateralis abducts the eyeball, so as to direct the cornea itwards, and the rectus medialis adducts the eyeball, so as to rect the cornea inwards. When the eyeball rotates round its trans;rse axis vertical or upward and downward movements take place, id the cornea is directed upwards or downwards according to the uscle which acts. The rectus superior elevates the eyeball, and e rectus inferior depresses it. It is to be borne in mind, however, at these two muscles in passing forwards have each a slight innation outwards. Whilst, then, they respectively elevate and depress e cornea on the transverse axis of the eyeball, each of them also ^es it a certain amount of inward movement on the vertical axis, companied by slight rotation on the antero-posterior axis. In e case of the rectus superior this inward and rotatory movement corrected by the obliquus inferior acting in association with it, and



1252


A MANUAL OF ANATOMY


in the case of the inferior rectus by the obliquus superior acting association with it.

Direct elevation of the eyeball is therefore effected by the re< superior, aided by the obliquus inferior, and direct depression of eyeball is effected by the rectus inferior, aided by the obliquus supei The superior oblique, acting alone, would depress the cornea abduct it, making the eye look downwards and outwards, and obliquus inferior, acting alone, would elevate and abduct it, tl movements in each case being accompanied by slight rotation on antero-posterior axis.

Fascia of the Orbit.—This fascia forms (i) the fascial sheath


the eyeball, fascia bulbi; and (2) sheaths for the ocular muscles.

The fascia bulbi is practically the thickened wall of a lyn space round the sclerotic coat of the eyeball, and extends from

point of entrance of the o]


nerve to near the margin of cornea. Posteriorly it is perfora by the ciliary vessels and ner and blends with the dura ma sheath of the optic nerve, ; anteriorly it fades away when meets the ocular conjunctiva, outer surface of the capsule h contact with the orbital fat, ; anteriorly with the ocular c junctiva. The fascial sheath (c sule of Tenon) forms a cavity socket, within which the eyel glides with perfect freedom fr friction.

The lower part of the fas< sheath of the eyeball is said to thickened by the suspensory li ment of the eye (Lockwood). This is attached laterally to Whitna tubercle on the zygomatic bone, and medially to the lacrimal bo It is expanded beneath the eyeball, to the fore part of which it a as a sling or support.

The muscular sheaths are derived from the fascial sheath of eyeball. The tendons of the six ocular muscles pierce the fas( sheath on their way to their insertions, which latter are under cover the fascial sheath, each muscle receiving a prolongation from the mar ; of the cleft in the sheath through which its tendon passes. Th prolongations extend backwards around the muscles, and ultimat blend with their perimysial sheaths. As regards the obliquus super muscle, the prolongation around its tendon extends upwards, inwar and forwards as far as the margin of the pulley, to which it is attach The prolongation around the tendon of the obliquus inferior mus extends downwards as far as the outer part of the floor of the orbit


It has an endothelial lining (dotted line) which is reflected along the tendons to their insertions; the fibrous basis is reflected back towards the muscle.



THE HEAD AND NECK


1253


The sheaths of the four recti muscles give off important expanms. The expansion from the sheath of the rectus lateralis is strong, id is attached to the frontal process of the zygomatic bone, and at from the sheath of the rectus medialis, also strong, is attached the lacrimal crest of the lacrimal bone. These two expansions their bony attachments are connected with the lateral extremities the suspensory ligament of the eye. The expansion from the eath of the rectus superior blends with the deep layer of the tendon the levator palpebrae superioris, and that from the sheath of the

tus inferior is connected with the inferior tarsus. These expansions

>m the sheaths of the recti, especially from those of the recti lateralis medialis, moderate the action of the muscles, and the latter two e hence known as the check ligaments.

Nerves in the Orbit—Optic Nerve.—The optic nerve extends forirds and outwards from the optic chiasma, and enters the orbit rough the optic foramen, having the ophthalmic artery below it first, and then on its outer side. It receives sheaths from the ira mater and arachnoid, the former being strong, and at its entrance to the orbit it is surrounded by the origins of the four recti muscles.

? direction is forwards and outwards, with a slight inclination wnwards, to the back part of the eyeball, where it pierces the sclera out inch medial to, and a little below, the centre. It then pierces e choroid coat, and ends in the nerve-fibre layer of the retina. The iary ganglion is close to the outer side of the nerve towards the back rt of the orbit, and in front of this the nerve is surrounded by the iary nerves and vessels. It is crossed superiorly by the ophthalmic tery, the superior ophthalmic vein, and the naso-ciliary nerve, feriorly, about J inch behind the eyeball, the central artery of the tina enters it and then runs forward within it to the retina.

Third or Oculo-motor Nerve.—This nerve, having left the outer dl of the cavernous sinus, breaks up at the superior orbital fissure into 0 divisions, upper and lower. These enter the orbit between the 0 heads of the rectus lateralis muscle, the naso-ciliary nerve being uated between the two.

The superior division enters the deep surface of the rectus superior pplying it, after which it pierces the muscle and ends in the levator lpebrae superioris.

The inferior division, larger than the upper, has three branches, lich supply the rectus medialis, the rectus inferior, and the obliquus hrior. The twigs to the recti medialis et inferior enter these muscles their deep or ocular surfaces. The branch to the obliquus inferior a long nerve which passes forwards between the recti inferior et eralis, and its twigs enter the obliquus inferior muscle at its posterior 'der. Posteriorly it furnishes the ganglionic branch, which forms the 3 rt or parasympathetic root of the ciliary ganglion.

The fourth, trochlear, or pathetic nerve, of small size, having left 2 wall of the cavernous sinus, enters the orbit through the superior sital fissure above the muscles, and medial to, but on a slightly


I2 54


A MANUAL OF ANATOMY


higher plane than, the frontal nerve. Having passed inwards o 1 the levator palpebrae superioris, it enters the posterior part of the ol quus superior muscle on its superficial or orbital surface, this bei the only muscle which it supplies.

The sixth or abducent nerve, having left the cavernous sinus, ent the orbit through the superior orbital fissure, and passes between 1

two heads of the rectus lateralis muscle, this situation it has the lower division of 1 oculo-motor nerve above it, and the super ophthalmic veins below it. It supplies 1 rectus lateralis, its twigs entering the mus on its deep or ocular surface.

Branches of the Ophthalmic Division of I Trigeminal Nerve. — The ophthalmic ner having left the outer wall of the cavernc sinus, and before reaching the superior orbi fissure, divides into frontal, lacrimal, a naso-ciliary nerves.

The frontal nerve, of large size, enters 1 orbit through the superior orbital fissure abc the muscles. In this situation it has the 1; rimal nerve lateral to, and on the same pla with it, and the trochlear nerve medial to but on a slightly higher plane. It then pas: forwards on the upper surface of the levai palpebrae superioris, underneath the periostei of the roof of the orbit, and before arrivi at the supra-orbital margin it divides into t branches, supra-orbital and supratrochlear.

The supra-orbital nerve, which in size a direction is the continuation of the front passes forwards to the supra-orbital notch foramen, through which it leaves the orbit company with the supra-orbital artery. ( the forehead it divides into two branches, late and medial, which have been already descrit (see p. 1153). Sometimes this division takes place within the ort and in these cases the inner branch usually passes through the sup: orbital notch.

The supratrochlear nerve, of small size, passes forwards and inwai to the pulley to the obliquus superior muscle, above which it runs the forehead, where it has been already described (see p. 1154)- Bef( leaving the orbit it gives off a small twig, which passes downwar close to the pulley of the obliquus superior, to form a loop with i infratrochlear branch of the naso-ciliary nerve.

The lacrimal nerve enters the orbit through the superior orbi fissure above the muscles, and external to the frontal nerve. It tt passes forwards and outwards along the upper border of the rec


Fig. 758. —The Third and Sixth Cranial Nerves in the Orbit .


I.O., nerve to inferior oblique; other branches running directly forward from lower division of the third nerve are going to inferior rectus.








THE HEAD AND NECK


1255


eralis in company with the lacrimal artery. On reaching the lacrimal

md it gives numerous branches to its deep surface, and is then coniued through the orbital septum to the skin and conjunctiva of the ter part of the upper eyelid, and the skin in the region of the zygoitic process of the frontal bone. Near the lacrimal gland it sends wnwards a small twig, which joins the zygomatico-temporal nerve. The naso-ciliary nerve (nasal nerve) is more deeply placed than the rntal and lacrimal. It enters the orbit through the superior orbital sure, and passes between the two heads of the rectus lateralis muscle, [ng between the upper and lower divisions of the oculo-motor nerve, then passes obliquely inwards and forwards to the inner wall of the bit, lying beneath the rectus superior and above the optic nerve, d, later on, between the obliquus superior and the rectus medialis. iving reached the inner wall of the orbit at the anterior ethmoidal


g. 759- —Scheme of the Distribution of the Oculo-motor, Trochlear,

and Abducent Nerves (Flower).

f U - D - { L rJ: Sg2£sSKZ" SUPeri ° riS

! rR.Int. Rectus Medialis

Oculo-Motor Nerve ' L.D. Lower Division -j R.Inf. Rectus Inferior

( O.I. Obliquus Inferior


C.G. Ciliary Ganglion ^ M.R. Motor Root

S.R. Sensory Root (from Naso-ciliary Nerve) Sy.R. Sympathetic Root S.C. Short Ciliary Nerves Trochlear Nerve—O.S. Obliquus Superior Abducent Nerve—R.E. Rectus Lateralis.


ramen, it parts with its infratrochlear branch, and then passes through e foramen in company with the anterior ethmoidal artery, and so iters the anterior fossa of the base of the skull. It then passes forwards id inwards in a groove on the upper surface of the cribriform plate the ethmoid bone, lying under cover of the dura mater. Having ached the nasal slit at the side of the fore part of the crista galli, descends through this slit, or through a small foramen just in front it, into the nasal cavity, and immediately gives off two internal nasal anches. Then the nerve descends in a groove on the posterior surface the nasal bone, giving offsets to the mucous membrane of the outer all of the nasal cavity in front of the superior and middle nasal •nchae. Finally, the nerve comes out, as the external nasal branch, dween the lower border of the nasal bone and the upper nasal cartilage, id supplies the skin of the tip and lower part of the side of the nose.






A MANUAL OF ANATOMY


1:256

In connection with this remarkable course of the nerve it is to t noted that it is to be met with in four different regions—name! (1) in the orbit; (2) on the cribriform plate of the ethmoid bone : the anterior cranial fossa; (3) in the nasal cavity; and (4) on the fa< in the region of the tip of the nose.

Branches. —The ramus communicans to the ciliary ganglion forms tl long or sensory root of that ganglion. It is slender, about ^ inch Ion and arises from the naso-ciliary as it passes between the two hea( of the rectus lateralis. It enters the ciliary ganglion at its poster superior angle.

The long ciliary nerves , usually two in number, arise from tl naso-ciliary immediately after it has crossed the optic nerve, and the


Supra-orbital Nerve (in two divisions)


Supratrochlear Nerve—: In fra trochlear Naso-ciliary—'


Olfactory Bulb Naso-ciliary Nerved


Optic Nerve—

?

Ophthalmic Artery — Oculo-motor Nerve- - """


Trochlear Nerve


-•Frontal Nerve on Levator Palpebrae Superioris


    • • Lacrimal Nerve passing along

Rectus Lateralis


~ Maxillary Nerve Ar Ophthalmic Nerve

      • Mandibular Nerve

'.Trigeminal Ganglion

Abducent Nerve"' j ,,v ‘ Sensory Root of Trigeminal Nerve

Motor Root of Trigeminal Nerve

Fig. 760. —Dissection of the Orbit from above (Hirschfeld and

Leveille) .


communicate with the short ciliary nerves from the ciliary ganglioi which they accompany to the back part of the sclera. Here they pierc the sclera, and are distributed along with the short ciliary nerves.

The infratrochlear nerve arises from the naso-ciliary close to th anterior ethmoidal foramen, and passes forwards beneath the obliqur superior muscle. Near the pulley of that muscle it receives a twi from the supratrochlear nerve, and then, passing beneath the puller it leaves the orbit at the medial angle to be distributed to the ski and conjunctiva of the inner parts of the eyelids, the side of the roc of the nose, the lacrimal sac, and the caruncula lacrimalis.

As the nerve traverses the anterior ethmoidal canal it gives twig to the mucous membrane of the frontal sinus and of the anterior etl moidal sinus.






THE HEAD AND NECK


1257


A posterior ethmoidal nerve is described as passing through the isterior ethmoidal canal to supply the mucous membrane of the jsterior ethmoidal sinus and of the sphenoidal sinus.

For the branches of the naso-ciliarv nerve to the exterior of the nose id to the nasal fossa, see p. 1276.

Ciliary Ganglion (Lenticular Ganglion).—This is a small quadriteral body, about the size of a moderately large pin-head, which is

uated in the posterior part of the orbit, where it lies flattened upon

e outer side of the optic nerve. It is usually in close contact with


A



Fig. 761.—A, The Ciliary Ganglion; B, The Nerves of the Orbit (Lateral Aspect) (Hirschfeld and Leveille).


lternal Carotid Plexus phthalmic Nerve aso-ciliary Nerve ympathetic Root of Ciliary Ganglion


rigeminal Ganglion 'culo-motor Nerve bducent Nerve lternal Carotid Artery ptic Nerve

ommon Tendinous Ring for Recti


A

5. Sensory Root of Ciliary Gang lion

6. Long Ciliary Nerves

7. Branch of Oculo-motor Nerve

to Obliquus Inferior

B

7. Levator Palpebrae Superioris

8. Rectus Superior

9. Frontal Nerve

10. Rectus Lateralis

11. Obliquus Superior

12. Rectus Inferior

13. Short Ciliary Nerves


8. Motor Root of Ciliary Ganglion

9. Ciliary Ganglion

10. Infratrochlear Branch of Naso ciliary Nerve

11. Short Ciliary Nerves


14. Branch of Oculo-motor Nerve to

Obliquus Inferior

15. Ciliary Ganglion

16. Ophthalmic Nerve

17. Maxillary Nerve

18. Mandibular Nerve


it nerve, and is recognized by its reddish-pink colour. Posteriorly receives its three roots, and anteriorly the short ciliary nerves pass wards from it. The roots are called sensory, motor, and sympathetic, e sensory root is derived from the naso-ciliary nerve as it passes

ween the two heads of the rectus lateralis. It is slender, about

nch long, and enters the postero-superior angle of the ganglion, e motor root is derived from the long branch of the lower division the oculo-motor nerve which supplies the obliquus inferior muscle, 1 it enters the postero-inferior angle of the ganglion. The sym









1258


A MANUAL OF ANATOMY


pathetic root is a very minute nerve which is derived from the interi carotid plexus of the sympathetic, and it usually reaches the gangli in company with the sensory root. It may, however, join the gangli separately, and then it does so in close proximity to the entrance the long root.

The branches of the ciliary ganglion are called the short cilic, nerves. They are from six to eight in number, and come off in b groups from the antero-superior and antero-inferior angles. T nerves of the lower group usually exceed those of the upper in numb As they pass forward above and below the optic nerve they divide, a give rise to from sixteen to twenty delicate filaments. Having reach the back of the eyeball, they pierce the sclera around the entrar of the optic nerve. They then pass forwards between the sclera a


Infratrochlear Artery Medial Palpebral Arteries


Dorsal Nasal Artery-— Pulley of Obliquus Oblique-.


Anterior Ethmoidal Artery.

Posterior Ethmoidal Artery..


Central Artery of the Retina (in outline)

Obliquus Superior Rectus Superior (cut)

Levator Palpebra? Superioris (cut)


Optic Nerve Optic Chiasma (right half)


Lacrimal Gland


Supra-orbital Artery


Long Posterior Ciliary Arteries

Lacrimal Artery


Rectus Lateralis (cut) Ophthalmic Artery


Right Optic Tract

Fig. 762. —Dissection of the Right Orbit from above, showing the Op Nerve, Ophthalmic Artery, and Superior Oblique Muscle.


the choroid, giving twigs to the latter, and they are finally distribul to the ciliary muscle, the iris, and the cornea. The short cilic nerves thus convey co the eyeball sensory fibres from the ophthalr division of the trigeminal nerve, motor fibres from the oculo-mo nerve, and sympathetic fibres from the internal carotid plexus of 1 sympathetic.

Summary of the Ophthalmic Nerve. —This nerve is entirely sensory, supplies (1) the skin of (a) the frontal region and top of the skull; (&) the up eyelid, and (c) the root, tip, and lower part of the side of the nose; (2) the cari cula lacrimalis and lacrimal sac; (3) the mucous membrane of the nasal cavi and the conjunctiva; (4) the eyeball; and (5) the lacrimal gland.

Summary of the Ciliary Ganglion. —The branches of this ganglion supply 1 cornea, iris, and ciliary muscle. The fibres which supply the sphincter pUpi are derived from the oculo-motor nerve by means of the motor root of the gangli





THE HEAD AND NECK


1259


le fibres which supply the dilator pupillse are derived from the sympathetic by eans of the sympathetic root of the ganglion, which is derived from the internal rotid sympathetic plexus.


Branch of the Maxillary Division of the Trigeminal Nerve.—The rgomatic nerve (temporo-malar nerve), of small size, arises from the axillary in the pterygo-palatine fossa. It enters the orbit through Le inferior orbital fissure, and soon divides into two branches, zygoatico-temporal and zygomatico-facial. The zygomatico-temporal nerve imp oral branch) ascends upon the outer wall of the orbit, and, having ceived a communicating twig from the lacrimal nerve, it leaves the ivity by passing through the zygomatico-temporal canal in the rgomatic bone. Its destination is the skin of the anterior part of Le temporal region.


Medial Palpebral Arteries Supratrochlear Artery


Dorsal Nasal Artery


Anterior Ethmoidal Artery


Posterior Ethmoidal Artery Ophthalmic Artery

Posterior Ciliary Arteries Ophthalmic Artery (in Optic Foramen)


Lacrimal Gland


-\ Lateral Palpebral . j Arteries


Supra-orbital Artery


Lacrimal Artery

- Muscular Arteries Arteria Centralis Retinae '■ Posterior Ciliary Arteries

— Internal Carotid Artery


Fig. 763. —Diagram of the Ophthalmic Artery and its Branches.


The zygomatico-facial nerve [malar branch ) passes forwards in the lgle between the outer wall and floor of the orbit, and leaves the vity by passing through the zygomatico-facial canal, from which comes out through the corresponding foramen. It is distributed 1 the skin over the zygomatic bone.

Ophthalmic Artery.—This vessel arises from the internal carotid tery on the inner aspect of the anterior clinoid process, and enters e orbit through the optic foramen, lying beneath the optic nerve, ithin the orbit it is situated for a short distance on the outer side the optic nerve, and then it passes obliquely inwards and forwards a tortuous manner over the nerve to the inner wall of the orbit, len it passes forwards to the region of the medial angular process the frontal bone, near which it divides into its three terminal branches dorsal nasal, supratrochlear, and palpebral.





I26o


A MANUAL OF ANATOMY


Branches. —These are as follows:


1. Central artery of the retina.

2. Posterior ciliary.

3. Lacrimal.

4. Muscular.

5. Supra-orbital.


6. Posterior ethmoidal.

7. Anterior ethmoidal.

8. Palpebral (two), g. Nasal.

10. Frontal.


The central artery of the retina (arteria centralis retinae) aris from the ophthalmic at the back part of the orbit below the opt nerve. Its direction is forwards beneath the nerve, and at a poii about \ inch behind the eyeball it enters the nerve, and passes forwan in its centre to the retina, upon which it ramifies. It must be unde stood that this is the only blood-supply of the retina, and that i obliteration means blindness of the eye to which it goes; it is therefor in spite of its small size, one of the most important arteries in the bod;

The posterior ciliary arteries arise from the ophthalmic whilst is below the optic nerve. They are arranged in two sets, lateral an medial, which pass forwards on either side of the optic nerve to the bac part of the eyeball. Here they pierce the sclera, and the majorit of them enter the choroid coat under the name of the short postern ciliary arteries. Two of them, however, are fairly large, and are know as the long posterior ciliary arteries. They pass forwards betwee the sclera and the choroid, one on each side, and are distributed 1 the ciliary muscle and iris.

The lacrimal artery arises from the ophthalmic on the outer sic of the optic nerve, and passes forwards along the upper border of tl rectus lateralis muscle to the lacrimal gland. In its course it furnish* the following branches: (1) a recurrent meningeal branch, whic passes through the outer part of the superior orbital fissure to tl middle cranial fossa, where it anastomoses with the middle meninge; artery; (2) muscular and anterior ciliary branches, the latter piercir the sclera very near the corneal margin; (3) zygomatic offsets, whic pass through the zygomatico-temporal and zygomatico-facial canals ( the zygomatic bone to the face and temporal region in company wit the respective branches of the temporo-zygomatic nerve; (4) tw lateral palpebral arteries, superior and inferior, which pass inwarc in the upper and lower eyelids, and anastomose with the medi; palpebral branches of the ophthalmic, thus forming arterial arches and (5) glandular branches to the lacrimal gland.

The muscular branches arise from the ophthalmic in two set: outer and inner, and also from some of its branches— e.g., the lacrime and supra-orbital. They furnish a few of the anterior ciliary arteries

The supra-orbital artery arises from the ophthalmic as it crossc inwards over the optic nerve. It courses forwards to the supra orbital notch, through which it passes, with the corresponding nerv* to the forehead. It supplies the upper eyelid and the frontal regior and anastomoses with the superficial temporal and supratrochlea arteries.


THE HEAD AND NECK


1261


Ihe posterior ethmoidal artery, a small vessel, passes through the jsterior ethmoidal canal on the inner wall of the orbit, and is distributed the mucous membrane of the posterior ethmoidal sinus and the ucous membrane of the upper and back part of the outer wall of e nasal cavity. The latter branches pass through foramina in the ibriform plate.

The anterior ethmoidal artery is larger than the preceding. It isses through the anterior ethmoidal canal with the naso-ciliary

rve, and enters the anterior fossa of the base of the skull. Here

crosses the cribriform plate of the ethmoid bone to the nasal slit T the side of the crista galli. It then descends through this slit, rverses the nasal groove on the posterior surface of the nasal bone, id finally passes between the lower border of the nasal bone and the >per nasal cartilage to the tip of the nose. Its branches supply the ira mater in the anterior cranial fossa, the mucous membrane of e anterior ethmoidal sinus and corresponding frontal sinus, the mucous smbrane of the upper and Lcsxl wing of Sphenoid

.tenor parts of the nasal T . , . T ;

isa, and the skin of the tip Frontal Nerve o P uc

the nose. Nerve

The medial palpebral ar- Upper Division of Oculo-motor Nerve_

ies are superior and in- Lower Division /

'ior, and are distributed Abdueent Nerve -.ym /

. .. A . Ophthalmic Vein V/

the eyelids, they arise, _ T _

^ • • A r Fig. 764.—Diagram of the Left Superior

a ^jy °, r c ? n J om t^y» ^ rom Orbital Fissure, showing the Trans e ophthalmic close to the mitted Structures (Posterior View).

Hey of the obliquus su rior muscle, and each takes an outward course in the corresponding elid. They anastomose with the two lateral palpebral branches of e lacrimal artery, thus forming arterial arches.

The dorsal nasal artery leaves the orbit above the medial palpebral

ament, and is distributed to the upper part of the side of the nose

the region of the root, where it anastomoses with the angular and teral nasal branches of the facial artery.

The supratrochlear artery (frontal artery) is the third terminal anch of the ophthalmic. It leaves the orbit at the inner angle, d then ascends to the frontal region, along with the supratrochlear rve, to be distributed to the integument by the side of the median ie. It anastomoses with the supra-orbital artery and its fellow the opposite side. The above description is fairly typical, but the 3 de of origin of the orbital arteries is very variable and, as in most rts of the body, the normal is seldom seen.

Ophthalmic Veins.—These are superior and inferior. The superior hthalmic vein, of large size, begins at the inner angle of the orbit, iere it communicates freely with the facial through the angular in. It accompanies the ophthalmic artery, passing outwards and ckwards over the optic nerve. Having reached the inner end of the perior orbital fissure, the vessel passes between the two heads of the




1262


A MANUAL OF ANATOMY


rectus lateralis muscle, and through the fissure, after which it ope: into the anterior part of the cavernous sinus. Its tributaries corr spond for the most part to the branches of the ophthalmic arter It does not, however, receive the supratrochlear nor the supra-orbit vein. The inferior ophthalmic vein arises in connection with t] lower posterior ciliary and lower muscular veins. It passes backwar along the floor of the orbit, and may join the superior ophthalmic vei open independently into the cavernous sinus, or pass through t] inferior orbital fissure into the pterygoid plexus, with which in ai case it freely communicates.

Structures passing through the Superior Orbital Fissure (Sphenoid Fissure). —These structures are as follows:


1. The oculo-motor nerve.

2. The trochlear nerve.

3. The naso-ciliary, lacrimal,

and frontal nerves.

4. The abducent nerve.

5. The sympathetic root of the

ciliary ganglion.


6. The ophthalmic veins.

7. The orbital branch of t]

middle meningeal artery

8. The recurrent branch of t]

lacrimal artery.

9. The dura mater.


The lacrimal, frontal, and trochlear nerves enter the orbit abo 1 the rectus lateralis muscle, in the order named from without inwards The oculo-motor nerve, the naso-ciliary nerve, and the abduce nerve enter the orbit between the two heads of the rectus lateral muscle, the oculo-motor nerve having already broken up into t\ divisions; and the ophthalmic veins leave the orbit between the t\ heads of the rectus lateralis. The order of parts between the two hea of the rectus lateralis, from above downwards, is as follows:


1. The superior division of the oculo-motor nerve.

2. The naso-ciliary nerve.

3. The inferior division of the oculo-motor nerve.

4. The abducent nerve.

5. The ophthalmic veins (or vein).


The sympathetic root of the ciliary ganglion passes through t superior orbital fissure independently, or along with the naso-cilia nerve, or sometimes with the oculo-motor nerve.

Structures passing through the Inferior Orbital Fissure (Spher maxillary Fissure):

1. Infra-orbital vessels.

2. Infra-orbital nerve.

3. Zygomatic nerve.

4. Inferior ophthalmic vein.

5. Orbital branches of the spheno-palatine ganglion.

6. Lymphatics.


The opening is bridged over by fascia in which involuntary mus: fibres, representing Muller’s muscle of the lower animals, are found. i



THE HEAD AND NECK


1263


THE FACE.

Landmarks.—The glabella can be seen between the eyebrows, and [tending outwards from it on either side is the superciliary arch, ihind the inner part of which is the corresponding frontal sinus! elow the superciliary arch the supra-orbital margin can readily be It, and at the junction of its inner third and outer two-thirds is the [pra-orbital notch, or foramen for the passage of the supra-orbital irve and artery. A line drawn from the position of the suprabital notch to the base of the mandible in such a manner as to pass itween the lower premolar teeth, or, which comes to the same thing, 1 the angle of the mouth, crosses in succession the infra-orbital and ental foramina. The infra-orbital foramen lies in this line at a point )out l inch below the infra-orbital margin, and it indicates the exit the infra-orbital nerve and artery from the infra-orbital canal. The ental foramen in the adult lies midway between the alveolar and Lsilar borders of the mandible, and locates the exit of the mental irve and artery from the mandibular canal.

In line with the tragus of the auricle the zygomatic arch can be It, and leading backwards from it above the orifice of the external iditory meatus is the posterior root of the zygoma. This root is >ntinued into the supramastoid crest, which corresponds to the level the tegmen tympani. Below the supramastoid crest, and just above id behind the external auditory meatus, is the suprameatal triangle, bis triangle lies superficial to the tympanic antrum, and is a most lportant surgical landmark.

The superficial temporal artery and auriculo-temporal nerve lie rectly in front of the tragus, the division of the artery into its anterior id posterior branches taking place about the level of the upper part the auricle. The anterior branch of the artery lies nearly an inch diind the zygomatic process of the frontal bone, and the posterior

  • anch about an inch above the upper part of the auricle.

The parotid gland is situated in front of the auricle. It is limited )ove by the zygoma, behind by the auricle, and interiorly it extends r a limited distance into the digastric triangle of the neck. Anteriorly extends for a short distance superficial to the masseter muscle, and ie parotid duct issues from its anterior border. The course of this ict may be indicated by a line drawn from the intertragic notch to a )int midway between the nostril and the red margin of the upper lip. bout the middle third of this line corresponds to the duct. Above is the transverse facial artery, and below it are the infra-orbital ranches of the facial nerve.

The posterior border of the ramus of the mandible is easily felt, leads superiorly to the condyloid process and mandibular joint, id interiorly to the angle of the bone. Extending forwards from e angle is the base of mandible, which, about an inch from the angle, is a groove for the facial artery, pulsation being readily felt during e in this part of the vessel in front of the masseter muscle, the


1264


A MANUAL OF ANATOMY


anterior vein intervening between the two. In this situation lymphatic gland lies in contact with the artery. From this po the facial artery extends in a tortuous manner to the medial an of the eye, passing close to the angle of the mouth, the anterior fac vein pursuing a comparatively straight course.

Near the mid-line of the face the structures to be noted are ' nasal bones, nasal cartilages, dorsum and apex of the nose, alae n; columna, and the philtrum, which latter is the median groove lead from the columna to the upper lip.

For the component parts of the auricle, see p. 1294.

The eyelids or palpebrae are to be noted, along with the palpeb fissure between them, and the medial and lateral angles at eitl extremity. The tarsus of the upper eyelid can be demonstrated everting the eyelid, and connected with its inner extremity is 1 medial palpebral ligament. This latter may be made tense by draw: the eyelids outwards. It crosses the lacrimal sac a little above 1 centre. The eyelids being everted, the outlines of the tarsal glai may be seen as yellowish streaks perpendicular to the palpeb margins. Behind the eyelashes, or cilia, on the margins of the eyel are the minute orifices of the ducts of the tarsal glands, which ; arranged in a row. Along the line of the eyelashes the skin of i eyelid becomes continuous with the conjunctiva, and along the line reflection of the conjunctiva on to the eyeball the recess, known the fornix, is to be noted. At the medial angle, where the eyelids not meet, there is a recess, known as the lacus lacrimalis, between 1 lids and the eyeball, which lodges a small red fleshy protuberan called the caruncula lacrimalis, provided with a few delicate hai Lateral to this is the fold called the plica semilunaris, which is a vest: of the nictitating membrane or third eyelid of birds. Upon t eyelids at their inner ends the lacrimal papillae are visible, and each papilla is a minute orifice, called the punctum lacrimale. T lower papilla is larger than the upper, and is placed a little farther 0 Each punctum leads into a lacrimal canaliculus, and by these can the tears are conveyed into the lacrimal sac, and thence by the na: lacrimal duct into the inferior meatus of the nose. The position the lacrimal sac may be indicated by drawing the eyelids outwan so as to render tense the medial palpebral ligament, which, as stafi crosses the sac a little above its centre.

Muscles of the Face.

Orbicularis Oculi (Orbicularis Palpebrarum)—Orbital Portion

Origin .—The outer surface of the frontal process of the maxilla, a the medial angular process of the frontal bone.

Insertion .—It is usually said that the orbicular fibres form compl< circles, but it is almost certain that they are serially inserted into t skin, and their place taken by fresh fibres rising from the skin. It only necessary to watch the puckering of the skin on the outer si


THE HEAD AND NECK


1265

ie orbit, where the ' crow’s feet ’ are formed, or the wince of pain w the lower eyelid, to be convinced that there are distinct insertions bres into the skin in these parts.

Palpebral Portion— Origin. —The upper and lower surfaces of the iial palpebral ligament.

Insertion. — 1 he upper and lower surfaces of the lateral palpebral re.

\erve-supply. —Temporal and zygomatic branches of the facial re, in which there may be fibres derived from the nucleus of the o-motor nerve.

Action —Orbital Portion.—(1) The upper half depresses the eyev, and antagonizes the frontal belly of the occipito-frontalis muscle; the lower half elevates the skin of the infra-orbital region. PalpePortion.—This closes the eyelids, as in winking, the upper lid tg depressed and the lower raised, the former movement being e free than the latter. By means of its connection with the medial >ebral ligament the palpebral portion draws forwards the front

of the lacrimal sac, and so contributes to the removal of the tears,

en the entire muscle contracts, the lids are forcibly closed and vn slightly inwards.

rhe upper part of the muscle is related by its deep surface to the dal belly of the occipito-frontalis, the supra-orbital vessels and re, and the supratrochlear nerve, the chief deep relations of the ix part of the levator labii superioris, and, beneath that, the infratal nerve.

Medial Palpebral Ligament (Internal Tarsal Ligament or Tendoli).—It is attached medially to the outer surface of the frontal

ess of the maxilla immediately in front of the naso-lacrimal groove,

direction is outwards in front of the lacrimal sac, and it bifurcates

he medial angle, the divisions diverging, and being attached to

inner extremities of the corresponding tarsus. As the ligament >es just in front of the lacrimal sac it gives origin to the palpebral don of the orbicularis oculi, which explains the action of that don of the muscle upon the sac.

Lateral Palpebral Raph6 (External Tarsal Ligament).—This is tched laterally to the frontal process of the zygomatic bone. Its ction is inwards, and it bifurcates at the lateral angle of the eye the outer extremities of the tarsi.

Lacrimal Portion of Orbicularis Oculi (Tensor Tarsi or Muscle of ner)— Origin. —The crest of the lacrimal bone behind the lacrimal

Insertion .—By means of two slips into the inner extremities of the i of the eyelids, where the fibres become continuous with the ciliary ss of the orbicularis oculi.

Nerve-supply. —As for the rest of orbicularis oculi.

The direction of the muscle is outwards and forwards, and its two s pass behind the lacrimal canaliculi.

Action. —To draw backwards the outer part of the medial palpebral

80



1266


A MANUAL OF ANATOMY


ligament, and in this manner compress the lacrimal sac, the effec which is to force the tears into the naso-lacrimal duct.

Corrugator Supercilii— Origin .—The inner extremity of the su ciliary arch of the frontal bone.

Insertion .—The deep surface of the skin of the eyebrow at centre.

Nerve-supply .—Temporal branches of the facial nerve.


Auricularis Superior


Auricularis Anterior


Auricularis Posterior*


Occipital Belly of -y Occipito-frontalis


Branches from Third and Fourth Cervical Nerves to Trapezius

Scalenus Medius


Lateral Supraclavicular Nerve


Trapezius


"‘Frontal Belly of Occipito frontalis


Orbicularis Oculi


Greater Occipital Nerve Semispinalis Capitis'"' Lesser Occipital Nerve""

Splenius Capitis


Levator Labii Superioris Alaeque N

Levator Labii Super Zygomaticus Minor "Zygomaticus Major “•Masseter


‘“'Orbicularis Oris Depressor Labii Infer! Depressor Anguli Oris Mentalis


Levator Scapulas — Great Auricular Nerve — Accessory Nerve

    • Anterior Belly of Digast

Stemo-hyoid

Mfr SnpeTi ° r Omo-hyoid


- Sterno-mastoid . Anterior Cutaneous Nerve of N


— Medial Supraclavicular Nerve Intermediate Supraclavicular N


Scalenus Anterior

/

Inferior Belly of Omo-hyoid Subclavian Artery (third part)

Fig. 765. —The Right Side of the Head and Neck. The platysma has been removed, and the nerves are shown.


The direction of the muscle is outwards and upwards, and to re the skin the fibres pass through the upper part of the orbicularis 0 and the adjacent portion of the frontal belly of occipito-frontalis.

Action .—To draw the skin of the eyebrow inwards and do wards, giving rise to vertical wrinkles between the eyebrows, a: frowning.

The muscle is under cover of the inner portion of the upper ]











THE HEAD AND NECK 1267

the orbicularis oculi, and it conceals the supratrochlear nerve as merges from the orbit.

Muscles of the Nose—Procerus (Pyramidalis Nasi)— Origin .—The neurosis of the compressor naris over the lower part of the nasal ie.

Insertion. —The deep surface of the skin over the glabella of the ital bone. Some of the fibres become continuous with the medial tion of the frontal belly of occipito-frontalis.

Nerve-supply .—Upper buccal branches of the facial nerve.

Action .—To draw downwards the skin between the eyebrows, ng rise to transverse wrinkles.


Fig. 766. —Dissection of Muscles of Face.

Compressor Naris— Origin .—The maxilla between the canine fossa the nasal notch.

Insertion .—By means of an expanded aponeurosis which blends h its fellow of the opposite side over the cartilaginous portion of nose, and gives origin superiorly to the procerus.

A J erve-snpply .—Upper buccal branches of the facial nerve.

Action .—To depress the cartilaginous portion of the nose.

The muscle is triangular, and at its origin is under cover of the dor labii superioris alaeque nasi.

Levator Labii Superioris Alaeque Nasi— Origin .—The outer surface he frontal process of the maxilla by a pointed extremity. insertion .—By means of two slips. The medial or nasal slip is







1268


A MANUAL OF ANATOMY


inserted into the skin of the ala of the nose, and is often absent. 1 lateral or labial slip is inserted into the skin of the upper lip, some its fibres blending with the levator labii superioris, and others w the upper part of the orbicularis oris.

Nerve-supply .—Buccal branches of the facial nerve.

Action. —(i) To raise the upper lip, and (2) to raise and dilate nostril.

The muscle is triangular, and covers the origin of the compres naris.

Depressor Alse Nasi or Depressor Septi— Origin .—The incisive fo: of the maxilla.

Insertion .—The posterior part of the ala, and the adjacent part the septum of the nose.

N erve-supply .—Upper buccal branches of the facial nerve.

Action .—To depress the ala of the nose.

Dilator Naris Anterior— Origin .—The cartilage of the aperture the nose.

Insertion .—The deep surface of the skin over the ala of the nose

Nerve-supply .—Upper buccal branches of the facial nerve.

Action .—To dilate the nostril.

Dilator Naris Posterior— Origin. —(1) The margin of the na notch of the maxilla; and (2) the accessory cartilages of the nose.

Insertion .—The skin over the back part of the ala of the nose.

Nerve-supply .■—Upper buccal branches of the facial nerve.

Action .—To dilate the nostril.

Levator Labii Superioris— Origin .—The maxilla between the inf orbital foramen and the lower margin of the orbit.

Insertion .—The skin of the upper lip.

Nerve-supply .—Buccal branches of the facial nerve.

Action .—To raise the upper lip.

The muscle is quadrilateral. At its origin it is overlapped by 1 lower half of the orbicularis oculi, and it covers the infra-orbital nei and artery as they leave the infra-orbital foramen. At its insert] the fibres interlace with those of the upper half of the orbicularis ori

Levator Anguli Oris— Origin .—The upper part of the canine fo; of the maxilla under cover of the levator labii superioris.

Insertion .—The angle of the mouth, where some of the fibres < inserted into the skin, whilst others decussate with those of the < pressor anguli oris, and enter the lower lip, mingling with those of 1 lower half of the orbicularis oris.

Nerve-supply .—Buccal branches of the facial nerve.

The direction of the muscle is downwards and slightly outwards

Action .—To raise the angle of the mouth, and at the same time draw it slightly inwards.

The infra-orbital nerve and artery are superficial to the muscle.

Zygomaticus Minor— Origin .—The anterior and lower part of t zygomatic bone close to the maxilla.

Insertion .—The skin of the upper lip immediately lateral to t


THE HEAD AND NECK I2 6 9

itor labii superioris, with the outer border of which muscle some ts fibres blend.

Nerve-supply . Buccal branches of the facial nerve.

The muscle is directed downwards and inwards, and is often irded as part of the orbicularis oculi.

Action.— -To raise feebly the upper lip, and at the same time to w it slightly outwards.

Zygomaticus Major— Origin.— The outer surface of the zygomatic e near the zygomatico-maxillary suture.

Insertion.—The skin at the angle of the mouth, where its fibres id with those of the orbicularis oris.

Nerve-supply. —Buccal branches of the facial nerve.

The muscle is directed downwards and inwards.

Action.— To draw the angle of the mouth upwards and outwards.


Buccal Nerve (cut)


i

Upper Head of Lateral Pterygoid

i


Capsule of Mandibular '^ Joint


Lower Head of Lateral Pterygoid

Pterygo-mandibular

Ligament

  • Parotid Duct


X Buccinator


Medial Pterygoid


Fig. 767. —The Pterygoid and Buccinator Muscles.


Risorius— Origin. — The deep fascia which covers the masseter scle and parotid gland.

Insertion. The skin at the angle of the mouth, where its fibres id with the orbicularis oris.

Nerve-supply. —Buccal branches of the facial nerve.

The direction of the muscle is inwards, some of its fasciculi also ending.

Action. —To draw the angle of the mouth outwards and slightly mwards. It is often the first muscle affected in tetanus, and gives to the ‘ risus sardonicus/

The muscle consists of a few scattered fasciculi, which are emded in the adipose tissue over the buccinator; it is a detached tion of the platysma.

Buccinator— Origin. — (1) The outer surfaces of the alveolar pro




1270


A MANUAL OF ANATOMY


cesses of the maxilla and mandible, opposite the three molar socl and (2) the anterior aspect of the pterygo-mandibular ligament.

Insertion. —The orbicularis oris at the angle of the mouth.

The central fibres decussate, those from above entering the lc lip, and those from below entering the upper lip. The highest lowest fibres take no part in this decussation, the highest pas directly into the upper lip, and the lowest into the lower lip Fig. 768).

N erve-supply. —Lower buccal branches of the facial nerve.

Action. —To draw the angle of the mouth outwards, and p the lips and cheeks against the teeth, thus preventing the food f accumulating between the lips and the teeth during masticat and to contract the vestibular part of the mouth spasmodically, a whistling.

The muscle is expanded over the cheek, but towards the angl the mouth it becomes narrow and thick. It is pierced by the par duct opposite the second upper molar tooth, and the buccal n( also passes through it on its way to the mucous membrane of cheek. Externally the muscle is overlapped by the anterior bo] of the masseter, from which it is separated by the suctorial of fat.

Suctorial Pad of Fat (Buccal Pad). —This is a well-defined colleci of fat which is situated upon the buccinator muscle close to the ante border of the masseter. Well developed in healthy young adults may be absorbed or replaced very quickly, causing marked chang< the facial expression.

Depressor Anguli Oris (Triangularis Menti)— Origin. —The obli line of the mandible from about the level of the canine socket to t of the first molar.

Insertion. —The angle of the mouth, where some of the fibres attached to the skin, whilst others decussate with those of the leva anguli oris and enter the upper lip, in which they mingle with upper part of the orbicularis oris.

N erve-supply. —The mandibular branch of the facial nerve.

Action .—To depress the angle of the mouth.

Depressor Labii Inferioris (Quadratus Menti)— Origin. —The loi part of the outer surface of the body of the mandible close to symphysis, and extending outwards to below the mental foramen.

Insertion .—The skin of the lower lip.

Nerve-supply. —The mandibular branch of the facial nerve.

The muscle is directed upwards and inwards.

Action .—To draw the lower lip downwards and slightly outward

The muscle is overlapped laterally by a portion of the depres anguli oris, and medially it is in contact superiorly with its fellow the opposite side. The deep surface is related laterally to the men foramen and the mental nerve and vessels, and medially to part the mentalis. In the lower lip its fibres pass amongst those of 1 lower part of the orbicularis oris.


THE HEAD AND NECK


1271


Mentalis ^Levator Menti)— Origin. —The incisive fossa of the

mdible.

Insertion. — The skin of the chin.

Nerve-supply. —The mandibular branch of the facial nerve.

The muscle is directed downwards and forwards.

Action. — (1) To raise the integument of the chin, and (2) to elevate

d protrude the lower lip.

Orbicularis Oris. —This is a complex muscle composed of three ‘ata. The superficial stratum consists of fibres which are prolonged >m the elevators and depressors of the angles of the mouth, and tend as far as the centre of the lip, but are not continuous with ose of the opposite half. They are inserted into the skin, and are rtially reinforced by fibres from the elevators of the upper lip, thegomatic muscles, the risorius, the posterior fibres of the platysma, d the depressor labii inferioris.

The intermediate stratum consists of fibres which are derived from e buccinator muscles. These fibres are disposed transversely, ard


Fig. 768. —Plan of Composition of Orbicularis Oris.


ose of opposite sides are directly continuous. The fibres of this ratum extend to the margins of the lips.

The foregoing fibres are destitute of bony and cartilaginous attaches.

The deepest stratum consists of fibres which arise from the incisive sSct of the upper and lower jaws, as well as from each side of the

terior nasal spine.

Nerve-supply. —The low*er buccal and mandibular branches of the

dal nerve.

Action .— 1 To close the oral aperture; and [2) to press the lips ainst the alveolar margins.

The muscle is separated from the buccal mucous membrane by the Mai arteries and the labial mucous glands.

The labial mucous glands, which are racemose, or acino-tubular, e numerous, and each is about the size of a small pea. They are uated on the deep surface of the mucous membrane of the lips, lere thev lie in the loose areolar tissue between the mucous memane and the orbicularis oris. Their ducts open into the vestibule the mouth.







I2J2


A MANUAL OF ANATOMY


The buccal mucous glands, also racemose, or acino-tubular, situated between the mucous membrane of the cheek and the d surface of the buccinator.

The molar mucous glands, also racemose, or acino-tubular, superficial to the buccinator in the vicinity of the terminal pari the parotid duct. They are four or five in number, and their du having pierced the buccinator, open into the vestibule of the mo opposite the molar teeth.


Nerves of the Face.

The nerves of the face are thirteen in number on either si Twelve of these are sensory nerves, and one is motor—namely, facial nerve.

The facial or seventh cranial nerve will only be described b after its emergence from the facial canal in the petrous part of temporal bone. It comes out of that canal through the stylo-mast foramen, after which it passes downwards and then forwards into parotid gland. Near the posterior border of the ramus of the mandi it breaks up into two terminal parts, called the temporo-facial c cervico-facial divisions.

Branches. —The posterior auricular, digastric, stylo-hyoid, c the terminal divisions.

The posterior auricular nerve arises from the facial close to stylo-mastoid foramen. It ascends between the auricle and mastoid process, where it lies deeply, and divides into two branch auricular and occipital. The auricular branch passes upwards beh: the auricle and deep to the auricularis posterior, to be distributed that muscle, and it may be to the auricularis superior, as well as the small intrinsic muscles on the inner aspect of the auricle. 1 occipital branch passes backwards to supply the occipital belly of i occipito-frontalis muscle. The posterior auricular nerve communica with the great auricular, the lesser occipital, and the auricular brar of the vagus.

The digastric branch is directed downwards to the posterior be of the digastric muscle. One of the digastric branches communica with the glosso-pharyngeal nerve.

The stylo-hyoid branch usually arises in common with the p ceding. It is of some length, and, passing forwards, it enters the sty hyoid muscle about its centre.

The terminal branches continue to pass forwards in the paro gland, crossing superficially the posterior facial vein and the exteri carotid artery, the direction of these vessels being vertical. In t part of their course these branches receive the following communi< tions: two branches from the auriculo-temporal nerve, and brand from the great auricular nerve. Each terminal branch breaks, within the gland into smaller branches, and as these pass in varic directions over the face and upper portion of the neck they ram


THE HEAD AND NECK


1273


3ely. The latter branches frequently communicate with each other a plexiform manner, both in the parotid gland and on the face, the exus thus formed being known as the parotid plexus (pes anserinus). le ramifications also communicate with the branches of the three visions of the trigeminal nerve which appear on the face, these being nsory nerves.

The terminal branches of the facial nerve are; The temporal branches cend over the zygomatic arch to the temporal region, and are dis

Upper Terminal Division of Facial Nerve

Temporal Branches of Facial Nerve


Zygomatic Branches of Facial Nerve


llo-temporal Nerve

5 rior Auricular Nerve

ater Occipital Nerve

acial Nerve at Stylomastoid Foramen

Digastric Branch of Facial Nerve

er Terminal Division of Facial Nerve


Branch of Lacrimal Nerve


Supra-orbital Nerve (in two divisions)

.. Infratrochlear Nerve


Zygomatico-facial

Nerve

Ext. Nasal N. Infra-orbital N.

Upper Buccal Branches of Facial Nerve

-Buccal Nerve


.. Mental Nerve


Lesser Occipital Nerve

Great Auricular Nerve Anterior Cutaneous Nerve of Neck


Parotid Gland

' Lower Buccal Branches of Facial N.

\

'Mandibular Branches of Facial Nerve Cervical Branches of Facial Nerve


External Jugular Vein


ig. 769. —Superficial Dissection of the Right Side of the Head and Upper Part of the Neck (Hirschfeld and Leveille).

1, sterno-mastoid; 2, trapezius.


ibuted to the auriculares anterior et superior, the intrinsic muscles 1 the outer surface of the auricle, the frontal belly of the occipito^ntalis, the upper part of the orbicularis oculi, and the corrugator percilii. These branches communicate with the supra-orbital and -rimal branches of the ophthalmic, the zygomatico-temporal nerve =>m the maxillary, and the auriculo-temporal of the mandibular, l of these being sensory nerves.

The zygomatic branches pass forwards over the zygomatic bone wards the outer angle of the orbit, and supply the outer part of the

















I2 74


A MANUAL OF ANATOMY


orbicularis oculi. They form communications with the lacrimal bran of the ophthalmic and with the zygomatico-facial nerve.

The upper buccal branches pass forwards to the region betwe the lower margin of the orbit and the upper lip. They supply t lower part of the orbicularis oculi, the muscles of the nose, the elevah of the upper lip, and the upper part of the orbicularis oris. Th communicate with the following sensory nerves: the infra-orbital the maxillary, the infratrochlear of the naso-ciliary, and the exteri nasal branch of the naso-ciliary from the ophthalmic. The commu:


C.A. Communicating Twigs with Auditory G.G. Facial Ganglion G.S.P. Greater Superficial Petrosal S.S.P. Branch to Lesser Superficial Petrosal E.S.P. External Petrosal

S. Branch to Stapedius Muscle C.T. Chorda Tympani A Auricular Branch S.M.F. Stylo-mastoid Foramen P.A. Posterior Auricular S.H. Branch to Stylo-hyoid Muscle

D. Branch to Posterior Belly of Digastric


A.T. Communicating Branches from Auriculotemporal

T.F. Upper Terminal Division T. Temporal Branches M. Zygomatic Branches I.O. Upper Buccal Branches G.A. Communicating Branches from Great Auricular

C.F. Lower Terminal Division B. Lower Buccal Branches S.M. Mandibular Branches I.M. Cervical Branches


cations with the infra-orbital nerve take place under cover of t levator labii superioris muscle, and form a somewhat intricate plexi called the infra-orbital plexus.

The lower buccal branches pass forwards over part of the massei and the buccinator muscles to the angle of the mouth. They supply t buccinator and the outer part of the orbicularis oris, and are connect with the infra-orbital branches of the temporo-facial division, and wi the buccal nerve , which is a branch of the mandibular division of t trigeminal nerve. The latter communications take the form of a plex












THE HEAD AND NECK


1275


ituated on the superficial surface of the buccinator muscle, called the uccal plexus.

The mandibular branches pass forwards over the mandible to the sgion below the lower lip. They supply the lower part of the orbicuiris oris, depressor anguli oris, depressor, labii inferioris and mental luscles. They communicate with the mental branch of the inferior ental from the mandibular nerve under cover of the depressor anguli ris.

The cervical branch descends beneath the upper part of the platysma nd the deep cervical fascia to the suprahyoid region. Having pierced tie deep fascia, it divides into branches which curve forwards and upply the platysma on its deep surface. It communicates freely


Fig. 771.— Diagram of the Sensory Nerves of the Right Side of

the Head.


1. Supra-orbital

2. Supratrochlear

3. Infratrochlear

4. External Nasal

5. Lacrimal


6 . Zygomatico-temporal

7. Zygomatico-facial

8. Infra-orbital

9. Auriculo-temporal

10. Buccal


11. Mental

12. Great Auricular

13. Lesser Occipital

14. Greater Occipital


ith the upper branch of the anterior cutaneous nerve of the neck from tie cervical plexus.

Summary of the Facial Nerve. —The facial nerve, after leaving the facial anal through the stylo-mastoid foramen, supplies the following muscles: (1) the xtrinsic and intrinsic muscle of the auricle; (2) the posterior belly of the digastric nd the stylo-hyoid; (3) the occipito-frontalis; (4) the superficial muscles of the ice, including the buccinator, but not the masseter, nor the levator palpebrae aperioris; and (5) the platysma. All these muscles, except the posterior belly f the digastric and the stylo-hyoid, are spoken of as muscles of expression. The erve establishes free communications with all three divisions of the trigeminal erve, which are sensory. It also communicates with the lesser occipital, great uricular, and anterior cutaneous nerve of neck, which are branches of the ervical plexus.

Sensory Nerves of the Face. —These, with one exception, are deived from the trigeminal nerve, the exception being the great auricular, duch is a branch of the cervical plexus.






1276


A MANUAL OF ANATOMY


A. Branches of the Trigeminal Nerve.


Distal Sources.


Proximate Sources.


t. Ophthalmic nerve.


2. Maxillary nerve.


3. Mandibular nerve.


(a) Frontal

- ( b ) Lacrimal.

(c) Naso-ciliary.

[ (a) Maxillary.

| ( b ) Zygomatic.

f (a) Anterior division.

| ( b) Posterior division.

I ( c ) Inferior dental of I posterior division.


Terminations.

f Supra-orbital.

I Supratrochlear.

Lacrimal, j Infratrochlear.

( External nasal.

Infra-orbital.

/ Zygomatico-temporal. I Zygomatico-facial. Buccal.

Auriculo-temporal. j Mental.


B. Facial Branches of the Great Auricular Nerve.

Branches of the Trigeminal Nerve. —The supra-orbital and supri trochlear nerves have been already described (see p. 1153). T1 former is distributed to the skin of the frontal region and the upp< part of the scalp; and the latter to the skin of the lower and centr; portion of the frontal region. Both these nerves furnish twigs to tt skin of the upper eyelid.

The lacrimal nerve pierces the orbital septum, and is distribute to the skin and conjunctiva of the outer part of the upper eyelid, as we as to the skin in the immediate vicinity of the zygomatic process ( the frontal bone.

The infratrochlear branch of the naso-ciliary nerve leaves the orb below the pulley of the obliquus superior muscle, and furnishes twig to the skin and conjunctiva of the inner parts of the eyelids, the sic of the root of the nose, the lacrimal sac, and the caruncula lacrimalis.

The external nasal branch of the naso-ciliary nerve emerges betwee the lower border of the nasal bone and the upper nasal cartilage, an descends beneath the compressor naris muscle to the apex of the nos< Its twigs supply the skin of the tip and lower part of the side of th nose.

The infra-orbital nerve is the terminal part of the maxillary divisio of the trigeminal. It leaves the infra-orbital canal through the infn orbital foramen, where it is under cover of the levator labii superior! In this situation it communicates with the upper buccal branches ( the facial, forming the infra-orbital plexus, and it divides into three sel of branches—namely, palpebral, nasal, and labial. The palpebra branches ascend to supply the skin and conjunctiva of the lower eyelic The nasal branches pass inwards, and are distributed to the skin of th side of the nose. The labial branches, long and large, descend to suppl the skin and mucous membrane of one half of the upper lip. As the descend they furnish twigs to the skin between the infra-orbital forame and the upper lip.

The zygomatico-temporal nerve (temporo-malar nerve) is of sma

size. Having traversed the zygomatico-tempora] canal in the zygomati


THE HEAD AND NECK


1277

one, it pierces the temporal fascia about 1 inch above the front part f the zygoma, and behind the marginal process on the postero-superior r temporal border of the zygomatic bone, and is distributed to a mited portion of the skin over the anterior part of the temporal 3gion.

The zygomatico-facial nerve (temporo-malar nerve) is of small size, nd emerges from the zygomatico-facial canal in the zygomatic bone tirough the zygomatico-facial foramen. It is distributed to the skin ver the malar bone.


The buccal nerve is a branch of the anterior division of the mandiblar nerve. Coming from under cover of the middle of the anterior order of the masseter on to the superficial surface of the buccinator, divides into branches which communicate freely with the buccal ranches of the facial nerve, forming the buccal plexus. Its final (stribution is to the skin and mucous membrane of the cheek, the ranches to the latter piercing the buccinator.

The auriculo-temporal nerve, which is a branch of the posterior ivision of the mandibular nerve, has been already described as ! gards its cutaneous distribution (see p. 1157).

The mental nerve is one of the terminal branches of the inferior 5ntal, which in turn is a branch of the posterior division of the






A MANUAL OF ANATOMY


1278

mandibular nerve. Leaving the mental foramen under cover of t depressor anguli oris, and in line with the interval between the t\ lower premolar sockets, its branches supply the skin and muco membrane of one half of the lower lip, and the skin covering the bo< of the mandible.

The supra-orbital, infra-orbital, and mental nerves being frequent the seat of neuralgia, their positions for purposes of operative tre; ment can readily be ascertained in the following manner: A line dra\ upwards from the position of the mental foramen, which is in line wi the interval between the two lower premolar sockets, to the supr orbital notch, which is situated at the junction of the outer two-thir and the inner third of the supra-orbital arch, will cross the infra-orbil foramen. This line, therefore, is over the points of emergence of the three important sensory nerves.

From a clinical point of view it is sometimes more important recognize the areas supplied by the three divisions of the trigemir nerve than to identify the distribution of each particular branc These areas are shown in Fig. 772. It must be clearly understoc however, that here, as in all other parts of the surface of the bod one nerve area overlaps another very greatly.

Branches of the Great Auricular Nerve.—The facial branches the great auricular nerve, which is a branch of the cervical plexi are distributed to the skin over the parotid gland. They send twi into the gland which communicate with the branches of the fac: nerve.


Arteries of the Face.

The arteries of the face are as follows:


Sources.

External

carotid.

Ophthalmic,

from

internal

carotid.

Lacrimal,

from

ophthalmic.


Arteries.

| Facial.

'Dorsal nasal.

Supra-trochlear.

Supra-orbital.

Medial palpebral

(superior and inferior). f Lateral palpebral

(superior and inferior). [ Zygomatic.


Sources.

Superficial

temporal.

Maxillary.

Inferior dental, from

maxillary.


Arteries.

(Transverse facial.

■j Anterior temporal ’ Zygomatic. Infra-orbital.«  Buccal. ~

l Mental.

)


The chief of these arteries are the facial and the transverse faci;

Facial Artery.—The facial artery (external maxillary ) is the highe of the three anterior branches of the external carotid. It is situat at first in the upper portion of the anterior triangle of the neck, whe it has been previously described (see p. 1217). It leaves the neck ai enters upon its facial course by mounting over the body of d mandible in front of the anterior border of the masseter, where it very superficial, being covered only by the platysma and the integ ment. From this point it has a very tortuous course to the angle



THE HEAD AND NECK


1279


e mouth, the angle of the nose, and the inner angle of the eye, though may end at either of the two former points. The facial part of the

ssel is never very deepfy placed.

Relations— Siiperficial. —The skin and platysma, the risorius, the gomatic muscles, and branches of the facial nerve. It may be deep superficial to the levator labii superioris; where it crosses the body the mandible the anterior facial vein is often superficial to it. Deep. The body of the mandible (where pulsation can readily be felt in the

ssel), the buccinator, the levator anguli oris, and the infra-orbital
rve.


Fig. 773. —The Arteries of the Right Side of the Head (after

L. Testut’s ‘ Anatomie Humaine ’).


Facial Branches.—-(1) Muscular branches, of small size, arise from e outer side of the vessel, and are distributed to the structures in the asseteric, buccal, and infra-orbital regions, where they anastomose ith the buccal, transverse facial, and infra-orbital arteries. (2) The ental branch [inferior labial artery of the O.T.) passes forwards over e body of the mandible, and deep to the depressor anguli oris, to pply the structures between the lower lip and the base of the mandible, anastomoses with the inferior labial, mental, and submental arteries. ) The inferior labial a,rtery (inferior coronary artery ) arises just below e angle of the mouth, and passes inwards deep to the depressor iguli oris. In the lower lip it lies near the margin, between the bicularis oris and the mucous membrane, and anastomoses with its How of the opposite side, and with the previous branch. (4) The




I28o


A MANUAL OF ANATOMY


superior labial artery (superior coronary artery ), of larger size than 1 inferior, arises just above the angle of the mouth under cover of 1 zygomaticus major. Its position in the upper lip is similar to that the inferior labial in the lower lip, and it anastomoses with its fell of the opposite side. Near the middle line it furnishes the sefi branch , which ramifies on the columna as far as the tip of the no The superior and inferior labial arteries of each side sometimes ar together. The vessels of each side, superior and inferior, form in ea lip a tortuous arterial arch, which is necessarily divided in operatic upon one or other lip. (5) The lateral nasal branch arises oppos the nose, and lies on the sulcus above' the ala. It anastomoses w: the dorsal nasal branch of the ophthalmicy^the septal branch, t terminal branch of the anterior ethmoidal artery, and its fellow of i opposite side, the facial at the medialNartery of the eye.

lies either deep to, or; embedded in, the levator labii superioris alaeq nasi, and supplies the. side of the root of the nose and the adjacc part of the orbicularis oculi. It anastomoses with the dorsal na branch of the ophthalmic artery. ; x x

The anterior facial vein starts above the medial angle of the e by the union of the supratrochlear and ^upfa-orbital veins. T course of the vessel is a straight one, downwards ancboutwards, late: to the artery, and at a little distance from 1 it, except over the low border of the mandible, where' it lies close to its outer side and contact with the anterior border of the masseter. In its course crosses the end of the parotid duct. The cervical part of the ve which ends in the internal jugular, has been already described. T

muscular relations of the vein are the same as those of the arte]

’ ' ., - ? 1 *

except that it is always superficial to the levator labii superioris.

Its tributaries are: (1) the supratrochlear vein (frontal veil (2) the supra-orbital vein, which communicates with the ophthaln vein; (3) the lateral nasal veins, and laterally a few superior palpeb: veins, whilst posteriorly it communicates with the superior ophthaln vein, and may communicate with its fellow of the opposite side by mea of the transverse nasal vein, which lies over the bridge of the no< (4) a few inferior palpebral veins, which are in communication wi the infra-orbital vein; (5) the superior labial vein, which issues fron plexus in the upper lip (the blood from the similar plexus in the low lip passing to the submental region, where it takes part in the formati of the anterior jugular vein); (6) the deep facial vein, of variable si: which, coming from the pterygoid plexus, appears deep to the anter: border of the ramus of the mandible and of the masseter muscle; a: (7) parotid, masseteric, and buccal branches.

Facial Lymph Glands. — These glands lie on the face along t course of the anterior facial vein. Some are situated upon the mandil deep to the platysma, one of them being placed upon the base of t mandible close to the facial vessels; others ( buccal ) rest upon t fascia, covering the buccinator muscle; and the remaining glar of this group are met with between the angle of the mouth and t


THE HEAD AND NECK 1281

edial angle of the eye. I hey receive their afferent vessels from ie neighbouring structures, and their efferent vessels pass to the ibmandibular lymph glands. ‘

Transverse Facial Artery.— This vessel arises from the superficial mporal in the parotid gland, and passes horizontally forwards, fter leaving the anterior border of the gland it crosses the masseter, iving the zygoma above it and the parotid duct below it, the upper lccal branches of the facial nerve being in turn below the parotid ict. The order of structures from above downwards is, accordingly, tery, duct, and nerves. The artery is distributed to the parotid and, the masseter muscle, and the structures on the side of the

ce, and it anastomoses with the infra-orbital, zygomatic, facial id buccal arteries.

The transverse facial vein joins the superficial temporal vein, ihe dorsal nasal artery is one of the terminal branches of the ihthalmic, and leaves the orbit at the medial angle of the eye above e medial palpebral ligament. It is distributed to the lacrimal sac id the side of the root of the nose, and anastomoses with the terminal anches of the facial artery. Sometimes it gives off a transverse isal branch, which crosses the root of the nose and anastomoses th its fellow of the opposite side.

The supra-orbital and supratrochlear arteries have been already scribed (see p. 1153).

Ihe medial palpebral arteries, superior and inferior, arise from e ophthalmic and leave the orbit at the medial angle, one passing •ove and the other below the medial palpebral ligament. Their urse is outwards between the palpebral fibres of the orbicularis uli and the tarsi of the eyelids, and they anastomose and form arches th the lateral palpebral branches of the lacrimal artery. They e distributed to the palpebral structures, the lacrimal sac, and e caruncula lacrimalis.

The corresponding veins from the upper and lower eyelids open to the commencement of the anterior facial vein.

The terminal branch of the anterior ethmoidal artery emerges, )ng with the terminal branch of the naso-ciliary nerve, between e lower border of the nasal bone and the upper nasal cartilage, is distributed to the skin of the apex and the lower part of the ie of the nose.

The lateral palpebral arteries, superior and inferior, are branches the lacrimal artery within the orbit. Their course is inwards tween the palpebral fibres of the orbicularis oculi and the tarsi the eyelids, and they anastomose and form arches with the palpebral inches of the ophthalmic.

the lateral palpebral veins end in the zygomatic vein, which opens

0 the middle temporal, and this in turn joins the superficial temporal

m.

The zygomatic branches of the lacrimal artery accompany the ^omatico-facial and zygomatico-temporal nerves.


81


1282


A MANUAL OF ANATOMY


The zygomatic artery and anterior branch of the superficial tempo artery have been already described (see p. 1158).

The infra-orbital artery arises from the third part of the maxilh in the pterygo-palatine fossa. Having passed horizontally forwar with the infra-orbital nerve, through the infra-orbital canal, it ri with that nerve through the infra-orbital foramen, lying under co of the levator labii superioris muscle. It then gives branches upwai to the lower eyelids, inwards to the side of the nose, and downwai towards the upper lip. It anastomoses with the palpebral, faci transverse facial, and buccal arteries.


Sometimes, when the facial artery ends at the angle of the mou the infra-orbital is very large, and supplies all the upper part of face, including the nose. This arrangement, common enough pronograde mammals, shows that the infra-orbital, and not superficial temporal, is morphologically the terminal twig m external carotid arterial tree.

The infra-orbital vein, having traversed the infra-orbital car

opens into the pterygoid plexus.

The buccal artery is a branch of the second part of the maxilla It accompanies the buccal nerve to the superficial surface of







THE HEAD AND NECK


1283


ccinator muscle, and is distributed to that muscle and to the mucous ■mbrane of the cheek. It anastomoses with branches of the facial

ery.

The mental branch of the inferior dental from the first part of the ixillary is found with the mental nerve at the mental foramen, lying der cover of the depressor anguli oris muscle. It supplies the uctures here, and anastomoses with the inferior labial and submtal arteries.

The mental vein joins the inferior dental vein, which opens into s pterygoid plexus.

Lymphatics.—The lymphatics of the face are arranged in two

s, superficial and deep. The superficial lymphatics for the most

rt take a course similar to that of the anterior facial vein, and end the submandibular lymph glands. They receive the lymphatics (1) the inner part of the frontal region at the medial angle of the eye; the inner parts of the eyelids; (3) the side of the nose; (4) the part the face between the lower eyelid and upper lip; and (5) sometimes e upper lip. The lymphatics from the temporal and outer part of e frontal regions, from the front of the auricle, from the greater rt of the eyelids, and from the outer part of the cheek end in the perficial parotid lymphatic glands. The deep lymphatics , including ose of the orbit, anterior part of the nasal cavity, roof of the mouth, d temporal and infratemporal fossae, run to the deep facial lymph mds.

Parotid Lymph Glands (Pre-auricular Lymph Glands).—These mds are arranged in two groups —superficial and deep.

The superficial parotid lymph glands lie upon the superficial surface the parotid salivary gland immediately beneath the parotid fascia, d in front of the tragus of the auricle. They receive their afferent ssels from the following sources.

1. The outer surface of the auricle.

2. The anterior wall of the external auditory meatus.

3. The eyebrow, and upper and lower eyelids.

4. The root of the nose.

5. The upper part of the cheek.

Their efferent vessels pass to (1) the upper superficial cervical lymph mds, and (2) the superior deep cervical lymph glands.

The deep parotid lymph glands lie within the parotid salivary gland )ng the terminal part of the external carotid artery. They receive eir afferent vessels from the following sources :

1. The tympanic cavity in part.

2. The frontal region of the scalp.

3. The anterior temporo-parietal region of the scalp.

4. The parotid salivary gland.

5. The deep facial lymph glands.

Their efferent vessels pass to the superior cervical lymph glands.


1284


A MANUAL OF ANATOMY


Buccinator Lymph Glands.—These glands are situated on buccinator muscle. They receive a few afferent lymphatics from zygomatic region and the lateral aspect of the face, but most of t drainage is from the inner side of the cheek, and their efferent lympha pass to the parotid and submandibular lymph glands.

Parotid Gland.—This gland is an inverted pyramid, having 1 sides and a base, and fills the space which is left by the ramus of mandible anteriorly, the sterno-mastoid muscle posteriorly, the sty process medially, and the articular eminence and root of the zyg(


Fig. 775. —The Parotid Gland in Position.

superiorly. Where the anterior border of the sterno-mastoid touc the angle of the mandible the apex is situated. The anterior, poster and medial surfaces are grooved by the structures which bound gland.

The lateral surface is flat, flush with the side of the face, £ overlaps the ramus of the mandible and masseter muscle for a c siderable extent, forming the accessory part, from the anterior bor of which the parotid duct, the transverse facial artery, and the branches of the facial nerve leave the gland.




THE HEAD AND NECK


1285


Embedded in the upper part of the lateral surface are the superficial otid lymph glands already described (p. 1283), while from the surface gs of the great auricular nerve come out to supply the skin covering gland.

The anterior surface is very deeply grooved by the posterior border the ramus of the mandible and of the masseter muscle, the outer of the groove projecting forwards as the accessory part already ken of, while the inner or deep lip pushes its way forwards into triangular space left between the lateral and medial pterygoid scles. It is at the anterior border of the latter part of the gland t the maxillary artery leaves and the maxillary vein enters the


Fig. 776. —Horizontal Section through Parotid Gland and

Neighbouring Structures.


id. The deep Surface is grooved by the styloid process and the scles rising from it, though not very deeply, and the lips of the ove may be conveniently referred to as pre- and post-styloid ridges.

' pre-styloid ridge is in contact with the internal carotid artery, le the post-styloid is, perhaps, the most important and interes ting t of the whole gland, because it touches the internal jugular vein i the accessory and glosso-pharyngeal nerves, which are so closely iciated with that vein, and also because, near its upper end, the facial ve, and near its lower end the external carotid artery enter the id. In addition to these, the posterior auricular artery runs up ier just deep to or embedded in the post-styloid ridge until it lies t behind the point of entry of the facial nerve.





1286


A MANUAL OF ANATOMY


The projection of the post-styloid ridge is evidently due to gland pushing its way in between the styloid process in front and transverse process of the atlas behind, and that part of the deep surf; of the gland which lies behind the post-styloid ridge is close to transverse process and to the muscles rising from it; while, near apex, the posterior facial vein leaves the gland on this aspect.

The posterior surface is usually grooved by the mastoid proc above and the sterno-mastoid muscle lower down, and entering


Fig. 777.—To show Deep Relations of Parotid (Interrupted Line)

lower part of the superficial lip of this groove is the great auricu nerve.

The base of the gland is very deeply notched anteriorly by the ne of the condyloid process, behind which the superficial temporal arte and vein are seen leaving and entering the gland, the vein being sup ficial; in front of them the temporal branch of the facial nerve rr from the gland across the root of the zygoma, while behind them the superficial temporal branch of the auriculo-temporal nerve. T nerve is, as a rule, not really embedded in the gland, but rests for t most part on its base, between the parotid and the skull, as it ru


Orb. Oculi


— Orb. Oris

-Masseter

Buccinator

_—r Mandible

Ext. Carotid

Plat ysma




THE HEAD AND NECK


1287


lcIc from the region of the foramen spinosum, where it embraces the iddle meningeal artery. Having passed back on the deep aspect of e superficial temporal vessels, the nerve gives off its auricular, parotid, id articular branches, and then runs outwards and upwards just Tind the articulation and just in front of a thin, tongue-like process

the gland which moulds itself into the non-articular part of the ticular fossa, behind the squamo-tympanic fissure, and in contact ith the tympanic plate.

Summing up the foregoing, it will be understood that the parotid and forms an accurate cast of the cavities which the surrounding ructures have left for it, pushing its processes and its pre- and postyloid ridges into every available cranny. Doubtless, too, it is able > adapt its shape to these cavities as they change with every moveten t of the jaw.

Several important structures traverse the gland: (1) The external irotid artery ascends deeply in it as high as the level of the neck f the mandible, where it divides into the superficial temporal and laxillary arteries, which are at first embedded in the gland. Whilst 1 the gland the superficial temporal artery gives off its transverse facial nd auricular branches. (2) The superficial temporal and maxillary eins unite in the gland, at the level of the neck of the mandible, to form tie posterior facial vein, which descends from that level within the land, lying superficial to the external carotid artery, and close to the iwer border of the gland it breaks up into an anterior and a posterior ivision. (3) The external jugular vein is formed near the lower part f the gland by the union of the posterior auricular vein with the osterior division of the posterior facial vein. (4) The facial nerve raverses the gland from behind forwards, and in doing so breaks Lp into its terminal divisions, the branches of which leave the gland nteriorly and superiorly. The nerve is superficial to the external arotid artery and posterior facial vein. (5) Entering the lower part f the gland are branches of the great auricular nerve, which comaunicate within the gland with the facial nerve. (6) The auriculoemporal nerve is related to the upper part of the gland, where it

ives branches to it which communicate with the facial nerve.

Parotid duct, or duct of Stensen, dense and tough, leaves the anterior )order of the gland, and passes forwards on the masseter muscle, ying fully \ inch below the zygomatic arch. In this part of its course t is accompanied for a short distance by the accessory part of the )arotid gland which, with the transverse facial artery, lies above it, vhilst the upper buccal branches of the facial nerve are placed below t. After leaving the surface of the masseter muscle the duct dips leeply through the fat covering the buccinator, and pierces that muscle, [t then passes forwards for a very short distance between the muscle uid tEe buccal mucous membrane, which it finally pierces to end in 1 minute opening on a small papilla situated opposite the crown of he second upper molar tooth. The duct is about the size of a crowpiill, its diameter being about J inch, except at its buccal orifice,


12 88


A MANUAL OF ANATOMY


where it becomes narrow. It is about 2 inches in length, and it course may be indicated by a line drawn from the intertragus note! or from the junction of the lobule and cartilage of the auricle, to point midway between the nostril and the red margin of the uppe lip. About the middle third of this line corresponds to the duct.

Blood-supply. —The arteries are derived from (1) the externa carotid, (2) the superficial temporal, (3) the transverse facial, an* (4) the posterior auricular.

Lymphatics.— These pass to the superficial and deep cervical lympj glands, having previously traversed the parotid lymph glands, and in the case of some, the submandibular glands.

Nerve-supply. —(1) The auriculo-temporal nerve, which conveys t the gland secretory fibres of the glosso-pharyngeal nerve through it


Parotid Duct


tympanic branch, the lesser superficial petrosal nerve, and the oti< ganglion; (2) the great auricular nerve; (3) the sympathetic plexu; on the external carotid artery; and (4) the facial nerve.

Structure. —The parotid gland is a compound racemose or acino-tubular gland and is composed of large lobules, which are united by connective tissue. Eacl of these is made up of smaller lobules, likewise connected by connective tissue Each small lobule is a gland on a minute scale, and is made up of a group of mor< or less sacculated tubules, called alveoli or acini. A duct passes from each smal lobule, which unites with adjacent ducts, and these in turn unite, larger and stil larger ducts being formed, the resultant being the principal duct, called th< parotid duct. Each alveolus is serous or albuminous as regards the nature of it secretion, and is composed of a basement membrane continuous with the wal of the duct, and surrounded by a plexus of capillaries. The alveolus is linec with polyhedral cells, which contain albuminous granules, and almost com pletely fill the tube, leaving only a small lumen. The first portion of the duct called the intercalary duct, is lined with flattened epithelium. Beyond this the





THE HEAD AND NECK


1289


becomes constricted into a neck, which is lined with cubical cells, these being

aced in the intralobular duct by columnar cells. These cells are granular irds the lumen of the tube, but striated in the outer part. Each of the larger

s is composed of a basement membrane, strengthened externally by a layer

onnective tissue, superadded to which there stratum of plain muscular fibres.

Development of the Salivary Glands. —The >tid is of ectodermal origin, the submandiband sublingual are derived from entoderm, y appear as solid outgrowths of the epiium of the buccal cavity, which grow into adjacent mesodermic connective tissue. The helial constituents of each gland are derived 1 the buccal lining, whilst the capsule and lective-tissue elements are of mesodermic in.

Each solid epithelial outgrowth ramifies t freely, and these ramifications, as well as primary outgrowth, become tubular. The owing process commences in the primary growth, and extends thence throughout its lerous ramifications. The primary outgrowth represents the principal duct ach gland, and the acini, or alveoli, appear as dilatations of the walls of the final ramifications.

rhe sublingual gland, from its numerous ducts, is to be regarded as a cluster

mall alveolo-lingual glands.

Appendages of the Eye.

The appendages of the eye consist of the eyelids and the lacrimal jaratus.

Eyelids. —The eyelids, or palpebrae, are two movable curtains placed front of the eyeball, to which they form an important protection.

inner surface of each is covered by mucous membrane, which stitutes the conjunctiva. The upper eyelid is larger than the lower, l, when closed, covers the transparent part of the eye or cornea, s also more movable than the lower, being provided with a special /ator muscle, the levator palpebrae superioris. The elliptical srval between the lids is called the palpebral fissure, and the lateral remities of this fissure are called the angles of the eye. The lateral lie (canthus) is formed by the junction between the two lids. At medial angle (canthus) the lids are separated by a recess, called lacus lacrimalis, in which there is a small body, called the caruncula rimalis. In this region the eyelids are separated from the eyeball a vertical, semilunar fold of the conjunctiva, called the plica semiaris. The margin of each eyelid shows, at the commencement of lacus lacrimalis, a slight conical elevation, called the papilla lacrilis, the apex of which presents a small orifice, termed the punctum rimale, its direction being towards the eyeball. Each punctum is entrance to a passage, called the lacrimal canaliculus, by which the rs are conveyed from the surface of the eyeball into the lacrimal , and thence, through the naso-lacrimal duct, into the inferior rtus of the nasal cavity.


Fig. 779. —Structure of the Parotid Gland.





1290


A MANUAL OF ANATOMY


The free margins of the eyelids, lateral to the puncta lacrima are provided with hairs, called the eyelashes. They are short, stc and curved, and are arranged in two rows. Those of the upper are more numerous and larger than those of the lower. The up eyelashes are curved upwards and the lower downwards, and in 1 manner intermingling is avoided. Within the lines of attachment the eyelashes there is a row of modified sweat-glands, known as ciliary glands (glands of Moll), the openings of which are associa with the follicles of the eyelashes, and with the condition known as s Structure of the Eyelids. —Each eyelid is composed of the follow structures, from before backwards:


1. Skin.

2. Subcutaneous tissue.

3. Palpebral fibres of the orbicularis

oculi.


4. Cellular tissue.

5. The tarsi.

6. Tarsal glands.

7. Conjunctiva.



Fig. 780.—A, to show the Reflection of Conjunctiva at Upper ani Lower Fornices; B, Plan of the Palpebral Fissure.

In addition to the foregoing structures the upper eyelid contc the tendinous insertion of the levator palpebrse superioris muscle.

The skin is very thin, and at the ciliary margins of the eye it becomes continuous with the conjunctiva, which is a mucous m< brane. The subcutaneous connective tissue is scanty and devoid fat, and in consequence the slightest contraction of the muscle cai a noticeable movement of the skin. The palpebral fibres of the orbi laris oculi form a very delicate, pale sheet. The cellular layer, d to the orbicularis oculi, is lax, and allows the muscle to move frc over the tarsal plate. The tarsus in each eyelid is composed of c( pact fibrous tissue. The upper tarsus is larger than the inferior, ; is semilunar, its depth at the centre being about J inch. Its up part gives insertion to the levator palpebrae superioris. The lo tarsus is narrow, and is almost of the same depth throughout. ciliary margins of the tarsi are free, straight, and comparatively th: The orbital margins are attached to the circumference of the orbit a membranous expansion, called the orbital septum. The upper


THE HEAD AND NECK


1291


the orbital septum (superior palpebral ligament) is attached above the upper part of the circumference of the orbit, where it blends h the periosteum, and below it blends with the tendon of insertion the levator palpebrae superioris on the upper , tarsus. The lower i of the orbital septum (inferior palpebral ligament) extends between

lower part of the circumference of the orbit and the lower margin

the lower tarsus.

Laterally and medially the tarsi are attached to the palpebral iments. The lateral palpebral ligament is formed by the junction the upper and lower parts of the orbital septum, and is attached the malar bone. The medial palpebral ligament is independent the orbital septum. Medially it is attached to the lateral surp of the frontal process of the maxilla in front of the lacrimal cus. From this point it passes horizontally outwards for about Uch, and then divides into two laminae, which are attached to the si of both eyelids. It passes in front of the lacrimal sac, giving an set, which passes behind the sac to be attached to the crest of the ripial bone. The ligament gives origin to a few fibres of the )icularis oculi.

The tarsal glands (Meibomian glands) are situated on the deep rface of each tarsus, and lie between the plate and the conjunctiva right angles to the ciliary margin. There are about thirty in the pef ej^elid and about twenty in the lower, and they are arranged in rallel rows, which occupy grooves on the ocular surface of each 'sus. Each gland opens by an independent orifice, and these orifices j arranged in a single row, lying a little behind the ciliary margin the eyelid.

Structure. —The tarsal glands are modified sebaceous glands, and their retiqn lubricates the margins of the eyelids, and prevents them from adhering, ch consists of a tube, closed at one end, and having its sides beset with r erticula. The wall of the tube is composed of a basement membrane, which lined with cubical epithelium throughout the greater part of the gland, but se tq the orifice this is replaced by stratified epithelium.

In fhe neighbourhood of the closed ends of the tarsal glands there 5 some convoluted tubules, which are known as the posterior tarsal mds f the orifices of which are placed close to the conjunctival fornix.

Conjunctiva. —This is the mucous membrane which covers the ular surfaces of the eyelids and the front of the eyeball. It consists two parts—palpebral and ocular.

The palpebral portion lines the ocular or deep surfaces of the elids, and at their ciliary margins it is continuous with the skin on eir outer surfaces. It is also continuous through the puncta lacrialiq, with the lining membrane of the lacrimal canaliculi, lacrimal c, naso-lacrimal duct, and inferior meatus of the nose. In the region the medial angle of the eye it gives rise to the plica semilunaris, and at e outer part of the upper eyelid it is continuous with the lining embrane of the lacrimal ducts. The palpebral portion is fairly thick id highly vascular, and it has numerous papillae.


1292


A MANUAL OF ANATOMY


The ocular portion consists of two portions—sclerotic and cornea It is continuous with the palpebral portion, and the line of reflectic from the eyelids is known as the conjunctival fornix, superior ar inferior respectively. Here the orifices of the posterior tarsal glanc are met with. The conjunctiva is loosely connected to the scler; and is thin, non-papillary, transparent, and contains only a fe bloodvessels, the whiteness of the sclera being unaffected by it.

The palpebral portion is covered by columnar epithelium, whic at the ciliary margin passes into the stratified epithelium of the skir the sclerotic portion is also covered by columnar epithelium, but tl corneal part is represented by the stratified epithelium of the corpe;

The conjunctiva is supplied with blood by offsets from the palpebr; branches of the ophthalmic artery and its lacrimal branch. Tt vessels are disposed in a tortuous manner, and are movable upon tl eyeball when the conjunctiva is pressed upon and displaced. TI nerves are numerous, and form plexuses. The lymphatics begin clos to the corneal margin in a network, from which vessels proceed to network in each evelid behind the tarsus. The efferent vesse. ultimately reach the parotid and submandibular lymph glands.

The caruncuia lacrimalis occupies the lacus lacrimalis in the regio of the medial angle of the eye. It is a small, reddish, spong body, consisting of a detached portion of skin containing modifie .sweat and sebaceous glands. The latter open into the follicles of ver delicate hairs with which the surface of the caruncle is provided, an they furnish the white secretion which may accumulate at the medic angle.

The plica semilunaris is a vertical, semilunar fold of the conjunctiv which is situated on the outer side of the caruncle, its concave margi: being directed outwards. It corresponds to the membrana nictitam or third eyelid, of some animals.

Development of the Eyelids and Tarsal Glands.— The eyelids make thei appearance as two folds of skin, above and below the developing eyeball. Eac fold contains some mesodermic tissue which gives rise to the connective-tissu element and tarsus of the lid, muscle cells extending into the lids later from th platysma sheet. The ectoderm of the posterior surfaces of the lids acquires th characters of mucous membrane, and forms the conjunctival epithelium. In th course of the third month the eyelids grow together and unite along their margins a space being thereby enclosed between the lids and the front of the developin eyeball. The union affects the epithelium only, and persists until near the em of intra-uterine life.

During the period of fusion of the eyelids the tarsal glands and the cilia o eyelashes are formed. The tarsal glands are developed from the epitheliur along the line of fusion of the lids. Solid rods of epithelial cells are formei which grow into the mesodermic tissue of the two lids and give off lateral prc cesses. These solid rods become hollow, and so form the tarsal glands. Som of the epithelial rods give rise to the ciliary glands. A short time before birt the eyelids become separated, and the palpebral fissure is thereby formed.

The plica semilunaris is developed as a vertical fold of conjunctiva near th medial angle of the eye, external to the caruncle, but it attains little developmen in man.

The caruncle is developed from that portion of the margin of the lowe




THE HEAD AND NECK


1293


?lid which intervenes between the inferior punctum lacrimale and the medial y\e. The tarsal glands in this region become modified, and the tissue conning these modified glands becomes raised, and forms the reddish, spongy

•uncle.

Lacrimal Apparatus.—The constituent parts of the lacrimal paratus are as follows:

1. The lacrimal gland. 3. The lacrimal sac.

2. The lacrimal canaliculi. 4. The naso-lacrimal duct.

The lacrimal gland will be found described on p. 1247.

The lacrimal canaliculi are two in number, superior and inferior, ley commence at the puncta lacrimalia on the summit of the papillae

rimales, which latter are situated on the ciliary margins of the

elids close to the lacus lacrimalis. The superior canaliculus at first cends vertically for about T V inch, after which it makes a sudden


Tarsal Glands


Lacrimal Gland Lacrimal Ducts


Plica Semilunaris


Superior Punctum Lacrimale ! Caruncula Lacrimalis

Superior Lacrimal Canaliculus


•V. Lacrimal Sac

it

4

rjsL Inferior Lacrimal Canaliculus Naso-lacrimal Duct


Inferior Punctum Lacrimale

Fig. 781. — The Lacrimal Apparatus of the Right Eye.

The tarsal glands of the upper eyelid are also shown.

tid, and passes inwards and downwards to the lacrimal sac. The ierior canaliculus at first descends vertically for about T \ inch, after lich it makes a sudden bend, and passes almost horizontally inwards the lacrimal sac. The tw r o canaliculi open into the lacrimal sac, her close together or by a common orifice, and their mucous memane is lined with stratified squamous epithelium. The two slips the lacrimal portion of the orbicularis oculi are closely related to the rizontal portions of the canaliculi.

The lacrimal sac is the dilated upper part of the passage by which 2 tears are conveyed from the lacrimal canaliculi to the inferior iatus of the nose. It occupies the lacrimal groove of the lacrimal ne and frontal process of the maxilla. Above it has a round, closed tremity, and below it opens into the naso-lacrimal duct. Externally receives the lacrimal canaliculi separately or conjointly, and in front is crossed by the medial palpebral ligament. Behind it is related the lacrimal part of the orbicularis oculi.





1294


A MANUAL OF ANATOMY


The naso-lacrimal duct (nasal duct) extends from the lower end the lacrimal sac to the anterior part of the inferior meatus of the n< under cover of the front part of the inferior nasal concha. Its len^ is about f inch, and its diameter about ^ inch. It is directed dov wards, outwards, and backwards, and its opening into the anterior p; of the inferior meatus of the nose is usually guarded by an imperfi mucous fold, known as the lacrimal fold (valve of Hasner). The na orifice of the duct is about ij inches from the anterior nasal apertur

Structure of the Lacrimal Sac and Naso-lacrimal Duct. —The wall is compo of fibro-elastic tissue, which adheres closely to the periosteum of the boi and is covered by mucous membrane. The epithelial lining is of the colum variety, and at intervals the cells are furnished with cilia. The mucous m( brane is continuous superiorly with the conjunctiva through the lacrimal car iculi and puncta, and inferiorly it is continuous with the nasal mucous membra In the naso-lacrimal duct it may present one or two folds.

Development of the Naso-lacrimal Duct and its Appendages. —The effer lacrimal apparatus consists of (i) the lacrimal canaliculi, (2) the lacrimal s and (3) the naso-lacrimal duct.

In the course of the development of the face, the maxillary process and lateral nasal process of either side are separated by a groove which extei from the inner angle of the eye to the olfactory pit. This groove is called naso-optic, or oculo-nasal groove, and it indicates deeply the position of lacrimal duct. In the bottom of this groove a solid epithelial cord makes appearance, which, becoming hollow, forms the naso-lacrimal duct. The up extremity of the duct bifurcates, its two divisions becoming connected w the margins of the eyelids near their inner ends, and forming the lacrimal cai iculi. The lower end of the naso-lacrimal duct at a much later period opens i the lower part of the nasal cavity. The lacrimal sac is the upper expam extremity of the naso-lacrimal duct.


Auricle.

The auricle, or pinna, is that part of the external ear which proje from the side of the head. It has two surfaces, outer and inner.

The outer surface is irregularly concave, and about its centre th is a large deep fossa, called the concha of the auricle, which leads the external auditory meatus. Towards the upper and anterior p of the concha there is an elevation, called the crus of helix, whicl directed upwards and forwards to the anterior border of the auri< The concha is thus divided into two parts, upper and lower. In fr< of the concha there is a small, somewhat conical prominence, called tragus, which projects slightly backwards over the orifice of external auditory meatus, and is provided with hairs on its in: aspect. A short distance behind the tragus, and on a lower le than it, there is another prominence, called the antitragus, whicl separated from the tragus by a deep notch, called the intertragic not The skin over the antitragus is also provided with hairs. Below antitragus and intertragic notch is the most dependent part of auricle, called the lobule, which is comparatively soft in consister The prominent rim of the auricle is called the helix. It is incurv and begins at the upper and front part of the concha in the crus


THE HEAD AND NECK


1295


e helix, already referred to. It then surrounds the margin of the hide, and ends below in the back part of the lobule. In some cases e auricular tubercle (Darwin’s tubercle) is situated on the incurved argin slightly above the level where the antihelix, to be presently iscribed, bifurcates into its crura. This projection is well developed the ears of quadrupeds, and forms the point or tip. A short distance [thin the helix there is another curved elevation, called the anti>lix. This begins at the back part of the antitragus and ascends

hind the concha, above which it divides into two diverging crura,

)per and lower. Between the helix and the antihelix is an elongated, irrow fossa, called the scaphoid fossa, and between the diverging ura of the antihelix there is a depression, called the triangular fossa.


Auricular Tubercle


Scaphoid Fossa -/--

Helix


Antihelix


Concha/


Superior Crus of Antihelix Fossa Triangularis

Helix


'—;'r - Inferior Crus of Antihelix


- - Crus of Helix -Tragus

'-Orifice of External Auditory Meatus


‘'Intertgraic Notch "'■Antitragus


Lobule


Fig. 782. —The Right Auricle (Lateral Surface).


The inner or cranial surface of the auricle presents convexities irresponding to the fossae on the outer surface, the convexity opposite le concha being especially prominent.

Structure Of the Auricle. —The auricle, with the exception of the lobule, is mposed of a plate of yellow elastic fibro-cartilage covered by skin. This ate imparts firmness and elasticity to it, and is provided with ligaments and trinsic muscles. The skin is thin, and adheres closely to the fibro-cartilaginous ate. It is provided with hairs, which are most plentiful in the regions of the agus and antitragus. The cartilage of the auricle is rolled upon itself so as to rm the outer or cartilaginous part of the external auditory meatus. This >rtion of it is attached medially to the external auditory process of the temporal >ne by fibrous tissue. The rolled or tubular portion has a deficiency at the iterior and upper part, between the tragus and the helix, which is occupied by fibrous membrane. It has also a variable number of transverse clefts, which e filled with fibrous tissue. The lower extremity of the cartilage of the helix separated from the cartilage of the antihelix by a deep cleft. The part of the rtilage of the helix behind this cleft is known as the tail of the helix. At the >per and anterior part of the auricle, where the helix begins to curve backwards, e cartilage has a small sharp projection called the spine of the helix.




1296


A MANUAL OF ANATOMY


Ligaments of the Auricle.—These are anterior and posterior. ' anterior ligament extends from the spine of the helix to the zygonu the temporal bone close to its root. The posterior ligament extei from the cranial aspect of the concha, under cover of the auricul; posterior, to the mastoid process.

Intrinsic Muscles.—These muscles, which are very thin and p; are confined to the auricle, and are six in number, four being situa on the outer surface and two on the inner surface.

Muscles on Outer Surface.—These are: (1) the helicis major; (2) helicis minor; (3) the tragicus; and (4) the antitragicus.


Auricuiaris Anterior Helicis Major

Helicis Minor


--Auricuiaris Superior


^Auricuiaris Posterior


> Tail of Helix

1

Antitragicus


Fig. 783.—The Outer Surface of the Left Auricular Cartilage and

Muscles (Arnold).


The helicis major extends from the spine of the helix along i anterior part of the helix as high as the level at which it curves bat wards.

The helicis minor lies upon the crus helicis.

The tragicus lies upon the outer surface of the tragus, its fib: being almost vertical.

The antitragicus extends from the outer surface of the antitrag backwards and slightly upwards, to be attached to the tail of the hel

Muscles on Inner Surface.—These are: (1) the transversus auricn and (2) the obliquus auriculae.

The transversus auriculae extends over the depression which cor sponds to the antihelix on the outer surface, its attachments being






THE HEAD AND NECK


1297


convexity of the concha on the one hand, and the convexity of the a of the helix on the other.

The obliquus auriculae extends over the depression corresponding he lower crus of the antihelix on the outer surface.

Action of the Intrinsic Muscles.—The tragicus and antitragicus inish the orifice of the external auditory meatus, and the muscles of helix, major and minor, have an opposite effect.

Blood-supply of the Auricle.—The arteries are derived from (1) the terior auricular branch of the external carotid, (2) the anterior icular branches of the superficial temporal, and (3) the deep auricular nch of the first part of the maxillary, the last named giving offsets he cartilaginous part of the external auditory meatus.


, 784. —The Inner Surface of the Left Auricular Cartilage and its

Muscles (Arnold).

The veins end in the posterior auricular, superficial temporal, and xillary veins, and one or two of them may open into the mastoid issary vein.

The lymphatic vessels of the inner surface of the auricle pass chiefly the mastoid lymph glands; but a few end in the superior deep viced lymph glands. The lymphatics of the lobule pass to (1) the 'erficial cervical lymph glands, and (2) the superior deep cervical lph glands. The lymphatics of the outer surface of the auricle pass

he superficial parotid lymph glands.

Nerve-supply.—The inner surface receives three cutaneous nerves. 5 great auricular supplies about the lower three-fourths, the lesser ipital about the upper fourth, and the auricular branch of the vagus

82










1298


A MANUAL 'OF ANATOMY


supplies the integument over the convexity of the concha. The oui surface is supplied by two cutaneous nerves. The auriculo-tempoi nerve supplies the upper two-thirds, and the great auricular suppli the lower third. The motor nerve of the intrinsic muscles is the fac nerve.

The Nose.


The nose has a root, situated below the glabella of the frontal bor an apex (tip), situated interiorly; and the dorsum nasi, which occup] an intermediate position. The upper part of the dorsum is kno\ as the bridge of the nose. At the lower part of the nose there are t openings of the nostrils, or nares. The outer margin of each nost is slightly prominent and curved, and is called the ala. The nostr are separated from each other by a septum, called the columna na which, as well as the ala, is composed of fibrous tissue and skin. With the circumference of each nostril there are several stout hairs or vibriss

The superficial or facial aspect of the nose derives its arteries frc (1) the lateral nasal branches of the facial, (2) the dorsal nasal bran of the ophthalmic, and (3) the infra-orbital branch of the maxillary.

The nerves are derived from the naso-ciliary and infra-orbil nerves, the branches from the naso-ciliary being the infratrochlear ai the terminal cutaneous offsets.

The cutaneous lymphatics of the root of the nose pass to the supt ficial parotid lymph glands. Those from the greater part of the na< integument pass to the submandibular lymph glands, the lymph glan forming gland-stations in their path.

The framework of the nose is both osseous and cartilaginous.

Cartilages of the Nose.—The na<


cartilages are five:


Nasal Bone


Frontal Process of Maxilla


Upper nasal cartilage. Lower nasal cartilage. Septal cartilage.


Upper Nasal Cartilage Septal Cartilage


Small Alar Cartilages


^ 'V '

Subcutaneous Fat


The upper nasal cartilages (upp lateral cartilages) are situated imir diately below the nasal bones. Th are triangular, and their anten borders are continuous with ea other, and with the anterior marg of the septal cartilage, in each ca superiorly. Inferiorly, the anteri borders are separated by a slig interval, in which the anterior m£ gin of the septal cartilage is visible. The posterior border of ea cartilage is attached to the lower sloping border of the nasal bone, a: also to the upper part of the nasal notch on the medial border of t maxilla. The lower border is connected by fibrous tissue to the upp margin of the lower nasal cartilage.


Lower Nasal Cartilage

Fig. 785.—The Cartilages of the Nose (Anterior View) (Arnold).





THE HEAD AND NECK


1299


The lower nasal cartilages (lower lateral cartilages) are situated )w the upper pair, and each is bent so as to lie in front and on each j of the nostril, which it keeps open. Its outer portion is called lateral process, and its inner portion the septal process.


Small Cartilages of Ala


'ig. 786.—The Cartilages of the Nose (Lateral Aspect) (Arnold).

The lateral process is attached by fibrous tissue to the upper nasal tilage, and to the lower part of the nasal notch on the medial border the maxilla. The septal process is folded backwards, and touches fellow of the opposite side. It lies along the upper part of the umna nasi, and along the antero-inferior border of the septal cartie. Anteriorly it is separated from its fellow by a notch.

In the fibrous tissue which con:ts the lateral process to the .xilla two or more isolated porns of cartilage are met with, led the small cartilages of the ala inor cartilages).

Development. —The upper and lower >al cartilages are developed in the sral nasal process.

The septal cartilage is medially teed, and is usually inclined slightly one side, most frequently the left, forms a large part of the nasal )tum anteriorly, and has the form an irregularly four-sided, latery compressed plate. Its anterior border is attached to the back of e nasal bones, along the course of the internasal suture; below this is connected to the anterior borders of the upper nasal cartilages,


Lower Nasal Cartilages


A _ Septal Process

' Lateral Process

Anterior Aperture


J Small Cartilages of Ala


Subcutaneous Fat


Septal Cartilage

Fig. 787. — The Cartilages of the Nose (Inferior Aspect) (Arnold).





1300


A MANUAL OF ANATOMY


and below these it lies between the septal processes of the lower na cartilages. Its posterior border is accurately applied to the irregu anterior margin of the perpendicular plate of the ethmoid bone. inferior border is received into the front part of the groove on the antei border of the vomer. The antero-inferior border passes upwards a forwards from the front part of the inferior border to the antei border. In early life the septal cartilage is prolonged backwards


~T Frontal Sinus


Sphenoidal Sinus


-Nasal Bone


Perpendicular Plate of Ethmoid


Horizontal Plate of Palatine Bone (in section)


\ Septal Process of Lc \ Nasal Cartilage Septal Cartilage Womero-nasal Cartilage


Vomer


Palatine Process of Maxilla (in section)


Fig. 788. —The Osseous and Cartilaginous Nasal Septum (Right

Lateral Aspect).


the body of the sphenoid bone in the form of a narrow strip, whi intervenes between the lower border of the perpendicular plate the ethmoid and the vomerine groove. This portion is known the sphenoidal process. Along the inferior border of the sepi cartilage, between it and the anterior border of the vomer, there 2 two narrow, elongated strips of cartilage, right and left, which £ called the vomero-nasal cartilages (cartilages of Jacobson).

Development. —The septal cartilage is derived from the chondrocranium.








THE HEAD AND NECK


1301


The Temporal and Infratemporal Regions.

Muscles of Mastication. —These are four in number—namely, the

seter, temporal, lateral pterygoid, and medial pterygoid.

Masseter — Origin —(1) Superficial Portion. —The anterior twods of the lower border of the zygomatic arch. (2) Deep Portion, he posterior third of the lower border, and the whole of the medial 'ace of the zygomatic arch.


Orb. Oculi


Orb. Oris

Masseter

Buccinator


Mandible


Ext. Carotid


Platysma


Fig. 789.—The Masseter Muscle.

Insertion .—The superficial portion is inserted into the lower margin d the deep portion into the upper half of the outer surface of the nus of the mandible. The superficial fibres extend as far as the E*le, and the deep fibres encroach on the coronoid process. Nerve-supply .—The masseteric branch of the anterior portion of p mandibular division of the trigeminal nerve. This branch leaves

pterygoid region by passing over the mandibular notch of the

nus of the mandible below the zygoma, and it therefore enters the iscle on its deep surface accompanied by the masseteric artery.

The superficial portion of the muscle is directed downwards and







1302


A MANUAL OF ANATOMY


slightly backwards, and the deep portion downwards and very sligl forwards.

Action. —To elevate the mandible. The superficial portion ; draws it slightly forwards.

Relations — Superficial. —The parotid gland and its duct, branc of the facial nerve, the transverse facial artery, the risorius, and platysma. Deep. —The ramus of the mandible, and the masset nerve and artery. The anterior border overlaps the buccinator, fi which it is separated by the suctorial pad of fat.

Temporalis — Origin. —(i) The temporal fossa, extending as higl the inferior temporal line of the frontal and parietal bones, and as as the infratemporal crest on the external surface of the greater w of the sphenoid, but excluding the portion of the fossa formed by zygomatic bone; and (2) the deep surface of the temporal fascia 0 its upper part.

Insertion. —(1) The medial surface, summit, and anterior bor of the coronoid process of the mandible; and (2) the elongated triangi surface on the medial surface of the ramus of the mandible, close wit the anterior border, and extending as low as a point on the inner «  of the last molar socket. w Nerve-supply. —The deep temporal nerves, usually three in numl which are branches of the anterior portion of the maairitofcv divis of the trigeminal nerve, and which enter the deep surface of the mus

The muscle is fan-shaped. The anterior fibres descend aim vertically; the middle fibres pass obliquely downwards and forwai and the posterior fibres pass forwards almost horizontally.

Action. —To raise the mandible, as in closing the mouth, posterior fibres also retract the mandible, and act in opposition to lateral pterygoid, which protracts it.

Relations — Superficial. —The temporal fascia, supporting the auri lares anterior et superior; the superficial temporal artery, aurici temporal nerve, and temporal branches of the facial nerve; the zygor and fat, which is continuous with the suctorial pad. Deep — 1 temporal fossa, the deep temporal arteries and nerves, and the late pterygoid muscle.

The buccal nerve passes downwards and forwards under cover the muscle close to the anterior border of the ramus of the mandil and the masseteric nerve and artery pass outwards close to the poster border in the region of the mandibular notch.

For the temporal fascia, see p. 1161.

Lateral Pterygoid (External Pterygoid) — Origin — (1) Upper Head

The infratemporal surface and infratemporal crest of the greater w of the sphenoid. (2) Lower Head. —The outer surface of the late pterygoid plate of the sphenoid. The upper head is small, and the lo\ head is of large size.

Insertion. —(1) The depression on the front of the neck of 1 mandible; and (2) the front of the articular capsule and disc of 1 mandibular joint.


THE HEAD AND NECK


1303


Nerve-supply. —The nerve to the lateral pterygoid, from the anterior ision of the mandibular nerve.

The direction of the muscle is backwards and slightly outwards. Action. —(1) To draw forwards the neck and condyloid process of

mandible, and also the articular disc. When the muscles of opposite

es act in concert the mandible is protruded, and the lower incisor 1 canine teeth project beyond the level of those of the maxilla. The scles of opposite sides, however, usually act alternately and thus >duce the oblique or grinding movement, the lower molars of one e being carried forwards and inwards under the corresponding per molars, and vice versa. At the same time the elevators of the ndible are in action. (2) To take part in opening the mouth by iwing the condyloid process of the mandible and articular disc forrds on to the articular eminence of the temporal bone. The lateral


Buccal Nerve (cut)


Lower Head of Lateral Pterygoid

^Pterygomandibular

Ligament

•Parotid Duct


Buccinator


Medial Pterygoid


Fig. 790. —The Pterygoid and Buccinator Muscles.


srygoid is antagonistic to the posterior portion of the temporalis iscle.

Relations — Superficial. —Part of the ramus of the mandible, the ver part of the temporalis, part of the pterygoid plexus of veins, the [ccal nerve, and perhaps the second part of the maxillary artery. lep. —The upper portion of the medial pterygoid muscle, the sphenomdibular ligament, in some cases the second part of the maxillary tery, the middle meningeal artery, a part of the pterygoid plexus of ins, the mandibular nerve, the otic ganglion, and the chorda tympani rve. Superior. —The masseteric and deep temporal nerves. Inferior. The inferior dental and lingual nerves, and the spheno-mandibular

ament. The buccal nerve, with the anterior deep temporal nerve,

akes its appearance between the upper and lower heads, and the axillary artery may sink between them.





1304


A MANUAL OF ANATOMY

Medial Pterygoid (Internal Pterygoid) — Origin. —(1) The inner surfs of the lateral pterygoid plate of the sphenoid, and the portion of t tubercle of the palatine bone which forms the lower part of the pterygc fossa; and (2) the outer surface of the tubercle of the palatine boi and the adjacent portion of the tuberosity of the maxilla.

Insertion. —(1) The inner aspect of the angle of the mandib and (2) the back part of the inner surface of the ramus, between t angle and the mandibular foramen.

Nerve-supply .—The medial pterygoid branch of the anterior port! of the mandibular nerve.

The direction of the muscle is downwards, backwards, and 01 wards.

Action.—{ 1) To elevate the mandible; and (2) to draw it forwarc

Relations- — Superficial .—The lateral pterygoid muscle to a slig extent superiorly, the spheno-mandibular ligament, the maxillary ai inferior dental vessels, and the inferior dental and lingual nervt

Deep .—The tensor palati muscle, and the superior constrictor muse of the pharynx.

For a description of the spheno-mandibular ligament, see p. 1316.

The Maxillary Artery (Internal Maxillary Artery) .—This vessei the larger of the two terminal branches of the external carotid, arises from that artery opposite the neck of the mandible and within tl parotid gland. Its course is at first forwards and inwards behind tl neck of the mandible, and superficial to the spheno-mandibular lig ment. It then inclines upwards and forwards through the infr; tempoial fossa, usually passing superficial to the lateral ptervgoi muscle, though in many cases it passes deep to it. Having reached tl interval between the two heads of the lateral pterygoid, it sinks deep] between them, and, passing through the pterygo-maxillary fissure, enters thepterygo-palatine fossa, where it gives off its terminal branche In those cases in which the artery passes deep to the lateral pterygoi muscle it forms a piojecting curve between the two heads of the muscl The course of the vessel is very tortuous in adaptation to the mobilit of the surrounding structures.

Owing to its complexity it is convenient to divide the artery inf thiee parts. The first or mandibular part is situated between tb neck of the mandible and the spheno-mandibular ligament, and it course is horizontally forwards and inwards. It is accompanied b the maxillary vein, and lies along the back part of the lower border c the lateral pterygoid muscle, crossing in front of the inferior dents nerve and embedded in the parotid gland. The second or pterygoi part usually lies superficial to the lower head of the lateral ptervgoic and under cover of the insertion of the temporalis. Its course througi the infratemporal fossa is upwards and forwards, and it sinks betweei the two heads of the lateral pterygoid on its way to the pterygo maxillary fissure. In many cases, however, the second part of th< vessel passes deep to the lower head of the lateral pterygoid, crossing m front of the medial pterygoid muscle and lingual nerve. Unde:


THE HEAD AND NECK 1305

e circumstances it forms a projecting curve between the two

is of the lateral pterygoid beneath the long buccal nerve. The i or pterygo-palatine part is situated in the pterygo-palatine fossa, ch it enters by passing through the pterygo-maxillary fissure. In fossa the vessel and its branches are intimately related to the ciliary nerve and the spheno-palatine ganglion, with its branches.


F ig . 791.— The Maxillary Artery and its Branches.

ramus of the mandible and one half of the calvaria have been removed. 1, lateral pterygoid muscle; 2, medial pterygoid muscle.

Branches. —These are as follows:

First Part.

p auricular.
erior tympanic,

idle meningeal, giving if accessory meningeal, srior dental.


Branches of the First Part.— The deep auricular artery, of small s, ascends within the parotid gland just behind the mandibulai it, and pierces the anterior cartilaginous wall of the external auditory atus. It supplies the cutaneous lining of that passage and .the ter surface of the tympanic membrane.


Second Part.

Masseteric.

Pterygoid.

Posterior deep temporal. Anterior deep temporal. Buccal.


Third Part.

Posterior superior dental.

Infra-orbital.

Greater palatine. Artery of the pterygoid canal.

Pharyngeal.

Spheno-palatine.








1306


A MANUAL OF ANATOMY


The anterior tympanic artery may be associated with the precedi at its origin. It ascends beneath the lateral pterygoid, and enters 1 tympanic cavity by passing through the squamo-tympanic fissu It is distributed to the structures within the tympanic cavity and the inner surface of the tympanic membrane. Around the circu ference of that membrane it forms an arterial ring with an offset the stylo-mastoid artery, which is a branch of the posterior auricula The middle meningeal artery, of large size, ascends beneath 1 lateral pterygoid muscle, and, passing between the two roots of ori$ of the auriculo-temporal nerve, it enters the cranial cavity throu


Deep Temporal Vessels and Nerves


Middle Meningeal Artery


Sph. Max. Fossa

Buccal A. and N.


Lingual N.

Sph. Mand. Lig.

Inf. Dental N. and A.


Sup. Constrictor


Fig. 792.—Dissection of Right Pterygoid Region.


the foramen spinosum in the sphenoid bone. It then passes upwar and forwards to the inner aspect of the antero-inferior angle of t] parietal bone, where it divides into two branches, anterior ai posterior, which ramify in the branching grooves on the inner surfa of the parietal bone. The artery is accompanied by a plexus sympathetic nerves, but its vein passes through the foramen oval For the distribution of the vessel within the cranium, see p. 159 Before disappearing through the foramen spinosum the midd meningeal artery usually gives off the accessory meningeal artery, whi< enters the cranial cavity through the foramen ovale.








THE HEAD AND NECK


1307


The inferior dental artery arises nearly opposite the middle meningeal ery, and descends upon the spheno-mandibular ligament in company

h the inferior dental nerve, lying on its posterior and outer side.

,ving reached the mandibular foramen, it gives off the small mylorid branch y and then it passes through the mandibular foramen and

ers the mandibular canal, which it traverses as far as the level

the mental foramen, where it ends by dividing into its mental and

isor branches. Within the mandibular canal the artery is accomnied by the inferior dental nerve and inferior dental vein.

Branches. —-The mylo-hyoid branch, of small size, arises at the r el of the mandibular foramen. In company with the mylo-hyoid rve it pierces the spheno-mandibular ligament, and descends in 3 mylo-hyoid groove to be distributed to the under surface of the do-hyoid muscle. The molar, premolar, and canine branches arise thin the mandibular canal, and supply the pulps of these teeth, Lich they reach by passing through the foramina on the extremities their fangs. Th e mental branch leaves the mandibular canal through s mental foramen, and has been already described (see p. 1283). ie incisor branch supplies the pulps of the incisor teeth of one side. Branches of the Second Part. —The branches of this part are muscular their distribution. The masseteric artery passes outwards, with the □responding nerve, over the mandibular notch, and enters the deep rface of the masseter. The pterygoid branches are distributed to e corresponding muscles. The posterior and anterior deep temporal teries pass upwards to the posterior and anterior parts of the temporal ssa beneath the temporalis. They supply the muscle and the bones rming the fossa, and anastomose with the middle temporal artery, lich is a branch of the superficial temporal. The anterior deep mporal artery also anastomoses with the lacrimal artery by twigs tiich pass through minute foramina in the outer wall of the orbit, le buccal artery passes downwards and forwards in company with e buccal nerve, and is distributed to the buccinator muscle and the lccal mucous membrane which lines it internally.

Branches of the Third Part.— The posterior superior dental artery ises from the maxillary as it is about to pass through the pterygoaxillary fissure into the pterygo-palatine fossa, and is sometimes isociated with the infra-orbital artery at its origin. It descends ion the zygomatic surface of the maxilla posterior to the zygomatic 'ocess, and its principal branches traverse the posterior dental canals > supply the pulps of the upper molar teeth of one side. It also irnishes twigs to the mucous lining of the maxillary sinus and to the 1m.

The infra-orbital artery arises in the pterygo-palatine fossa, somemes in common with the posterior superior dental. It passes through ie inferior orbital fissure in company with the maxillary nerve, and averses the infra-orbital groove and canal on the floor of the orbit, ie accompanying nerve being now called the infra-orbital nerve, rom this canal it emerges through the infra-orbital foramen on to


- 1308


A MANUAL OF ANATOMY


the face, where it has been already described (see p. 1282). The arter is accompanied by the infra-orbital vein. As the artery traverse the infra-orbital canal it furnishes (1) orbital branches to the structure on the floor of the orbit; and (2) the anterior superior dental branch which descends in the anterior dental canals in the maxilla, in compan with the corresponding nerves, to supply the pulps of the upper premok ingisor and canine teeth, and the mucous lining of the maxillary sinu:

The greater palatine artery (descending palatine artery) pass( downwards in the greater palatine canal, in company with the greatc palatine nerve, to the hard palate, where it passes forwards and in ware to the incisive fossa. In this situation it furnishes a branch whic ascends through the incisive canal, to anastomose with a branc of the spheno-palatine artery. As the artery traverses the greate palatine canal it gives off the lesser palatine arteries, which accompan corresponding nerves in the lesser palatine, canals, and supply the sol palate and tonsil.

The artery of the pterygoid canal (Vidian artery) passes backward through the pterygoid canal in company with the correspondin nerve, and its branches are: (1) to the upper part of the pharynx (2) to the pharyngo-tympanic tube; and (3) to the tympanum.

The pharyngeal branch (pterygo-palatine artery), of small siz< passes backwards through the pharyngeal canal in company with th pharyngeal branch of the spheno-palatine ganglion, and is distribute to the upper part of the pharynx, the pharyngo-tympanic tube, and th mucous lining of the corresponding sphenoidal sinus.

The spheno-palatine artery enters the superior meatus of the nasa cavity through the spheno-palatine foramen. Its branches are dis tributed extensively on the outer wall of the nasal cavity, and suppt the mucous membrane of the maxillary, ethmoidal, and frontal sinuses One branch, called the posterior septal (naso-palatine artery), descend upon the septum to the incisive canal, where it anastomoses with th terminal ascending branch of the greater palatine artery.

Pterygoid Plexus of Veins. —This is a large plexus which surround the lateral pterygoid muscle. Its tributaries correspond for th most part to the branches of the maxillary artery, and are chief!; as follows: the deep auricular, anterior tympanic, two middle menin geal, inferior dental, masseteric, pterygoid, deep temporal, bucca] superior dental, infra orbital, greater palatine, and spheno-palatine The blood is conveyed away from the plexus by two veins—namely the maxillary and the deep facial.

The maxillary vein (internal maxillary vein) is a short vessel whic] issues from the posterior part of the plexus, and accompanies th< first part of the maxillary artery. Opposite the neck of the mandibl it joins the superficial temporal vein within the parotid gland t( form the posterior facial vein.

The deep facial vein issues from the anterior part of the ptery goid plexus, and, passing downwards and forwards, it emerges deej to the mandibular ramus and masseter muscle, and joins the anterio:


THE HEAD AND NECK


1309,

ial vein on the buccinator muscle. The pterygoid plexus comnicates with the intracranial cavernous sinus by means of emissary ns, which pass through the foramen ovale, the emissary sphenoidal amen, and foramen lacerum; it communicates with the inferior - . ithalmic vein at the inferior orbital fissure and with the pterygoid TT _ yus behind and below. (a£jv*-$ <? )

Deep Facial Lymph Glands (Internal Maxillary Lymph Glands).—

ese glands lie upon the lateral pterygoid muscle. Their afferent >sels are derived from (1) the infratemporal and temporal fossae; 7 the orbit; (3) the palatal mucous membrane; (4) the nasal cavity part; (5) the cerebral dura mater; and (6) the tympanic cavity, eir efferent vessels pass to (t) the deep parotid lymph glands, and the superior deep cervical lymph glands.

Mandibular Nerve (Inferior Maxillary Nerve). —This is the third ision of the trigeminal nerve. It is a mixed nerve, and consists two roots—sensory and motor. The sensory root, which is of large e, arises from the trigeminal ganglion, and the motor root represents i entire motor root of the trigeminal nerve. Both roots leave the inial cavity through the foramen ovale, and immediately after their it they unite to form a mixed nerve—that is to say, a nerve composed both sensory and motor fibres. This nerve is very short, and lies eply in the infratemporal fossa, under cover of the lateral pterygoid iscle, where it gives off two branches—namely, the nervus spinosus d the nerve to the medial pterygoid muscle. Then it immediately saks up into two parts, known as the anterior and posterior trunks. ie nervus spinosus enters the cranial cavity through the foramen inosum, along with the middle meningeal artery, and divides into 0 branches—anterior and posterior. The anterior branch is stributed to the adjacent dura mater, and the posterior branch sses through the fissure between the petrous and squamous parts the temporal bone, to be distributed to the mucous lining of the istoid air-cells. The nerve to the medial pterygoid muscle arises from e deep surface of the undivided mandibular nerve, and passes downirds to enter the deep surface of the medial pterygoid muscle.

3se to its origin it. is intimately related to the otic ganglion.

Anterior Trunk of the Mandibular Nerve. —Ihis division is smaller an the posterior, and is principally motor in function, the only nsory branch furnished by it being the buccal nerve. Its branches e: (1) masseteric, furnishing the posterior deep temporal; (2) middle ep temporal; and (3) buccal, giving off the lateral pterygoid and terior deep temporal, after which it is purely sensory.

The masseteric nerve passes upwards deep to the upper head of e lateral pterygoid muscle, where it furnishes the posterioi deep mporal nerve. It then passes outwards over the upper bordei of e lateral pterygoid, and over the mandibulai notch behind the mporalis, to enter the upper part of the masseter on its deep surface.

The deep temporal nerves are three in numbet anterior, middle, id posterior. The anterior deep temporal nerve usually arises from


i3io


A MANUAL OF ANATOMY


the buccal after it has passed between the two heads of the latei pterygoid. It runs upwards superficial to the upper head of th muscle, and enters the anterior part of the temporalis muscle on i deep surface. The middle deep temporal nerve is a direct bran* of the anterior trunk of the mandibular, and it ascends beneath t] lateral pterygoid to enter the middle part of the temporalis on i deep surface. The posterior deep temporal nerve springs from t] masseteric nerve beneath the upper head of the lateral pterygoi


Fig. 793- The Nerves of the Temporal and Mandibular Regions

(Hirschfeld and Leveille).

i, temporalis; 2, lateral pterygoid; 3, medial pterygoid; 4, masseter;

5, buccinator.

and, passing upwards, it enters the posterior part of the temporal on its deep surface.

The buccal nerve {long buccal nerve ) passes outwards betwee the two heads of the lateral pterygoid, and then downwards an' forwards in contact with the inner surface of the temporalis at it insertion. Having emerged from deep to the mandibular ramus an' anterior border of the masseter, it is received upon the outer surfac of the buccinator, where it communicates with the buccal branche of the facial nerve to form the buccal plexus. After this its termini branches are distributed to the skin over the buccinator muscle an

















THE HEAD AND NECK


i 3 Tl


mucous membrane which lines it. The buccal nerve furnishes ' branches, the lateral pterygoid and the anterior deep temporal ye. The nerve to the external pterygoid muscle leaves it near its [in, and enters the lateral pterygoid muscle on its deep surface.

anterior deep temporal nerve arises from it after it has passed

ween the two heads of the lateral pterygoid. These two branches e all the motor fibres from the buccal nerve, which after this is irelv sensory.

Posterior Trunk. —This division is larger than the anterior, and dmost entirely sensory, the only motor fibres which it contains ng destined for the mylo-hyoid branch of the inferior dental nerve, branches are three in number—namely, (i) auriculo-temporal, inferior dental, and (3) lingual.

Auriculo-temporal Nerve. —This nerve, which is sensory, arises two roots, between which the middle meningeal artery ascends the foramen spinosum. Then the two roots join, and the nerve is backwards deep to the lateral pterygoid muscle. Having passed se behind the mandibular joint to the interval between that joint 1 the auricle, it enters the upper part of the parotid gland. It

n changes its course and passes upwards, after which it crosses
zygoma and descends close behind the superficial temporal artery

end in its terminal temporal branches.

Branches of Communication. —(1) Each root of the auriculonporal nerve receives a small branch from the otic ganglion. These inches contain fibres of the glosso-pharyngeal nerve through (a) its npanic branch, ( b) the tympanic plexus, and (c) the lesser superficial trosal nerve, which latter is reinforced by a branch from the ganglion the facial nerve. These glosso-pharyngeal fibres are destined for 3 parotid gland. (2) Two communicating branches pass to the nal nerve in the parotid gland.

Branches of Distribution. —(1) Articular branches enter the temporomdibular joint through the back part of the capsule. (2) Glandular inches are distributed to the parotid gland, to which they conduct res of the glosso-pharyngeal nerve. (3) The branches to the ■ external ditory meatus , upper and lower, enter the meatus between its carti^inous and osseous parts, and supply the skin which lines it, the •per branch also giving twigs to the outer layer of the tympanic mibrane. (4) Auricular branches are distributed to tfife skin of e tragus and the upper part of the outer surface of the auricle. The stribution of the meatal and auricular branches explains why pain le to affections of the lower teeth may be referred to the ear canal id auricle. (5) The temporal branches are terminal. They accommy the branches of the superficial temporal artery, and supply the in of the temporal region as high as the vertex of the skull. They mmunicate with the temporal branches of the facial and the zygoatico-temporal nerve.

Inferior Dental Nerve. —This nerve, though chiefly sensory, conins motor fibres, which, however, leave it in its mylo-hyoid branch.



1312


A MANUAL OF ANATOMY


It passes downwards, being at first under cover of the lateral ptery^ muscle. After escaping from beneath that muscle, it descends u the spheno-mandibular ligament and medial pterygoid muscle to mandibular foramen, through which it passes into the mandibular ca after having parted with its mylo-hyoid branch. The lingual ne is anterior and medial to it, and the inferior dental artery is postei and lateral to it. Within the mandibular canal the nerve is accc panied by the inferior dental artery, and, having arrived at the le of the mental foramen, it terminates by dividing into two brand mental and incisive.

Branches. —(i) The mylo-hyoid nerve is given off from the par trunk just before it passes through the mandibular foramen, takes all the motor fibres from the parent trunk, and in comp£


Internal Carotid Artery with Sympathetic Plexuses Facial Nerve in Facial Canal


Maxillary Neive

Abducent Nerve . Internal Carotid Artery


Oculo-motor Nerve Optic Nerve


Chorda Tympani Glosso-pharyngeal f Inferior Dental

Accessory "~j~ Mylo-hyoid


Supra-orbital Nerve


_ Supratrochlear -- Frontal '* Infratrochlear Naso-ciliary Lacrimal (cut) Ophthalmic Infra-orbital


Spheno-palatine Ganj Anterior Superior De Middle Superior Deni

I Posterior Superior / Dental


Hypoglossal

Vagus


Otic Ganglion frA ' Lingual ') Submandibular Ganglion


Nerve to Thyro-hyoid Muscle

Fig. 794 .—General View of the Trigeminal Nerve (Hirschfeld ani

Leveille.


1, sterno-mastoid; 2, mylo-hyoid; 3, medial pterygoid.


with the mylo-hyoid branch of the inferior dental artery pierces f lower part of the spheno-mandibular ligament, and then passes dow wards and forwards in the mylo-hyoid groove of the mandible. T nerve and artery are maintained in position within this groove by expansion from the lower part of the spheno-mandibular ligamei which is attached to the lips of the groove. Then the nerve pass forwards on the inferior surface of the mylo-hyoid muscle unc cover of the superficial part of the submandibular gland. Havi furnished twigs to the mylo-hyoid muscle, it terminates in the anteri belly of the digastric.

(2) The dental branches arise from the parent trunk, whilst traverses the mandibular canal. They communicate with each oth to form a delicate plexus, from which branches are given off to t







THE HEAD AND NECK


  • 3*3


'S of the lower molar and premolar teeth, as well as to the adjacent of the gum. The pulp branches correspond in number to the s of the teeth, and each enters through a minute opening on the emity of the fang.

3) The mental nerve is one of the two terminal branches. It rges from the mandibular canal through the mental foramen, its distribution, see p. 1277.

4) the incisive branch is the termination of the inferior dental. >egins at the level of the mental foramen, and passes almost ar as the middle line. Its dental branches communicate in a iform manner, and supply the pulps of the lower canine and »or teeth, as well as the adjacent portion of the gum.


Naso-ciliary Nerve


Frontal Nerve Lacrimal Nerve Ciliary Ganglion \ Internal Carotid Artery

Ophthalmic Nerve Trigeminal Ganglion ter Superficial Petrosal Nerve

1 to Lesser Sup. Pet. N.

acial Nerve in Facial Canal

ior Auricular Nerve

Facial Nerve * /

/ I ' /

Internal Carotid Artery ' ] / / /

Chorda Tympani Nerve’ / < ‘

Mandibular Nerve / / /

Inferior Dental Nerve / j Otic Ganglion Lingual Nerve


Lacrimal Gland Ciliary Nerves


Branch of Oculo-motor Nerve to Inferior Oblique Maxillary Nerve Spheno-palatine Ganglion


Long Spheno-palatine Nerve


•Greater Palatine Nerve


Submandibular Ganglion Sublingual Ganglion


Fig. 795. —Scheme of the Trigeminal Nerve and its Ganglia

(Hirschfeld and Leveille.)


jingual Nerve. —This nerve is sensory. It descends deep to the ral pterygoid muscle, lying anterior and medial to the inferior

al nerve. Whilst under cover of that muscle it receives near its

in the chorda tympani nerve, which joins it from behind at an

e angle, in a direction downwards and forwards, after leaving

tympanic cavity through the anterior canaliculus for the chorda pani nerve. Below the lateral pterygoid muscle the lingual nerve

es downwards and forwards between the medial pterygoid muscle

the mandibular ramus, and over the mandibular fibres of the aior constrictor muscle. Below the level of the third lower molar h it lies immediately beneath the mucous membrane of the mouth, is here easily reached. It then crosses the stylo-glossus, and es forwards superficial to the hyo-glossus close to the side of the 'ue. Upon the latter muscle it describes a slight curve with the /■exity downwards. It then passes deep to the mylo-hyoid muscle,

83






1314


A MANUAL OF ANATOMY


where it lies above the deep part of the submandibular gland a the submandibular duct, and has the submandibular ganglion s pended from it. Finally, having looped under the submandibu duct from without inwards, it continues its course as far as the tip the tongue. As it passes along the side of the tongue the nerve immediately beneath the mucous membrane.

Branches of Communication. —(1) Chorda tympani (sensory facial); (2) two branches to the submandibular ganglion; and (3) ( or two filaments to the hypoglossal nerve at the anterior border the hyo-glossus muscle.

Branches of Distribution. —(1) Buccal , to the mucous membrs of the floor of the mouth and of the gums; (2) glandular , to the si


Tympanic Plexus

\ Facial Ganglion


Fig. 706.—Relations of the Petrous Part of the Internal Carotii

Artery.


lingual gland; and (3) lingual , to the mucous membrane of the si( and dorsum of the tongue over its anterior two-thirds. These lingi branches pierce the muscular tissue of the tongue, and are destir chiefly for the filiform and fungiform papillae.

Otic Ganglion. —The otic ganglion is a small oval body, of a pink: colour, which is situated close to the foramen ovale on the deep surfc of the mandibular nerve at the place of origin of the nerve to t internal pterygoid muscle, with which it is closely connected. It I the middle meningeal artery behind it, and the cartilaginous part the pharyngo-tympanic tube on its inner side. The ganglion I three roots. One root (motor-sensory) is derived from the nerve internal pterygoid (motor and probably sensory fibres). A seco root (sensory-motor) is represented by the lesser superficial petro:




THE HEAD AND NECK


1315


/e, which joins the back part of the ganglion. The sensory fibres Le from the glosso-pharyngeal by means of (1) the tympanic nerve, the t}/mpanic plexus, and (3) the lesser superficial petrosal. The or fibres conveyed by this root come from the ganglion of the facial /e through the branch which that ganglion gives to join the lesser grficial petrosal nerve. The third root (sympathetic) comes from sympathetic plexus around the middle meningeal artery.

Branches—(1) Of Communication.— (a) Two branches pass to the iculo-temporal nerve, one to each root. These carry secretory so-pharyngeal fibres which are destined for the parotid gland. A branch joins the chorda tympani. (c) A branch joins the nerve he pterygoid canal.

(2) Of Distribution. —Muscular branches are said to be given to tensor tympani and tensor palati, though the modern view is that ti these nerves are direct branches of the nerve to the internal -ygoid muscle.

Submandibular Ganglion (Submaxillary Ganglion). —This ganglion f small size, and is connected with the lingual nerve in the subidibular region. It is situated upon the upper part of the hyo;sus muscle, between the lingual nerve and the deep part of the mandibular gland, and under cover of the posterior part of the lo-hyoid muscle. It is suspended from the lingual nerve by two necting branches, posterior and anterior, which stand apart from h other. The posterior connecting branch, sometimes broken up ) two or three twigs, conveys sensory fibres from the chorda tympani isory portion of the facial) and lingual nerves, the latter being a nch of the mandibular nerve. The anterior connecting branch resents fibres passing from the ganglion to the lingual nerve.

The posterior branch consists of fibres which are derived from the rda tympani of the facial, and from the lingual nerve. 1 his terior branch may exist as two twigs. The anterior branch is an et from the ganglion to join the lingual. I he sympathetic root of ganglion is derived from the plexus on the cervical portion of the al artery.

Roots of the Submandibular Ganglion.

Secretory. Sensory. Sympathetic.

tn chorda tympani From lingual. From plexus on cervical portion

of facial. of facial artery.

The submandibular ganglion has three roots—secretory, sensory.. I sympathetic. The secretory root comes from the chorda tympani ve; the sensory root from the lingual nerve; and the sympathetic t from the plexus on the cervical portion of the facial artery. I he retory and sensory roots are the posterior connecting branch of the tglion.

Branches. —These proceed from the lower and anterior parts of ganglion, and are as follows: (1) glandular, to the submandibular ad; (2) branches to the submandibular duct; (3) buccal, to the


1316


A MANUAL OF ANATOMY


mucous membrane of the floor of the mouth; and (4) an anter connecting branch, which passes to the lingual nerve. The anter connecting branch probably consists of both chorda tympani a lingual fibres, and it accompanies the lingual nerve to the tongue, furnishes twigs to the sublingual gland, and a small ganglion associa with these twigs has been described under the name of the subling ganglion.

Summary of the Mandibular Nerve—1. Cutaneous Distribution. —It supp

(1) a portion of the dura mater, and the mucous membrane of the mast air-cells; (2) the skin over the greater part of the temporal region; (3) the s of the external auditory meatus, and the outer surface of the tympanic m( brane; (4) the skin of the tragus, and of the upper part of the outer surface the auricle; (5) the skin over the body of the mandible, including the skin the chin and lower lip, as well as the mucous membrane of the lower lip; (6) mucous membrane of the floor of the mouth, and the lower gum; and (7) sides and dorsum of the tongue over its anterior two-thirds. 2. Articular I tribution. —It supplies the mandibular joint. 3. Dental Distribution. —It s plies the pulps of all the lower teeth of one side, and the mucous membr; of the outer surface of the lower gum of one side. 4. Glandular Distribution.gives branches to the parotid, submandibular, and sublingual glands. 5. Mi cular Distribution. —It supplies (1) the muscles of mastication—namely, ■ masseter, temporal, lateral pterygoid, and medial pterygoid; (2) the mylo-hy and anterior belly of the digastric; and (3) the tensor palati and tensor tympc

The Mandibular Joint.

The mandibular joint belongs to the class of synovial joints, a to the subdivision of hinge joints. The articular surfaces are (1) t anterior part of the articular fossa in front of the squamo-tympai fissure, and (2) the head of the mandible.

Ligaments.— The capsular ligament consists of scattered fibr which form a thin loose investment to the joint on its anterior, medi and posterior aspects, being completed on the outer aspect by t temporo-mandibular ligament.

The temporo-mandibular ligament (external lateral ligament) is

short strong bundle of fibres, which is attached above to the tuber* of root of the zygoma, and below to the condylar tubercle and the out and back part of the neck of the mandible. Its fibres are direct obliquely downwards and backwards. This ligament forms the latei portion of the capsular ligament.

The spheno-mandibular ligament (long internal lateral ligament) a long flat band, which stands off from the joint, and therefore has : direct relation to it. It is somewhat triangular, being narrow abo and broad below. Superiorly it is attached to the spine of the sphenc bone, and interiorly to the lingula and the inner margin of the mandibul foramen. Its fibres are directed downwards and slightly forwarc The first part of the maxillary artery separates it from the neck the mandible; and inferiorly the inferior dental vessels and ner intervene between it and the ramus of the mandible. At its low attachment it is spread over the upper end of the mylo-hyoid groo\ and is here pierced by the mylo-hyoid nerve and artery. The maxilla


THE HEAD AND NECK


1317


ry and the auriculo-temporal nerve pass between the temporoldibular and spheno-mandibular ligaments.

rhe spheno-mandibular ligament is formed beside the skeletal bar of the visceral arch.


Capsular Ligament


Fig. 797.—The Mandibular Joint (Medial Aspect).


The stylo-mandibular ligament is a stout process of the deep cervical

ia, which extends from the styloid process of the temporal bone

tr its tip to the angle and adjacent portion of the posterior border


Articular Disc


Fig. 798.—The Mandibular Joint opened (Lateral Aspect).


the ramus of the mandible. Superiorly it gives origin to a few res of the stylo-glossus and interiorly it is implanted between the sseter and medial pterygoid muscles. It separates the subman>ular gland from the lower portion of the parotid gland.





1318


A MANUAL OF ANATOMY


The articular disc is an oval plate which is interposed between t] two articular surfaces. It is thinnest at the centre, where it is occ sionally perforated, and thickest posteriorly. Its superior surface concavo-convex from before backwards, in adaptation to the co vexity of the articular eminence and the concavity of the articul fossa. Its inferior surface is concave, and fits upon the head of ti mandible. Its circumference is connected with the capsular ligamer and anteriorly it gives partial insertion to the lateral pterygoid muse] It divides the joint into two compartments, upper and lower, whit are usually distinct.

The synovial membranes are two in number, upper and lower, oi being above and the other below the articular disc. The upper synovi membrane is larger and looser than the lower, and when the articul; disc is perforated at the centre, the two synovial cavities are continuoi through the perforation.

Arterial Supply .—The superficial temporal artery chiefly.

Nerve-supply .—The auriculo-temporal nerve and offsets from tl masseteric nerve.

Movements. —These are as follows: (1) depression, (2) elevation, (3) protra tion, (4) retraction, and (5) lateral movements. There being two divisions the joint, upper and lower, different movements occur in each. The movemei in the upper compartment is of a gliding character, whilst in the lower compartme it is of a hinge character. When the mandible is depressed, as in opening t] mouth, the head and the articular disc move forwards on to the articular eminent In cases of over-depression, as in violent yawning, or forcing too large a boc into the mouth, the head is apt to slip over the articular eminence into tl infratemporal fossa, and when this takes place dislocation of the mandible the result. The movement of forward gliding on the part of the head at articular disc during depression takes place in the upper compartment of tl joint. Another movement, however, of a hinge character is taking place in tl lower compartment of the joint between the head and the articular disc. This co sists in the head rotating on the under surface of the plate round a transverse axi

When the mandible is elevated, as in shutting the mouth, the changes whi< occur in both compartments of the joint are the reverse of those just describe as taking place in depression. The head and articular disc glide backwan into the articular fossa, and at the same time the head rotates back to its previoi position. In protraction, as when the lower incisors are protruded beyond tl upper, and in retraction, the movement mainly takes place in the upper cor partment of the joint, and consists in the head and the articular disc glidii forwards and backwards. When these movements are performed alternate on each side the lateral oblique movements, as in grinding or chewing, take plac and the head and the articular disc of one side move forwards and backward whilst the other head and the articular disc move in the opposite directio During these movements oblique rotation is taking place in the lower compar ment of the joint.

Muscles concerned in the Movements.—Depression is effected by the platysm mylo-hyoid, anterior belly of the digastric, and genio-hyoid muscles; and elev. tion by the anterior fibres of the temporal, masseter, and medial pterygo muscles. Protraction is produced by the lateral pterygoid, the superficial fibr of the masseter, and slightly by the medial pterygoid; and retraction by tl posterior fibres of the temporal and the deep fibres of the masseter. The grindil movement is effected by the lateral pterygoid muscles acting alternately. Tl axis of the movement in opening and closing the mouth passes through tl mandibular foramina.


THE HEAD AND NECK


1319


The Maxillary Nerve.


The maxillary nerve is the second division of the trigeminal nerve, 1 in size is intermediate between the mandibular and the ophthalmic, is entirely sensory, and arises from the trigeminal ganglion. Its irse is forwards to the foramen rotundum, by which it leaves the nial cavity. Then it enters the posterior part of the pterygoatine fossa, and crosses the upper part of that fossa to the inferior )itai fissure, through which it passes on to the floor of the orbit. It w takes the name of the infra-orbital nerve, and traverses the infra)ital groove, and then the infra-orbital canal, on the floor of the )it. Finally, it leaves this canal through the infra-orbital foramen der cover of the levator labii superioris, and ends in its terminal inches. The course of the maxillary nerve and its continuation, > infra-orbital nerve, is almost directly forwards, with a slight •lination outwards just before the orbit is entered.

Branches.— These are as follows:


In Infra-orbital Canal.

Middle superior dental. Anterior superior dental.


Intracranial.

Meningeal.


On the Face.

Palpebral.

Nasal.

Labial.


In the Pterygo-palatine Fossa.

Zygomatic.

Ganglionic.

Posterior superior dental.


The meningeal branch supplies the dura mater of the middle anial fossa.

The zygomatic nerve (temporo-malar nerve) is the first branch of e maxillary in the pterygo-palatine fossa. It arises from its uppei rface, and enters the orbit through the inferior orbital fissure. F01

further course, see p. 1259.

The ganglionic branches (spheno-palatine nerves) are two in number, ley arise from the lower aspect of the parent trunk, and, aftei a

ry short descending course, they end for the most part in the sphenoilatine ganglion, to which they convey sensory fibres, and of which

ey are the sensory roots. Man} 7 of their fibres, howevei, pass cleai the grey matter of the ganglion, and are prolonged into the nasal

id palatine branches of the ganglion.

The posterior superior dental branches arise from the maxillaiy as is about to pass through the inferior orbital fissure. They are mally two in number, but sometimes they arise by a single trunk, hey descend in grooves on the posterior surface of the maxilla in impany with branches of the posterior superior dental artery, and ve off branches to the gum and contiguous parts of the mucous membrane of the cheek. Then they traverse the posterior denta inals, and within the substance of the bone communicate with each filer and with the middle superior dental nerve to form a delicate exus, from which branches are given^off to the pulps ot the thiee


!32o A MANUAL OF ANATOMY

upper molar teeth. Slender filaments are also furnished to the mucc membrane lining the maxillary sinus.

The middle superior dental branch arises from the main trunk it lies in the infra-orbital groove near the inferior orbital fissure, descends in the middle dental canal of the maxilla. Its brand communicate with each other, and with the posterior superior a anterior superior dental branches within the substance of the boi to form a delicate plexus, from which branches are given to the pu] of the upper two premolar teeth and to the gum. This nerve a' furnishes delicate filaments to the mucous membrane lining t maxillary sinus. Two enlargements are described in connection wi the middle superior dental branch. One is situated at its communk tion with the posterior superior dental branch, and is known as t ganglion 0} T alentin ; and the other at its communication with t anterior superior dental, this one being known as the ganglion Bochdalek. 86

The anterior superior dental branch arises from the infra-orbil

nerve near the front part of the infra-orbital canal, and descends, company with the anterior superior dental artery, in the anterior deni canal. Its branches communicate with each other, and with the midc superior dental branch, to form a delicate plexus, from which branch are given to the pulps of the upper canine and incisor teeth. Tt nerve also furnishes delicate filaments to the mucous membrane linii the maxillary sinus, and a nasal branch, which enters the nasal cavi and supplies the mucous membrane of the anterior part of the infer! meatus and adjacent portion of the inferior nasal concha.

The facial branches of the infra-orbital nerve—palpebral, nas£ and labial—have been already described (see p. 1276).

It is to be noted that there are three superior dental branche the posterior being a branch of the maxillary, and the middle and anteri being branches of the infra-orbital; whilst there is onlv one infer! dental nerve, which is a branch of the mandibular.

Spheno-palatine Ganglion (Meckel’s Ganglion). —It is a sms triangular, somewhat reddish body, situated in the upper part of tl pterygo-palatine fossa close to the spheno-palatine foramen, whic leads through the inner wall of the fossa to the superior meatus of tl nasal cavity. It is suspended from the maxillary nerve by some < the fibres of the two ganglionic branches of that nerve, many fibr< of these two branches passing clear of the grey matter of the ganglic into its nasal and palatine branches. The fibres conveved to tl grey matter of the ganglion by the two ganglionic branches represer its sensory root or roots.

The ganglion has sensory and sympathetic roots, but no mote root. The sensory roots are derived from two sources—maxillary an facial. The maxillary sensory root-fibres form two bundles, an represent portions of the two ganglionic branches, by which the ganglio is suspended from the trunk of the maxillary nerve in the pterygc palatine fossa. The facial sensory root-fibres are represented by tb


THE HEAD AND NECK


1321


iter superficial petrosal nerve , which is a branch of the ganglion the facial nerve. The sympathetic root is formed by the deep vsal nerve from the carotid plexus of the sympathetic.

The facial sensory root (greater superficial petrosal) and the svmhetic root (deep petrosal) join to form the nerve of the pterygoid al in the foramen lacerum. After traversing the pterygoid canal n behind forwards, the nerve enters the pterygo-palatine fossa l joins the back part of the spheno-palatine ganglion. In the rygoid canal the nerve gives off one or two nasal branches, which lS through the floor of the canal, and are distributed to the mucous mbrane of the posterior part of the roof of the nasal cavity and acent part of the septum.


Short Spheno-palatine Nerves Ganglionic Branches from Maxillary Olfactory Filaments j i Nerve of Pterygoid Canal


Nasal Branches


i. 799. —Nerves of the Nasal Cavity, and the Spheno-palatine Ganglion, with its Branches (Medial Aspect) (Hirschfeld and Leveill£).


Branches of the Spheno-palatine Ganglion. —These are arranged in ir sets:


iscending.

Orbital.


Posterior.

Pharyngeal. Nerve of pterygoid canal.


Medial.

Short sphenopalatine. Long sphenopalatine.


Descending.

Greater palatine. Lesser palatine.


Ascending Branches.—Orbital branches are two or three in number, d enter the orbit through the inferior orbital fissure to be distributed the periosteum. Thev have been described by Luschka as sending iments through the inner wall of the orbit to supply the mucous mbrane of the posterior ethmoidal and sphenoidal sinuses.

Posterior branches are the pharyngeal nerve and the nerve of the irygoid canal. The pharyngeal nerve passes backwards in the




I 3 22


A MANUAL OF ANATOMY


palatovaginal canal along with the pharyngeal branch of the maxillai artery, and is distributed to the mucous membrane of the upp< part of the pharynx in the region of the orifice of the pharyngi tympanic tube.

Medial branches are the long and short spheno-palatine nerve The short spheno-palatine nerves (superior nasal nerves) are of sma

size, and derive some of their fibres from the ganglionic branches < the maxillary nerve. They are about six in number, and, springir from the inner part of the ganglion, they enter the superior meatus < the nose through the spheno-palatine foramen. They supply tl mucous membrane of the superior and middle conchae, the superb meatus, the posterior ethmoidal sinus, the middle meatus, and tl upper and back part of the septum.

The long spheno-palatine nerve (naso-palatine nerve) enters tl nasal cavity along with the short spheno-palatine nerves. It cross< the roof of the cavity, and then passes downwards and forwards upc the septum, lying in the groove on the lateral surface of the vome Having arrived at the incisor crest, the left long spheno-palatir nerve descends through the anterior incisive canal, and the rigl descends through the posterior. Having reached the incisive fos< in this manner, the two nerves communicate in a plexiform manne and delicate filaments are furnished to the mucous membrane of tl hard palate behind the incisor teeth. In this situation communic; tions are established with the greater palatine nerve of each sid< As the long spheno-palatine nerve traverses the groove on the later; surface of the vomer, it furnishes twigs to the mucous membrane < the nasal septum, and in this part of its course it is accompanied b the posterior septal branch of the spheno-palatine artery; but th artery does not accompany it through the median incisive canal.

Descending branches are the greater and lesser palatine nerve They arise from the lower part of the ganglion, usually by a commo trunk, and they derive some of their fibres from the ganglionic branch* of the maxillary nerve.

The greater palatine nerve descends in the greater palatine cana and escapes from it through the greater palatine foramen. Then divides into branches which pass forwards and inwards, occupyin grooves on the hard palate, to the mucous membrane and glands ( which, as well as to the mucous membrane of the upper gum on it inner aspect, they are distributed. In the region of the incisive foss this nerve communicates with the long spheno-palatine nerve. A it descends in the greater palatine canal it furnishes nasal branche which enter the nasal cavit}/, and are distributed to the mucoi membrane over the inferior concha,, except anteriorly, and to that < the adjacent portion of the inferior meatus. The lesser palatine nerv< descend in the lesser palatine canal, after emerging from which the are distributed to the mucous membrane of the soft palate and tonsi They have been said to furnish branches to the levator palati an musculus uvulae, the fibres of these branches being derived from tl



THE HEAD AND NECK


i 3 2 3


liculate ganglion of the facial through the great superficial petrosal, ich contributes to the formation of the nerve of the pterysoid canal, i conveys motor fibres to the ganglion. The two muscles in question, wever, are supplied by the bulbar part of the accessory nerve through

pharyngeal plexus.

Summary of the Maxillary Nerve and the Spheno-palatine Ganglion.—1. Cuteous Distribution. —(1) The skin of the anterior part of the temporal region, I over the zygomatic bone; (2) the skin from the lower eyelid down to the per lip, including the skin of the side of the nose; (3) the mucous membrane the naso-pharynx in the vicinity of the orifice of the pharyngo-tympanic; the mucous membrane of the nasal cavity; (5) the mucous membrane of the xillary sinus; (6) the mucous membrane of the soft palate and tonsil; and the mucous membrane of the hard palate, with its glands, and that of the ler surface of the upper gum. 2. Dental Distribution. —The pulps of all the per teeth of one side, as well as the mucous membrane of the outer surface of j upper gum.

In addition to the foregoing, the maxillary nerve supplies the periosteum of ? orbit, and the dura mater of the middle cranial fossa.


Deep Dissection of the Neck.

Stylo-pharyngeus — Origin .—The base of the styloid process of the mporal bone on its inner aspect.

Insertion. —(1) The posterior border of the lamina of the thyroid rtilage, and (2) the lateral wall of the pharynx, its fibres blending th those of the palato- g-fv. process







1324


A MANUAL OF ANATOMY


bone, and, after traversing this canal, it enters the cranial cavit The vessel is divided into three parts—cervical, petrous, and cavernoi

The Cervical Part. —This part of the vessel extends from the level the upper border of the thyroid cartilage to the carotid canal on t inferior surface of the petrous part of the temporal bone. Its com is upwards, and at first it lies in the carotid triangle, where it is plac lateral to and behind the external carotid artery.

Relations — Superficial .—This part of the vessel is comparative superficial, being covered by the integument,, platysma, and sterr mastoid, the latter overlapping it. After leaving the carotid trian^ the artery becomes deeply placed, and passes deep to the posteri belly of the digastric and stylo-hyoid muscles, parotid gland, style process, and stylo-pharyngeus muscle. In this part of its com the vessel is crossed by the hypoglossal, accessory, and glosso-phary geal nerves, and the pharyngeal branch of the vagus, and by t occipital and posterior auricular arteries. The relation of the arte to the external carotid here undergoes a change. The level where t change takes place is as the internal carotid passes deep to the stylo process of the temporal bone, and the change consists in the extern carotid taking up a position directly anterior to the internal caroti I he two arteries are, however, separated from each other by the folio 1 ing structures: (i) the styloid process or stylo-hyoid ligament; (2) t' stylo-pharyngeus muscle; (3) the glosso-pharyngeal nerve; (4) t' pharyngeal branch of the vagus; and (5) the parotid gland.

Posterior .—The longus capitis, the superior cervical ganglion the sympathetic, and the superior laryngeal branch of the vagus.

Lateral .—The internal jugular vein and vagus nerve, the ner being on a plane posterior to both artery and vein. These thr structures are still surrounded by a sheath which is an upward e tension of the carotid sheath previously described. Close to t. base of the skull the glosso-pharyngeal, accessory, and hrypogloss nerves lie between the internal artery and the internal jugular vei The glosso-pharyngeal nerve soon passes forwards superficial to t. artery, the accessory nerve passes backwards superficial to the vei and the hypoglossal nerve passes forwards superficial to the arte at the lower border of the posterior belly of the digastric muscle.

Medial .—The ascending pharyngeal artery, the lateral wall the pharynx, the tonsil, and the superior laryngeal nerve.

Development. —The internal carotid artery is developed from the thi aortic arch and the part of the dorsal aorta in front of this arch.

The Glosso-pharyngeal Nerve.

The glosso-pharyngeal or ninth cranial nerve is a mixed nerv consisting of both afferent or sensory and efferent or motor fibre It leaves the cranial cavity through the middle compartment of t] jugular foramen, along with the vagus and accessory nerves, bi enclosed in a separate sheath of the dura mater, and lying anteri


THE HEAD AND NECK


1325


these two nerves. In passing through the jugular foramen the ve has two ganglia, the upper one, which is small and situated the upper part of the foramen, being called the superior ganglion yular ganglion) ; and the lower one, which is rather larger, being ied the inferior ganglion {petrous ganglion). The latter is about ich in length, and lies in the lower part of the foramen, where it upies a groove on the petrous portion of temporal bone. After leaving the jugular mien, the nerve at first descends between internal carotid artery and internal jugular n, being lateral to the vagus nerve. It n passes downwards and forwards in front the internal carotid artery, and under r er of the styloid process, stylo-pharyngeus scle, and external carotid artery. It next ves round the hinder border of the styloiryngeus, and crosses it (Fig. 800) superally in a forward direction. Finally, it

ses deep to the hyo-glossus muscle, and

reaches the posterior third of the tongue, ere it divides into its terminal branches.

The superior ganglion (jugular ganglion), as ted, is very small, and involves only a few the fibres of the nerve, the other fibres >sing clear of, but close to, the ganglion,

I being continued into the nerve beyond it. is ganglion neither gives nor receives any branches, and is someles absent.

The inferior ganglion (petrous ganglion), unlike the jugular, Fives all the fibres of the nerve, and it furnishes connecting branches I the tympanic nerve.

Branches of the Glosso-pharyngeal Nerve—1. From the Inferior Qglion — (a) Branches of Communication .—One to the superior cervical lglion of the sympathetic; one to the auricular branch of the superior lglion of the vagus; and one to the superior of the vagus.

(b) Branch of Distribution. —This is called the tympanic nerve rve of Jacobson). After leaving the inferior ganglion it ascends, company with the tympanic branch of the ascending pharyngeal ery, through the canaliculus for the tympanic nerve. In this y it enters the tympanic cavity at the junction of the inner wall and ir, and ascends upon the inner wall. Being joined by the caroticonpanic branch of the carotid plexus of the sympathetic, it breaks into branches which occupy grooves upon the promontory and m the tympanic plexus. From this plexus the tympanic nerve erges under the name of the lesser superficial petrosal nerve, which ves the tympanic cavity and traverses a minute canal in the petrous tie, passing in its course beneath the upper portion of the canal ich lodges the tensor tympani muscle. Whilst in this canal it is


Fig. 801.—Sketch showing the Relations between Ninth, Tenth, Eleventh, and Twelfth Nerves, in Carotid Sheath just below Skull.



1326


A MANUAL OF ANATOMY


Auriculo temporal Nerve Facial Nerve j Posterior Auricular Nerve •, .


Glosso-pharyngeal Nerve Accessory Nerve .


Greater Occipital Nerve Hypoglossal Nerve


Sup. Cervical Symp. Ganglion — External Carotid Artery Internal Carotid Artery Sympathetic Trunk.

Com. Car. Art. and'Symp. Plexus — V|j Phrenic Nerve -jM I


Right Ansa Subclavia


First Thoracic Ganglion


Right Posterior-;

Pulmonary Plexus


Vena Azygos Vascular Branch


Intercostal Vessels ( and Nerve 1 r


Ramus Communicans Sympathetic Trunk


Lesser Splanchnic Nerve—Greater Splanchnic Nerve Lowest Splanchnic Nerve.'


SL _

W m Hypoglossal Nerve

vZffl _ Superior Laryngeal Nerve

yriff-T . Vagus Nerve

- Middle Cervical Sympathetic

Ganglion

••jS-imv _ Recurrent Laryngeal Nerve

_Cardiac Branches of Vagus

_ Phrenic Nerve

Timex -- ’

rfii


_ Root of Right Lung


.. Right Vagus Nerve on CEsophagus


CEsophageal Plexus


Liver (cut)

Left Vagus Nerve


A.Descending Aorta Thoracic Duct


\ Branches of Vagus I on Stomach


Right Coeliac Ganglion "Coeliac Plexus


'•'Superior Mesenteric Artery and Plexus


Renal Artery and Plexus Abdominal Aorta

S.V.C. Superior Vena Cava


I’ig. 802.—Nerves of the Right Side of the Face, Neck, and Thorax

(HlRSCHFELD AND LeVEILLEI.


















THE HEAD AND NECK


1327


Led by a communicating branch from the ganglion of the facial ve. It leaves the canal through the hiatus for the lesser superil petrosal nerve on the surface of the petrous bone, and then ses forwards and inwards beneath the dura mater. After this asses through the canaliculus innominatus, when present, or through fissure between the petrous temporal and greater wings of the Lenoid, or sometimes through the foramen ovale, into the infraiporal fossa, where it joins the otic ganglion, to which it conducts sso-pharyngeal and facial fibres.

2. From the Trunk of the Nerve. —(1) A communicating branch netimes passes from the nerve a little below the inferior ganglion join the digastric branch of the facial nerve. (2) A carotid branch ises to the sympathetic plexus on the internal carotid artery. Pharyngeal Branches. —These are about four in number. Three of im unite, over the middle constrictor of the pharynx, with the subnsions of the pharyngeal branch of the vagus, and with branches the superior cervical ganglion of the sympathetic, to form the aryngeal plexus. The other pharyngeal branch pierces the superior istrictor, and is distributed to the mucous membrane of the upper rt of the pharynx. (4) A muscular branch to the stylo-pharyngeus iscle, some of the fibres of which pierce the muscle to supply the icous membrane of the pharynx. (5) Tonsillar branches form a cular plexus round the tonsil, known as the circulus tonsillaris; >m it branches supply the tonsil and region of the oro-pharyngeal hmus. (6) Lingual Branches. —Under cover of the hyo-glossus iscle, the terminal part of the nerve divides into two branches, rsal and lateral. The dorsal branch passes to the vallate papillae d the mucous membrane over the posterior third of the tongue, tending as far back as the front of the epiglottis. The lateral branch distributed to the mucous membrane of the side of the tongue r er about its posterior half.

Summary of the Glosso-pharyngeal Nerve— i- Cutaneous Distribution.— It

pplies (a) the mucous membrane of the tympanic cavity, the posterior third the tongue, the region of the oro-pharyngeal isthmus, and the pharynx, and the tonsil. 2. Muscular Distribution.— The stylo-pharyngeus. 3. Glandular stribution.— Through (1) its tympanic, subsequently lesser superficial petrosal, anch, (2) the otic ganglion, and (3) the auriculo-temporal neive, it furnishes

retory branches to the parotid gland.

The Vagus Nerve in the Neck.

The vagus, or tenth cranial, is a mixed nerve, consisting of both ferent and efferent fibres. It leaves the cranial cavity through the iddle compartment of the jugular foramen, being enclosed m the .me sheath of dura mater as the accessory, and, with that nerve, ing posterior to the glosso-pharyngeal. In the foramen it presents small enlargement called the superior ganglion. ATter emerging from le foramen it is joined by the cranial root of the accessory nerve, id here there is another enlargement, called the inferior ganglion.


1328


A MANUAL OF ANATOMY


This ganglion is larger and longer than the superior ganglion, full j inch in length, and presenting a somewhat plexiform appearana In this part of its course the nerve lies between the internal caroti artery and the internal jugular vein, the glosso-pharyngeal nerve bein in front of it and the accessory behind it. The hypoglossal'nerv lies at first deeply behind it, but subsequently turns round the oute side of the inferior ganglion. The vagus then descends within th carotid sheath, lying at first between the internal carotid artery an the internal jugular vein, and then between the common carotid arter and the internal jugular vein, being on a plane posterior to both vessels Within the sheath the nerve occupies a special compartment, situate in the back part of the septum which separates the artery from th vein. Below the root of the neck the right and left nerves have impor tant differences in their course and relations.

Branches —A. The Superior Ganglion (Ganglion of the Root)1. Branches of Communication. — (a) It receives two filaments from th cranial root of the accessory nerve. ( b) It communicates by a smal twig with the inferior ganglion of the glosso-pharyngeal nerve. ( c ) I communicates with the facial, and with the posterior auricular brand of the facial, through its auricular branch of distribution, (d) I receives a twig from the superior cervical ganglion of the sym pathetic.

2. Branches of Distribution. — (a) The meningeal branch takes c recurrent course, and, after entering the cranial cavity, supplies th< dura mater which lines the cerebellar fossa of the occipital bone ( b ) The auricular branch is of small size, and is soon reinforced by a twi£ from the inferior ganglion of the glosso-pharyngeal. It enters th( mastoid canaliculus through an aperture on the outer wall of th( jugular fossa. In this canaliculus it traverses the petrous portion 0: the temporal bone, crossing in its course the inner aspect of the descending portion of the facial canal a little above the stylo-mastoic foramen, where it forms its first communication with the facial nerve It then leaves the petrous temporal through the tympano-mastoic fissure, between the mastoid process and the tympanic plate, and then divides into two branches. One of these joins the posterioi auricular branch of the facial nerve, and the other is distributed tc (1 a ) the skin of the inner surface of the auricle, and (b) the skin of the lower and back part of the external auditory meatus.

B. The Inferior Ganglion (Ganglion of the Trunk)— 1. Branches of Communication. — (a) The most important branch of communication is the cranial root of the accessory nerve , which passes over the surface of the ganglion in intimate contact with it. Most of the cranial fibres are continued into the pharyngeal and superior laryngeal nerves, but some of them descend in the main trunk of the vagus, and pass into its cardiac and inferior laryngeal branches. The cranial fibres are to be regarded as of two kinds—namely, motor , for the muscles of the soft palate, pharynx, and larynx; and cardiac inhibitory, (b) Branches pass between the inferior ganglion and the hypoglossal nerve, (c) A


THE HEAD AND NECK


1329


municating branch is received from the superior cervical ganglion le sympathetic.

Branches of Distribution.—These are pharyngeal and superior ngeal.

fhe pharyngeal branch arises from the upper part of the inferior jlion, its fibres being chiefly derived from the cranial root of the ssory nerve. It passes forwards and downwards between the rnal and external carotid arteries, and divides into branches opposite middle constrictor muscle, which join the pharyngeal branches of ^losso-pharyngeal and superior cervical ganglion of the sympathetic )rm the pharyngeal plexus.

rhe pharyngeal plexus is situated upon the middle constrictor cle opposite the greater horn of the hyoid bone. It is formed by

he pharyngeal branch of the inferior ganglion of the vagus, derived

inally from the accessory; (2) the pharyngeal branches of the glossoryngeal; and (3) the pharyngeal branches of the superior cervical ^lion of the sympathetic.

Branches are distributed to (1) the constrictor muscles of the phai ynx, the mucous membrane of the pharynx; and (3) the palato-glossus, ito-pharyngeus, levator palati, and musculus uvulae. In this way the muscles of the soft palate except the tensor palati are supplied the accessory nerve. Branches of communication pass between plexus and the superior laryngeal and external laryngeal nerves, another branch, known as the lingual bvanch of the vagus, passes

he hypoglossal nerve. .

Superior Laryngeal Nerve.—This nerve, which is principally sensory,

es from the inferior ganglion of the vagus near its centre, and contains

es of the cranial root of the accessory nerve. It passes downwaids 1 forwards behind the internal carotid artery, having received comnicating branches from the superior cervical ganglion of the symhetic and from the pharyngeal plexus. As it passes behind the mnal carotid artery it divides into two branches, internal and externa . 5 internal laryngeal nerve, which is sensory, passes forwards, m npany with the superior laryngeal branch of the superioi thyroi ery, to the thyro-hyoid membrane, which it pierces under cover of

posterior border of the thyro-hyoid muscle. Having reached the

erior of the larynx, it divides into branches which supply the mucous mbrane of the epiglottis with its folds, a little of the back of the igue, the mucous membrane of the larynx as low as the vocal to ds, I that covering the lateral and posterior portions of the cricoid cartie. One branch descends over the inner surface of the lamina °f the /roid cartilage, and joins a branch of the lecunent aiyngea . e

ernal laryngeal nerve, of small size, descends deep o e s emo

^roid muscle to the crico-thyroid muscle, which it supplies. It 'nishes some twigs to the inferior constrictor, and a amen w ic \ ns the superior cardiac branch of the sympathetic. rec ? 1 ., s communicating branch from the supeiior ceivica gang ion o c

npathetic, and one or two branches from the pharyngea p exus.

84


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A MANUAL OF ANATOMY


Recurrent Laryngeal Nerve. —This nerve is mainly motor, and the principal motor nerve of the intrinsic muscles of the larynx, contains fibres of the cranial root of the accessory nerve. The ri{ nerve arises from the vagus at the root of the neck in front of t hrst. part of the subclavian artery, round the lower border of which bends, and then ascends behind it. Then it passes upwards ai inwards behind the carotid sheath and inferior thyroid artery to t groove between the trachea and the oesophagus. The left nerve aris in the thorax from the vagus in front of the arch of the aorta on a le\ with its lower border. It passes backwards below the arch and to t left of the ligamentum arteriosum, and then it turns upwards behii the arch. Having reached the groove between the trachea and t' oesophagus, it ascends therein to the neck. The right and left nerv pass upwards in the groove between the trachea and the cesophag on each side, lying usually behind the corresponding inferior thyro artery and in close relation with the lobes of the thyroid gland, i the level of the cricoid cartilage each nerve passes beneath the low border of the inferior constrictor muscle, and enters the larynx behii the crico-thyroid joint.

Extralaryngeal Branches. —(i) Communicating twigs pass betwe< the recurrent laryngeal nerve and the inferior cervical ganglion of tl sympathetic; (2) cardiac branches, which contain cranial fibres fro the accessory, are furnished to the deep cardiac plexus; (3) trache and oesophageal branches are supplied to these tubes; and (4) muscul offsets pass to the lower part of the inferior constrictor.

Intralaryngeal Branches. —These are chiefly muscular, and supp the intrinsic muscles of the larynx, except the crico-thyroid, whi( is supplied by the external laryngeal nerve. Sensory branches, howeve are given to the laryngeal mucous membrane below the vocal fold except over the lateral and posterior portions of the cricoid cartilag Within the larynx the nerve communicates with a branch of tl internal laryngeal nerve under cover of the lower part of the lamir of the thyroid cartilage.

For the explanation of the recurrent course of each recurrei laryngeal nerve, see p. 1121.

Cardiac Branches. —These are subject to variation as regan numbers. As a rule there are two, upper and lower, both of whic contain cranial fibres from the accessory. Those of the right sic pass behind the first part of the subclavian artery, and end in tl deep cardiac plexus. On the left side the upper nerve passes to tl deep cardiac plexus, but the lower nerve ends in the superficial cardie plexus.

Summary of the Vagus Nerve in the Neck— 1. Motor Distribution. —(1) Tl

muscles of the soft palate by accessory fibres, except the tensor palati; (2) tl constrictor muscles of the pharynx; (3) the intrinsic muscles of the larynx; ar (4) the muscular tissue of the oesophagus and trachea. 2. Sensory Distribution.It supplies (1) the pharynx, oesophagus, and trachea; (2) a limited portion of.tl dura mater; and (3) a small portion of the skin on the inner surface of the auricl as well as of the lower and back part of the external auditory meatus. 3. Con


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I 33 I


.cations. —Each vagus nerve forms connections with the facial, glossoyngeal, accessory, hypoglossal, and sympathetic nerves. It is also con:d with the loop between the first and second cervical spinal nerves. Its important connection is that which is established with the cranial root of icessory nerve. The bulbar fibres of the nerve are probably chiefly conid in the innervation of the muscles of the soft palate (except the tensor

i), pharynx, and larynx, but also to a certain extent in the innervation of

leart.


Accessory Nerve.

fhe accessory or eleventh cranial nerve consists of two roots— ial and spinal. In the jugular foramen these two parts either e to form one trunk or freely intermingle, and a communication stablished between the cranial root and the superior ganglion of vagus by means of two twigs. The nerve passes through the liar foramen, being enclosed he same sheath of dura mater he vagus, behind which it lies, lediately beneath the jugular men the two parts of the nerve irate from each other, rhe cranial root passes over, in intimate contact with, the rior ganglion of the vagus, its fibres are continued partly • the pharyngeal and superior ngeal branches of the inferior glion, and partly into the lk of the vagus below the glion. These latter fibres are mately prolonged into the iiac and recurrent laryngeal riches of the nerve. The lial fibres of the accessor}/ regarded as (i) the motor nerves of (a) the muscles of the soft ite, except the tensor palati, (b) the constrictor muscles of the ,rynx, and (c) the intrinsic muscles of the larynx; and (2) the ibitory fibres of the heart.

The spinal root of the accessory nerve passes backwards and downds either behind or in front of the internal jugular vein. It then

  • ces the deep surface of the sterno-mastoid, which it supplies along

h a branch of the second cervical nerve. Then it crosses the terior triangle of the neck obliquely downwards and backwards to anterior border of the trapezius, beneath which it passes, supplying muscle, in company with branches from the third and fourth rical nerves.

Summary. —The spinal root of the accessory nerve supplies the trapezius and sterno-mastoid. The cranial root, through its connection with the vagus /e and its branches, supplies (1) the muscles of the soft palate, except the


Fig. 803. —Showing Relations between Accessory Nerve, Hypoglossal Nerve, and Occipital Artery a little below Skull Base.


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A MANUAL OF ANATOMY


tensor palati; (2) the constrictor muscles of the pharynx; and (3) the intrin muscles of the larynx. It also furnishes the inhibitory fibres of the heart, wh: reach that organ through the cardiac branches of the vagus.


Hypoglossal Nerve.


The hypoglossal or twelfth cranial nerve consists at first of b bundles, which pierce the dura mater separately. In passing throu the anterior condylar canal these two bundles unite to form one trur After leaving that canal the nerve lies deeply under cover of the interr carotid artery and internal jugular vein. It then turns round t outer side of the inferior ganglion of the vagus, with which it is close connected, and passes forwards between the internal carotid arte and internal jugular vein. Then it descends to the lower border the posterior belly of the digastric, at which level it hooks round t occipital artery from without inwards, and crosses in front of t external carotid artery and its lingual branch. In this part of i course the nerve lies in the superior carotid triangle. It next ru forwards above the hyoid bone, passing deep to the tendon of f digastric and the lower part of the stylo-hyoid muscle, and superfici to the hyo-glossus. After this it disappears deep to the mylo-hyoi still resting upon the hyo-glossus, where it is accompanied by tl vena comitans hypoglossi, and is covered by the deep part of t] submandibular gland. At the anterior border of the hyo-glossus is connected with the lingual nerve, and then enters the genio-glossr

Branches —1. Of Communication. —After leaving the anterior co dylar canal, the hypoglossal nerve .communicates with the infer! ganglion of the vagus. It then receives a branch from the super! cervical ganglion of the sympathetic, and one from the first cervic nerve, or the loop between the first and second. As it hooks rour the occipital artery it receives the lingual branch of the vagus fro the pharyngeal plexus; and at the anterior border of the hyo-glossi it is connected with the lingual nerve.

2. Of Distribution. —One or two meningeal branches arise from tl nerve in the anterior condylar canal, which take a recurrent cours and enter the cranial cavity to supply the dura mater near the canal

The ramus descendens hypoglossi nerve has been already describe (see p. 1205).

The nerve to thyro-hyoid will be found described on p. 1206.

The muscular branches are given off from the nerve as it lies upo the hyo-glossus under cover of the mylo-hyoid. These supply tl stylo-glossus, hyo-glossus, genio-glossus, and genio-hyoid. The nen to the genio-hyoid is composed of spinal fibres derived from the fin and second cervical nerves.

Ihe terminal branches pierce the under surface of the tongue, an are distributed to its muscular tissue.

The hypoglossal nerve receives many spinal fibres. Those derive from the first cervical nerve, or the loop between the first and seconc soon become applied to it, and most of them pass off to form the ramr


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1333


endens hypoglossi. A few of these, however, still pass along the

n trunk. The spinal fibres derived from the second and third deal nerves in part ascend in the ramus descendens hypoglossi,

. then pass off from it to be applied to the main trunk in its onward rse.

Summary.—1. Distribution. —The hypoglossal fibres of the nerve supply stvlo-glossus, hyo-glossus, genio-glossus, and intrinsic muscles of the tongue, spinal fibres supply both bellies of the omo-hyoid, the sterno-hyoid, sternoroid, thyfo-hyoid, and genio-hyoid muscles. The hypoglossal nerve also plies the dura mater near the anterior condylar canal. 2. Connections. —-It blishes connections with (1) the inferior ganglion of the vagus; (2) the superior deal ganglion of the sympathetic; (3) the first two cervical nerves; (4) the ryngeal plexus, through the lingual branch of the vagus; and (5) the lingual /e from the mandibular division of the trigeminal nerve.

The Sympathetic Trunk.

Cervical Portion.—-This portion of the sympathetic trunk extends m the base of the skull, at the carotid canal on the under surface the petrous part of the temporal bone, to the root of the neck, ere it enters the thorax, passing on the right side behind the subvian artery. It lies directly behind the carotid sheath, and in nt of the transverse processes of the cervical vertebrae, resting upon

longus capitis and longus cervicis muscles. The cord presents

ee ganglia—superior, middle, and inferior.

Superior Cervical Ganglion.—This ganglion is fusiform and more in an inch long. It represents four ganglia united into one, and 'responding to the first four cervical nerves. It is situated in front the transverse processes of the second and third cervical vertebrae, d lies upon the longus capitis, the vagus nerve being lateral to it. either end it tapers, being continued superiorly into its ascending inch, and inferiorly into the descending trunk.

Branches.—-These may be conveniently arranged into internal rotid, lateral, medial.

The internal carotid nerve enters the carotid canal in the petrous rt of the temporal bone in company with the internal carotid artery, d divides into two parts. The lateral branch lies upon the outer le of the artery, and its subdivisions form by their interlacement the

ernal carotid plexus. From this plexus several communicating

anches are given off. (1) The carotico-tympanic nerve enters the mpanic cavity, and joins the tympanic branch of the glosso-pharynal, to take part in the tympanic plexus. (2) I he deep petrosal rve joins the greater superficial petrosal from the ganglion of the cial nerve in the upper part of the foramen lacerum, to form the rve of the pterygoid canal, which passes through the latter to join e spheno-palatine ganglion. (3) A branch (or branches) passes to in the abducent nerve. (4) One or more branches pass to join the Lgeminal ganglion. The internal carotid plexus furnishes filaments the coats of the internal carotid artery, and it receives a branch 3 m the tympanic plexus.


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A MANUAL OF ANATOMY


The medial branch of the internal carotid nerve lies upon the ini side of the internal carotid artery, to which it furnishes twigs, and subdivisions form by their interlacement the medial part of the inter] carotid plexus (cavernous plexus). This plexus lies in contact with 1 internal carotid artery as it traverses the cavernous sinus. Its co municating branches pass to join the oculo-motor, trochlear, a ophthalmic nerves, and the ciliary ganglion. The last-named brar forms the sympathetic root of the ciliary ganglion, and enters the or through the superior orbital fissure. It is the source of the motor sup] of the dilator pupillse muscle. The medial part of the internal caro plexus furnishes filaments to the coats of the internal carotid artei and offsets which accompany the branches of that artery, around whi they are disposed as plexuses.

The lateral branches are communicating, and pass to (i) each the upper four cervical nerves; (2) the inferior ganglion of the gloss pharyngeal; (3) the superior ganglion of the vagus; and (4) the hyp glossal nerve.

The medial branches are laryngo-pharyngeal and cardiac. T laryngo-pharyngeal branches, two or three in number, unite with t pharyngeal branches of the glosso-pharyngeal and vagus to formt pharyngeal plexus (see p. 1329).

The cardiac branch arises by two roots from the lower part of t superior cervical ganglion, and descends behind the carotid sheath, lyii medial to the main sympathetic trunk. The nerve of the right si passes in front of or behind the first part of the subclavian artery, ai then along the innominate artery, to end in the deep cardiac plexr In its course down the neck it receives twigs from the external larynge nerve, and is joined by the superior cervical cardiac branch of t] vagus nerve. As it enters the thorax it receives a filament from tl recurrent laryngeal nerve. The nerve of the left side within the thon accompanies the left common carotid artery, and passes in front the arch of the aorta to end in the superficial cardiac plexus.

The anterior branches are vascular, and pass to the external carot artery, upon which and its branches they form delicate plexuses.

Middle Cervical Ganglion. —This ganglion is situated opposite tl sixth cervical vertebra, and usually lies in front of the inferior thyro: artery. It is the smallest of the three, and is connected by gn rami communicantes with the fifth and sixth cervical nerves, thi representing two fused ganglia. Its branches of distribution a] thyroid and cardiac. The thyroid branches accompany the intern thyroid artery to the thyroid gland, and communicate with the extern; and recurrent laryngeal nerves. The cardiac branch of each side enc in the deep cardiac plexus. The nerve of the right side passes eith( in front of or behind the first part of the right subclavian artery. J then descends in front of the trachea, and joins the right half of tt deep cardiac plexus. The nerve of the left side enters the thora between the left common carotid and left subclavian arteries, and joins the left half of the deep cardiac plexus.


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1335


Inferior Cervical Ganglion. —This ganglion is situated between the nsverse process of the seventh cervical vertebra and the neck of j first rib, where it lies behind the subclavian near the root of the rtebral artery. It is intermediate in size between the superior and ddle ganglia, and, like the middle, it probably represents two ganglia ited into one. It is frequently fused with the first thoracic ganglion, e connection between the middle and inferior cervical ganglia passes bind the subclavian artery, but sometimes a cord or cords in front the vessel form a loop around it, called the ansa subclavia (ansa mssenii). The inferior cervical ganglion is connected by grey ni communicantes with the seventh and eighth cervical nerves, and branches of distribution are vascular and cardiac. The vascular inches accompany the vertebral artery in the form of the vertebral •xus, which gives filaments to the vessel and offshoots along its rious branches. The plexus is continued along the basilar artery d its branches, and on to the posterior cerebral arteries. The rdiac branch on each side joins the deep cardiac plexus. The nerve the right side passes behind the first part of the right subclavian tery, and then in front of the trachea. It is connected with the rdiac branch of the middle cervical ganglion and recurrent laryngeal rves. The nerve of the left side in many cases joins the cardiac anch of the middle cervical ganglion, and so reaches the deep cardiac

iXUS.

Constitution of the Cervical Sympathetic Trunk.

The sympathetic trunk in the neck contains the following important groups of res: (1) dilator pupillae, (2) vaso-constrictor and vaso-dilator, (3) secretory, d (4) accelerator.

The dilator pupillae fibres are derived from the upper three thoracic nerves , d ascend in the sympathetic trunk to the superior cervical ganglion, in which 3y end. From this ganglion they are continued as sympathetic fibres to 2 medial part of the internal carotid plexus, through this plexus to the ciliary nglion, and thence to the dilator pupillae muscle.

The vaso-constrictor fibres are derived from a variable number of thoracic rves, beginning at the second and ending at the eighth, ihe origin of the SO-dilator fibres is not definitely known. The vaso-constrictor fibres ascend the superior cervical ganglion, in which they end. hrom this ganglion they 2 continued as sympathetic fibres into the plexus around the external carotid tery, and thence along the branches of that vessel.

The secretory fibres are destined for the submandibular gland, and are derived iefly from the second and third thoracic nerves. They also ascend to the perior cervical ganglion, in which they end. They are thence continued as mpathetic fibres into the external carotid plexus, from that into the facial 2xus, and thence into the submandibular ganglion, from which the} r pass into e submandibular and sublingual glands. .

The accelerator fibres of the heart are chiefly derived from the second and ird thoracic nerves, but some also spring from the first, fouith, and fifth nerves, le spinal fibres pass to the middle and lower cervical ganglia, from each of which ey are continued as sympathetic fibres.

The Mouth Cavity.

The cavity of the mouth extends from the oral fissure in front, here it opens externally on the face, to the oropharyngeal isthmus hind, where it opens into the pharynx. It is divided by the upper


A MANUAL OF ANATOMY


1336

and lower alveolar arches into two compartments, the anterior of wh: is called the vestibule and the posterior the mouth cavity proper.

The vestibule of the mouth is bounded anteriorly and externa by the lips and cheeks, and internally by the alveolar arches and gur Superiorly and inferiorly it is bounded by the reflection of the mucc membrane from the lips and cheeks on to the gums. In the medi line, above and below, the mucous membrane forms a small vertical f( called the frenulum. On the inner surface of each cheek the vestibu mucous membrane presents a small papilla opposite the second upj molar tooth, and on this is the minute opening of the parotid duct.

The mouth cavity proper lies within the alveolar arches. It co municates with the vestibule by the interval between the upper a lower teeth, and also by an opening at either side situated behind t last molar tooth. Anteriorly and externally it is bounded by t alveolar arches and gums, and posteriorly it opens into the phary by means of the oropharyngeal isthmus. The roof, which is arched, formed by the hard palate and the soft palate. The floor is form by the tongue, and the reflection of mucous membrane from the inr surface of the lower alveolar arch on to its under surface. In t region of the tip of the tongue the lateral reflections of mucous me] brane from the two sides of the lower alveolar arch are continuo across the median line. In the median line the mucous membra forms a prominent fold, called the frenulum linguce, which is co nected above with the under surface of the tongue a little distan from the tip. In some children it may extend quite to the tip, impa ing the utility of the organ, and giving rise to the condition known 'tongue-tied/ Close to each side of the frenulum there is a sm; papilla, on which is the opening of the submandibular duct. A litl posterior to this is a fold of the mucous membrane at either sic produced by the upper border of the subjacent sublingual glan This fold is known as the plica sublingualis, and it extends from t side of the tongue to the alveolar arch. It is upon this plica that tl majority of the sublingual ducts open.

The lips are covered by skin externally, and mucous membra] internally. Between these two layers are the muscular fibres of ti orbicularis oris, blended with which are the fibres of the buccinatc and in the case of the upper lip fibres of the depressor anguli or: whilst in the case of the lower lip there are the fibres of the levat anguli oris. Between the mucous membrane and the muscul element there are a number of small racemose glands, called the labi glands, the ducts of which open on the inner surface of each lip. Tl tortuous labial arteries are embedded in each lip, and those of opposi sides anastomose at the median line.

Between the upper lip and the columna nasi there is a groov called the philtrum.

The lymphatic vessels of the upper lip pass on either side to tl submandibular, to the submental, or to the superficial parotid lymp glands. The lymphatic vessels of the lateral portion of the lower 1


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1337


50 pass on either side to the submandibular lymph glands, and ose of the medial portion pass to the submental lymph glands of the »rresponding side.

The cheeks are covered externally by skin, and internally are lined ith mucous membrane. The muscular element consists of the lccinator, which is covered by the buccal fascia. Posteriorly this scia is continuous with the pharyngeal fascia, which is derived from Le deep cervical fascia, the two being known as the bucco-pharyngeal scia. Superiorly and interiorly it is attached to the alveolar arches. The lymphatic vessels of the cheek pass to the superficial parotid lymph glands and the submandibular glands, the buccal lymph ands being a gland-station in the path of the latter.


Greater Palatine Artery


Palato-pharyngeus.^ $


Palato-glossus.


Posterior Wall of Pharynx^


Palatal RapW

.Uvula

Palato-pharyngeal Arch

^ '

Palatoglossal Arch ...Tonsil


. Dorsum of Tongue


u/ih " }i < <<(//{” ^\\v

jpUlin111.11


Fig. 804. —The Cavity of the Mouth and Oropharyngeal Isthmus.

The jaws are widely separated.


The suctorial pad of fat is situated upon the buccal fascia, and is ell developed in young children. It is continuous with the fat in le pterygoid region.

The buccal fascia, buccinator, and lining mucous membrane are ierced by the parotid duct. Between the buccinator and the mucous lembrane there are several racemose buccal glands. In addition to lese there are three or four molar glands, mucous in character, which re situated superficial to the buccal fascia in the angle between the lasseter and buccinator.

The masseteric fascia is an upward prolongation of the deep cervical iscia. It is attached superiorly to the zygoma, and externally is ontinuous with the parotid fascia.

The alveolar arches are formed by the alveolar borders of the laxillae and mandible, the teeth, and the gums.





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A MANUAL OF ANATOMY


The gums (gingivae) consist of dense fibrous tissue, which is covere by mucous membrane and is closely connected with the periosteum c the alveolar borders of the mandible and maxillae. The mucor membrane, which is very vascular, is continuous with the labial an buccal mucous membrane on the one hand, and with that of the floe of the mouth on the other. Close to the necks of the teeth it is bese with vascular papillae.

The lymphatic vessels of the upper gum pass on either side t the submandibular lymph glands. The lymphatic vessels of th lateral portion of the lower gum also pass on either side to the sut mandibular lymph glands; and those of the medial portion pass to th submental lymph glands of the corresponding side.

The mucous membrane of the gums is separated from the subjacen periosteum by dense connective tissue, which connects the two i: such a close manner that the mucous membrane is immovable. Clos to the necks of the teeth it is beset with papillae. The mucous mem brane of the hard palate, like that of the gums, is separated from th periosteum by a thick layer of dense connective tissue, which bind the two so closely that the mucous membrane is immovable. Ther is a median raphe, which is continued over the soft palate, and end in front at the incisive fossa in a small papillary elevation, known a the incisor papilla. On either side of the raphe anteriorly there ar a few transverse rugae. Each lateral half of the hard palate is traverse( by the ramifications of the greater palatine artery, the branches o which extend forwards and inwards from either lateral angle posteriorly The mucous membrane of the hard palate is provided with racemose palatal glands of a serous character, which are arranged in tw( symmetrical groups laterally disposed.

Occasionally a hard swelling, lying antero-posteriorly in the mid line of the hard palate, is seen, and must not be mistaken for a bom tumour or exostosis. It is known as the torus palatinus.

The lymphatic vessels of the mucous membrane of the hard palah pass to (i) the deep facial lymph glands, and (2) the superior deej cervical lymph glands.

Nerves. — The greater palatine nerve descends in the greatei palatine canal, which it leaves through the greater palatine foramen Then it divides into branches which pass forwards in groove! on the hard palate, and supply the mucous membrane, glands and inner aspect of the upper gum. The long spheno-palatine is distributed to the mucous membrane behind the incisor teeth, when it communicates with twigs of the greater palatine nerve. To react the hard palate the nerve of the right side passes through the posterior incisive foramen, whilst the left nerve passes through the anterio / foramen. The mucous membrane of the cheek is supplied by the buccal nerve, which is a branch of the mandibular division of the trigeminal nerve. The mucous membrane of the floor of the mouth derives its nerves from the submandibular ganglion.

Arteries.—These are the right and left greater palatine branches of


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1339


e third part of the maxillary. Each greater palatine artery takes ie same course as, and has a similar distribution to, the greater palatine

rve. At the incisive fossa it terminates in a small branch which

cends through the lateral incisive canal, and anastomoses at the }per end of that canal with the posterior septal branch of the sphenoilatine artery.

Development of the Mouth, Lips, and Gums (pp. 70 & 85).

In the early stages of formation of the embryo, a transversely directed ink or furrow exists between the overhanging fore-brain and the prominent ricardium. This is known as the oral fossa or stomodaeum, and is frequently


Fig. 805.— Embryos of 10 Mm., 12 Mm., and 13*5 Mm.

ne first gives the facial aspect, the mandible being in situ, dhe maxillary process has not vet come against the fronto-nasal process. The 12 mm. specimen, seen from below after the mandible has been removed, shows the maxillary process meeting the fronto-nasal. The 13 ’5 mm. specimen, seen from below and somewhat from behind, shows the beginning of the extension of maxillary mesoderm over the fronto-nasal process. The primitive posterior naris can be seen in this embryo, in which the bucconasal plug has been destroyed, as a small point behind the maxillary extension and to the outer side of the globular or fronto-nasal process. Ihe corresponding point in the previous stage can be seen, but there is no apeiture. The early palate folds are recognizable. FN, fronto-nasal process; M, maxillary process, cut at its base; R, opening of Rathke s pouch, 11 , anterior margin of passage into tubo-tympanic recess.


erred to as an early stage in the developing mouth; it is, however, nearly, not altogether, replaced by forward growths from the wall of the pharynx, dosing between them the cavity of the adult mouth. ie stomodS6Um shut off from the pharynx by the bucco-pharyngeal membrane, formed by 3 meeting of the ectoderm lining the stomodaeum with the entoderm lining the arynx. The membrane is attached to the mandibular and maxillary pro

ses, is carried forward by these as they begin to grow, and is quickly broken

d lost.




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A MANUAL OF ANATOMY


The mandibular arch grows forward above the pericardium and male a new floor for the mouth. The maxillary processes grow forward on each sid


Fig. 806.— Plans showing Distribution of Maxillary Mesenchyme.

I. The early simple process reaches and just overlaps the hinder ends of tl nasal folds. Its outer and thicker part (Im, lateral mass, dotted) thii away internally, covering the paraxial mesoderm, and its inner part (s septal process, interrupted lines) comes against the inner fold; it do not reach the middle line, and Rathke’s pouch (R) is widely open.

II. The palate fold is a definite but blunt inner edge to the lateral mass, whi( has thickened greatly and is fusing in front with the inner nasal fol The septal process has reached the middle line in front and has spree over the neighbouring area of the fronto-nasal process. The opening is smaller, being compressed by deeper paraxial growth.

III. The extremity of the lateral part (having broken down the epithelial septu at their junction) has invaded the fronto-nasal region and is spreadii over it in front of the area covered by sp; this extension is going to for the alveolus and lip in this part. The septal process is coming into r lation with R, and reaches the middle line in front of this.

IV. Shows modifications in the lateral mass, which presents a labial edge (la and an alveolar eminence (alv) as well as a definite palate fold. Tl primitive posterior naris is represented as having extended to some degre showing that the septal process is forming the back part of the septu between the nares, thus explaining its name. The opening R, now on a point, has been caught between the process and its fellow, and has bee displaced slightly forwards, as indicated by the dotted line.

forming a side wall and lateral roof, and come up against the outer nasal fola cross these, and come into contact with the fronto-nasal process. Thus tl mouth has the mandibular arch and growing tongue as its floor, while its ro<



THE HEAD AND NECK


I 34 1

limited laterally by the deep maxillary processes, and in front by the frontosal process, with which the maxillary processes are joined.

Associated with the mouth are (i) the pouch of Rathke, (2) the tongue, the salivary glands, (4) the tonsils, and (5) the teeth.

The pouch of Rathke is a diverticulum of the roof of the ectodermic stomo:um, ventral to the bucco-pharyngeal membrane. Its development is given p. 87. It gives rise to the anterior lobe of the hypophysis cerebri, the posterior e of which is developed from a diverticulum of the floor of the third ventricle the cerebrum.

The development of the tongue, salivary glands, tonsils, and teeth will be md after the description of each of these organs.

Each early nasal cavity lies above and behind the fronto-nasal process, and opening into the mouth, very small, and closed at first by the bucco-nasal 'mbrane, is placed just above the junction of the maxillary with that process, te opening extends in an upward direction (see p. 85), and at the same time late folds make their appearance on the inner side of the maxillary processes >se to the outer edges of these openings. These folds are turned down and lie side the tongue, which occupies the cavity and is in contact with its roof, le folds run into the outer edges of the fronto-nasal process in front.


Globular Process


Maxillary Palatal Process Maxillary Process .


Oral Cavity


Palatal Part ot fronto-nasal Process t

i

Aperture of Olfactory Pit

Lens . Lye

Palatal Shelf

Pouch of Rathke


Fig. 807. —Roof of Mouth (Marshall, after His).

About the end of the ninth week—by which time the nasal openings have tended up to the highest level of the roof of the cavity—the palate folds me on to the dorsal surface of the tongue, as a result of this being carried below z fronto-nasal process by the growing mandible. They are now pressed against e ‘ edge ’ of the septum between the two openings, to which they adhere, us shutting off the lower parts of these openings from the mouth and making e hard palate. The folds meet behind the fronto-nasal process, which forms e incisive papilla. The incisive canals are in the angles between folds and ocess.

Lips (Labia Oris) and Gums (Gingivae).— Shortly after the fusion of the maxary and globular processes to form the maxilla, a groove appears along each

these processes on either side. The margins of this groove, which form irallel ridges, are external and internal relatively to the oral cavity. The ternal or labial ridge gives rise to the upper lip, the globular portion of the Ige representing the premaxillary part of the lip, and the maxillary portion rming the remainder. The internal or gingival ridge is the rudiment of the >per gum.

The philtrum is probably developed from the mesodermic investment of the lited globular processes.

A similar groove and similar ridges ( labial and gingival) appear along each andibular arch, and from the ridges the lower lip and lower gum are developed.




I 34 2 ‘


A MANUAL OF ANATOMY


The angles of the mouth correspond to the union between the two lips o: either side, and each originally represents the angle between a mandibular arc and maxillary process.


The Tongue.

The tongue is a muscular and very sensitive organ, covered tr the buccal mucous membrane, and situated on the floor of the mouth It is concerned in the sense of taste, mastication, deglutition, am speech, and it consists of a root or base, a body, and a tip. The roo is attached to the hyoid bone. The tip is the anterior free extremity


EpiglottisGlosso-epiglottis Fold


Foramen Caecum _javWw//| ijllbtes Lymphoid Tissue


Median RaplA


Palatopharyngeal Arch

AvTi *

Palatoglossal Arch

i vi/jI

/ Tonsil


^ Vallate Papillas


-Fungiform Papillae


Fig. 808.—The Dorsum of the Tongue.


which, in the quiescent state, lies behind the upper incisor teeth. The body has an upper surface or dorsum, an under surface, and two lateral borders, right and left. The dorsum is convex from before backwards, and on its anterior twoThirds is a median depression oi rap>he, on either side of which the surface is convex from side to side. This ends posteriorly in the foramen ccscum. In this region the dorsum has a V-shaped groove, known as the sulcus terminalis. The joint ol the V is at the foramen caecum, and the two limbs pass outwards and forwards to the sides of the tongue, where the palato-glossal arches are connected with it. The sulcus terminalis marks the union of the










THE HEAD AND NECK


1343


0 parts from which the tongue is developed. The part behind it, presenting one-third, is the basal, lymphoid, or pharyngeal portion, occupies the buccal part of the pharynx, and overhangs the epi)ttis. The portion in front of the sulcus terminalis, representing twoirds, is known as the buccal or papillary portion.

Mucous Membrane.—The mucous membrane covering the basal pharyngeal portion of the tongue is destitute of proper papillae, but freely provided with lymphoid follicles like those of the tonsils, d with mucous glands. The follicles are ranged upon the walls crypts, the mouths of which open upon the surface. The mucous embrane in this region forms the glosso-epiglottic fold, which is sdially placed. On either side of this fold, between it and each


Plica fimbriata


Frenulum


Plica sublingualis


Fig. 809. —Under Surface of Tongue, with Sublingual Region.


laryngo-epiglottic fold, there is a pouch or depression, called the llecula. In front of the sulcus terminalis the mucous membrane the dorsum, borders, and tip of the tongue is freely covered by laracteristic papillae, which, being visible to the naked eye, impart this part its distinctive appearance. These papillae bear secondary ipillae, which, however, are concealed by the epithelial covering. ie mucous membrane on the under surface of the tongue in the median ie forms near the tip a vertical fold, called the frenulum linguce. little lateral to the frenum on either side is an indistinct fringed Id, called the plica fimbriata. The two plicae converge as they pass rwards towards the tip, and inside each the outline of the vena mitans hypoglossi may be visible. They represent the under tongue sublingua of lemurs and marmoset monkeys. On either side of




j 344


A MANUAL OF ANATOMY


Epithelial

Covering


the tongue, in the region of the limbs of the sulcus terminalis, the mucous membrane presents a few ridges which represent the papilla foliata of such animals as the rabbit.

Papillae.—These are of four kinds—filiform, fungiform, circum vallate,and foliate—and they are confined to the anterior two-thirds of the organ. The filiform papillae are the most numerous, and are arranged in more or less parallel, closely-set rows, directed forwards

and outwards from the median line except towards the tip, where the rows tend to become transverse. Or the sides of the tongue they are arranged in vertical parallel rows.

The fungiform papillae are scattered amongst the filiform, and are most numerous at the sides and tip being rather sparse over the dorsum. Each is round and enlarged at the surface, but tapers at its deep end like a button mushroom, and it bears secondary papillae, but there is no thread-like processes on the epithelial caps.

The vallate papillae are conspicuous, and vary in number from seven to thirteen. They are arranged in two diverging rows which lie anterior to, and parallel with, the limbs ol the sulcus terminalis. The two rows converge backwards and inwards, and so form a capital V. In the median


- Papilla


Fig. 8io.—The Filiform Papillae of the Tongue.


line, at the point of the V, there is a single vallate papilla, behind which is the foramen caecum. The free surface of each papilla is broad and flat, and bears secondary papillae, whilst the deep end is somewhat constricted, and is received into a circular pit of the mucosa. In this manner each papilla is surrounded by a space known as the trench. The outer wall of the trench projects slightly beyond the level of the free surface of the papilla, thus forming a circular elevation around it, called the vallum (rampart). It is from this circumstance that the papillae have received the name ‘ vallate/ Their sides, as well as the wall of the vallum, contain the taste-buds.

The tongue contains a number of acinous glands. Some of them open into the trenches around the vallate papillae, where taste-buds are present, and are serous in character (Ebners glands). Others open into the foramen caecum, into the crypts on the posterior third of the dorsum, and along the sides of the organ, these being mucous in character (Weber’s glands). Beneath the apex of the tongue, on either side of the median line, there is a small group of glands, partly






















THE HEAD AND NECK


1345


ous and partly mucous. These two groups are known as the

erior lingual glands (glands of Blandin or of Nuhn).


Fig. 811.—Extrinsic Muscles of Tongue.


The muscular tissue of the tongue is of the striped variety. It ms two sets of muscles—namely, extrinsic and intrinsic. The


Taste-bud


B


Fig. 812.—Vertical Section of a Vallate Papilla of the Tongue.

A, vallate papilla, beset with secondary papillae; B, taste-bud,

C, gustatory cell.

trinsic muscles are those which have their origins outside the tongue, id their insertions into it. They are: (1) the genio-glossus, (2) the














A MANUAL OF ANATOMY


1346


hyo-glossus (including the chondro-glossus), (3) the stylo-glossus, ai (4) the palato-glossus, all of which have been already described. T intrinsic muscles are those which are contained entirely within t tongue, and are: (1) the longitudinalis superior, (2) the longitudina inferior, (3) the transverse linguae, and (4) the verticalis linguae.

The longitudinalis linguae superior is an expanded sheet placed < the dorsum immediately beneath the mucous membrane. Its fibi are disposed longitudinally, and the muscle extends from the t backwards to the body of the hyoid bone. Posteriorly it is ovf

lapped by fibres of the hyo-glossi


Fig. 813. —Longitudinal Section of the Tongue of a Cat (injected).


1. Muscosa M

2. Longitudinal Superior

3. Transversus et Verticalis Linguae

4. Longitudinalis Inferior


Its fibres do not extend over t. whole length of the tongue, b take attachment at short intervc to the mucous membrane.

The longitudinalis linguae inf eri is disposed as a round bundle ( the inferior surface of the tongu Posteriorly it lies between the i sertions of the genio-glossus mec ally and the hyo-glossus laterall and anteriorly fuses with the styl glossus laterally. The muscle e: tends from the tip of the tongi to the body of the hyoid bone, wil which it is connected.

The transversus linguae const tutes a layer of considerable thicl ness which is placed between tl longitudinales superior et inferio It arises from the median septun and extends outwards, the upp< fibres curving upwards, to be ii serted into the mucous membrar of the side of the tongue an adjacent portion of the dorsun This muscular stratum is intei spersed with fat, and is muc


broken up by fibres of the verticalis linguae and genio-hyo-glossus.

The verticalis linguae extends from the mucosa of the dorsum that of the inferior surface. Its fibres describe curves, having tl convexities directed inwards, and they decussate freely with tl fibres of the transversus linguae.

Septum Linguae.—The septum of the tongue is a fibrous partitic which extends in the median line from the tip of the organ to tl body of the hyoid bone. It divides the tongue into two symmetric halves, and the transversus linguae muscle arises from it on eitb side.

Arteries.—( 1 ) The arteria profunda linguae (ranine artery), which :




















































THE HEAD AND NECK


1347


  • anch of the lingual, and is situated on the inferior surface immediy lateral to the line of insertion of the genio-glossus muscle. It

stomoses with its fellow beneath the tip, but elsewhere there is no stomosis across the septum linguae. (2) The dorsalis linguae, ally several branches. (3) The tonsillar branch of the cervical ion of the facial artery. (4) Pharyngeal branches of the ascending ryngeal artery.

The veins pass to the internal jugular vein.

Lymphatics.—The lymphatic vessels of the tongue are disposed in ' groups —apical, marginal, basal, and central.

The apical lymphatics pass to the submental lymph glands of the Le side, and to one of the medial chain of deep cervical lymph glands a. level with the cricoid cartilage of the larynx.

The marginal lymphatics carry lymph from the anterior twods of the lateral border and marginal part of the dorsum. The trior lymphatics of this set turn round the mylo-hyoid muscle,

. end in the anterior submandibular lymph glands. The posterior s to the superior deep cervical lymph glands, and more particularly one lying deep to the angle of the mandible. The small lingual ids, which lie upon the outer surface of the hyo-glossus muscle, je as gland-stations in their path.

The basal lymphatics return lymph from the posterior third of the gue, and end in the same way as the posterior marginal lymphatics t stated.

The central lymphatics return lymph from the median part of the gue, and pass to the deep cervical lymph glands, which extend from posterior belly of the digastric muscle to the level of the cricoid tilage of the larynx.

Nerves.—The sensory nerves are: (1) the lingual branch of the vidibular nerve , which is distributed to the mucous membrane over anterior two-thirds of the tongue, including the filiform and fungin papillce, upon which it confers common sensibility; (2) the rda tympani nerve, which accompanies the lingual nerve to the erior two-thirds of the tongue, of which it is usually regarded as nerve of taste; (3) the lingual branch of the glosso-pharyngeal ve, which is distributed to the mucous membrane of the posterior d and to the vallate papillce , of which it is the nerve of taste; (4) the irnal branch of the superior laryngeal nerve, which furnishes a few gs to the mucous membrane of the root of the tongue in the region the epiglottis; and (5) the hypoglossal nerve, which supplies the pial muscles.

Sympathetic filaments are also conducted to the tongue by the

  • ious arteries.

Taste-buds.—These gustatory organs are modified epithelial cells, 1 are present in the following situations: (1) The sides of the vallate fillae and the opposed surface of each vallum; (2) the sides of the

erior two-thirds of the tongue, partly in connection with the fungim papillae, and partly embedded in the stratified epithelium; (3) the



1348


A MANUAL OF ANATOMY


folds which form the papilla foliatce ; (4) the buccal surface of the s palate; and (5) the posterior surface of the epiglottis.

Each taste-bud is a flask-shaped body. The base rests upon 1 corium of the mucosa, and gives passage to nerve-fibres. The a] or narrow end lies between the surface-cells of the epithelium, a it is perforated by a minute opening called the gustatory pore , thror which the peripheral processes of the gustatory cells in the inter of the bud project as gustatory hairs.

Structure.—The wall of a taste-bud is composed of flatten* nucleated, epithelial walls, called the supporting cells. These cc are elongated in the direction of the bud, they taper at either ei and their margins are closely applied to each other. The interior the bud consists of . a bundle of gustatory cells. Each gustatory c is nucleated and spindle-shaped. The body of the cell is prolong at either end into a process, peripheral and central respectively. T peripheral process passes to the gustatory pore at the apex of the bi


Fig. 814.—The Visceral Arches of the Embryo (Posterior View) (Hi

I. Mandibular Arch III. Thyrohyoid Arch

II. Hyoid Arch IV. Fourth Arch


through which it projects as a gustatory hair. The central proce passes towards the base of the bud, which rests upon the corium 1 the mucosa. It is usually branched, and ends in free extremitie It does not therefore become continuous with nerve-fibres, and therei it differs from the corresponding process of an olfactory cell.

It has been seen that the base of each taste-bud gives passage i nerve-fibres. These, as they enter the bud, lose their medullar sheaths, and their axons end within the bud in arborizations aroun the constituent gustatory cells. Nerve-fibrils also enter the ep thelial wall of the bud, and ramify between the supporting cells.

Development. —The tongue is developed in the floor of the pharynx in tw parts—buccal and pharyngeal—which are separated from each other by th foramen caecum and V-shaped sulcus terminalis (see p. 72)."

The buccal or papillary part, which represents the anterior two-thirds, : developed from the tuberculum impar of the first or mandibular visceral arcl This eminence may give rise to the portion of the buccal part directly in fror of the foramen caecum.











THE HEAD AND NECK


  • 349


I'his, which appears very early, is a small rounded and well-defined swelling he middle line of the pharyngeal floor; it is in the line of the first pharyngeal )ve, but appears to belong really to the mandibular arch. It enlarges slowly


g 8is) but clearly as a separate formation, into which extend, fiom below 1 behind, the paired anterior ends of the ventral down-growths from post? (occipital) myotomes; with these the hypoglossal nerves and lingual vessels

ch the tongue.





  • 350


A MANUAL OF ANATOMY


This account is in keeping with the observations made on embryo material of all the stages involved. The usual description, that paf swellings on the mandibular arch envelop and in this way obliter; the tubercle as a separate structure, appears to have little support in f; (Fig. 815).

The pharyngeal or basal part of the tongue, the portion lying behind 1 foramen caecum and sulcus terminalis, is made from forward extension of 1 anterior end of the hypobranchial eminence coming against the back of the grc ing tuberculum impar and extending behind it and postero-laterally. 1 actual mass which comes forward in this way is probably a third arch derivati the mesoderm of this arch extending into and covering the anterior end of 1 hypobranchial eminence; the second arch, which at one time seems to rea the eminence also, is overpowered by the third arch growth, which covers it a comes forward above it. This is a part of the general movement in the pharyngi floor in which the second arch drops completely out of the floor, except in t tympanum, the third arch passing forward over it and coming against the fi: arch in front of it. In the middle, the third arch masses apply themselves the back of the tuberculum impar, and in doing so enclose temporarily a sm entoderm-lined space which opens by a relatively wide aperture, the futr foramen ccecum. This space would have the thyroglossal duct inserted into floor, if the duct had not separated (apparently) from it long before. The spa gradually fills up, as a rule, and the ‘ opening ' becomes the definitive foram caecum. Thus the foramen caecum is not the actual impression of the thyrc outgrowth, but, owing to the way in which it comes into existence, it is behind t tuberculum impar, and thus marks on the surface the spot from which—b at a deeper level—the thyroid growth took place.


The Soft Palate.

The soft palate is a movable musculo-aponeurotic curtain situah at the back part of the hard palate, where it projects downwards ar backwards into the pharynx. Anteriorly it is attached to the posters border of the hard palate, laterally it is connected with the side < the tongue and the wall of the pharynx, and postero-inferiorly it h; a free border. Its surfaces, which occupy an oblique plane, a; antero-inferior or buccal, which is concave, and postero-superior ( pharyngeal, which is convex and looks towards the naso-pharyn: The postero-inferior border at its centre has a conical proces called the uvula. On either side of the base of the uvula the] are two prominent folds of mucous membrane, which extend ou wards and downwards in a diverging manner. These constitul the palato-glossal and palato-pharyngeal arches (anterior and posteric pillars of the fauces). Each palato-pharyngeal arch belongs to tt postero-inferior border of the soft palate, and it sweeps outward downwards, and backwards to the lateral wall of the pharynx. 1 is due to the palato-pharyngeus muscle. Each palato-glossal arc belongs to the buccal surface of the soft palate, and it sweeps ou wards, downwards, and forwards to the back part of the side of tt tongue. It is produced by the palato-glossus muscle. Between th diverging palato-glossal and palato-pharyngeal arches on either sid there is a triangular interval, which is occupied by the tonsil. Tt passage which leads from the buccal cavity into the pharynx is calle the oropharyngeal isthmus (isthmus of the fauces). It is somewha


THE HEAD AND NECK


I35i


istricted, and is bounded above by the soft palate, below by the

k part of the dorsum of the tongue, and on either side by the

[ato-glossal arch.

Structure. —The soft palate is composed of a double fold of mucous imbrane, which contains between its two layers an aponeurosis, iscles, and many racemose glands, with bloodvessels and nerves, e mucous membrane on the buccal surface has a median raphe, iich is continuous with that on the mucous membrane of the hard late, and along which the originally separate halves of the soft late unite. On the buccal surface and along the postero-inferior rder it is covered by stratified squamous epithelium, but on the aryngeal surface by ciliated columnar epithelium. The glands.



Greater Palatine Artery


Palate pharyngeus __


Pnlato-glossus


Posterior Wall of Pharynx


Palatal Raph6


- Uvula

Palato-pharnygeal Arch —-Palato-glossal Arch

— Tonsil


Dorsum of Tongue


biG. 816 .—The Cavity of the Mouth and Oropharyngeal Isthmus.

The jaws are widely separated.


hich are racemose or acinous, are especially abundant on the buccal irface beneath the mucous membrane, where they are closely packed igether. The palatine aponeurosis is attached anteriorly to the Dsterior border of the hard palate, and laterally it becomes continuis with the aponeurosis of the pharynx. It affords attachment to artions of the palatal muscles.

Muscles.— These are arranged in pairs, and are palato-glossus, alato-pharyngeus, musculus uvulae, levator palati, and tensor palati.

Palato-glossus— Origin .—The surface of the palatine aponeurosis, is fibres being continuous across the middle line with those of the pposite muscle.

[ Insertion —The back part of the side of the tongue, where its bres blend with the fibres of the transversus linguas.






1352


A MANUAL OF ANATOMY


Nerve-supply. —The pharyngeal plexus.

The direction of the muscle is outwards, downwards, and forward Action. —(i) To depress the side of the soft palate, and (2) draw the tongue upwards and backwards. The two muscles al‘ approximate the palato-glossal arches. By means of these combine actions, aided by the tongue, the oropharyngeal isthmus is close< and the anterior part of the buccal cavity is shut off from the pharyn at the beginning of the second stage of deglutition.

The muscle forms the lowest layer in tt soft palate, and it gives rise to the mucoi fold, called the palato-glossal arch.

Palato - pharyngeus — Origin. — By tw layers, upper and lower. The posterior (uppei small layer arises from the palatine aponei rosis of the back of the soft palate abov the musculus uvulae, its fibres decussatin with those of the opposite side; and th anterior (lower) large layer arises from th posterior margin of the hard palate, as we as from the palatine aponeurosis, decussatin with its fellow of the opposite side.

Insertion. —(1) The superior and posterio borders of the lamina of the thyroid cartilage and (2) the lateral and posterior wall of th pharynx, its fibres blending with those 0 the stylo-pharyngeus.

The muscle receives an accessory sli] from the lower part of the cartilage of th pharyngo-tympanic tube, which is known a: the salpingo-pharyngeus muscle.

Nerve-supply .—The pharyngeal plexus. The muscle is directed downwards anc backwards.

Action. —(1) To approximate the palatopharyngeal arch to its fellow at the commencement of the second act of deglutition, and (2) to elevate the pharynx.

The muscle gives rise to the mucous fold called the palato-pharyngeal arch.

Musculus Uvulae (Azygos Uvulae)— Origin. — The side of the posterior nasal spine and the adjacent palatine aponeurosis.

Insertion. —The submucous tissue of the uvula, having previously united with its fellow of the opposite side.

Nerve-supply. —The pharyngeal plexus. The direction of the muscle is backwards and downwards.

Action. —To elevate and shorten the uvula.

The muscle is double at its origin, but single at its insertion. It


Fig. 817.—Scheme to show Planes in Composition of Pharyngeal Wall, with Relation of Muscles to Mucous Membrane (Dotted Line).

SUP., MID., INF., upper, middle, and lower constrictors. Sinus of Morgagni is the interval between upper constrictor and skull base; the tube is seen coming through this.




THE HEAD AND NECK


1353


s above the levator palati, and beneath the upper layer of the lato-pharyngeus.

Levator Palati— Origin. —(1) The rough surface on the inferior pect of the petrous part of the temporal bone between the apex d the carotid canal, and (2) the lower and posterior part of the rtilage of the pharyngo-tympanic tube.

Insertion. —The aponeurosis of the soft palate, its posterior fibres coming continuous across the middle line with the corresponding res of the opposite muscle.


Tubal Elevation


Posterior Border of the Vomer

Right Posterior Nasal Aperture Levator Palati




Salpingopharyngeus

Musculus Uvulae

Palato pharyngeus


Tensor Palati


-Medial Pterygoid Uvula

l- Root of Tongue


-- Epiglottis Wall of Pharynx

- Piriform Fossa

Arytenoideus Obliquus

- Arytenoideus Transversus


— Crico-arytenoideus Posterior


(Esophagus


Fig. 818. —The Pharynx opened from Behind.


Nerve-supply. —The pharyngeal plexus.

The muscle is directed downwards, forwards, and inwards.

Action. —To raise the soft palate, and probably to open the pharyngonpanic tube.

The muscle, which is round and fleshy, passes over the upper rder of the superior constrictor and through the pharyngeal apon:osis. At its origin it is closely related to* the membranous portion the pharyngo-tympanic tube.

Tensor Palati— Origin. —The scaphoid fossa at the root of the dial pterygoid plate of the sphenoid; and the ridge running back far as the spine; and the lateral lamina of the cartilage of the iryngo-tympanic tube.







1354


A MANUAL OF ANATOMY


Insertion. —(i) The transverse ridge on the under surface of th horizontal plate of the palatine bone near the posterior border; an (2) the aponeurosis of the soft palate.

Nerve-supply .—A branch from the nerve to the medial pterygoi muscle.

The muscle at first descends vertically as a flat fleshy band betwee the medial pterygoid plate and the medial pterygoid muscle, bein in close contact with the medial surface of the latter. As it approache the pterygoid hamulus it ends in a tendon, which turns round th process, a synovial bursa intervening, and then passes horizontal! inwards, expanding as it does so. From the fact that the muscle i bent around the pterygoid hamulus it has been called the circum flexus palati.

Action. —(1) To make tense the soft palate, and (2) to draw dowr wards and backwards the margins of the cartilage of the pharyngc tympanic tube, and so open the tube during deglutition. (See actio: of levator palati.)

Sensory Nerves. —These are the greater and lesser palatine nerve from the spheno-palatine ganglion, and the tonsillitic branches of th glosso-pharyngeal.

Arteries. —The soft palate is supplied by the following arteries (1) the ascending palatine of the cervical portion of the facial; (2) th palatine branch of the ascending pharyngeal; and (3) the lesse palatine branches of the greater palatine artery from the maxillary which descends in the greater and lesser palatine canals.

Relation of Structures in the Soft Palate. —Supposing the sof palate to be transfixed from its buccal to its pharyngeal surface, th following structures would be pierced: (1) the mucous membran covering the buccal surface, (2) the layer of closely-set racemos glands, (3) the palato-glossus, (4) tensor palati, (5) the lower laye of palato-pharyngeus, (6) the levator palati, (7) the musculus uvula (8) the upper layer of the palato-pharyngeus, and (9) the mucou membrane covering the pharyngeal surface.

Development. —The soft palate is developed from a differentiated portioi of the palatal shelf or plate of the maxillary process of either side. This different! ated portion does not undergo ossification, but acquires muscular tissue. Lik the hard palate, the soft palate and the uvula are developed in two symmetrica halves. The muscular tissue is derived from an upward growth from the wal of the pharynx invading the posterior part of the (maxillary) palate fold. Thi upgrowth makes the ‘posterior pillar of the fauces.’


The Tonsils.

The tonsils are two in number, right and left. Each is situatec in the triangular depression between the palato-glossal and palato pharyngeal arches on either side, and above it is a small recess, knowi as the intratonsillar cleft (supratonsillar fossa), which is the remain: of the inner portion of the second visceral cleft. The tonsil stands ou as an oval enlargement covered by mucous membrane, and it lie;


THE HEAD AND NECK


1355


posite the angle of the mandible, being under cover of it and the jacent portion of the ramus. The organ varies much in size, but an average it measures about 1 inch in length, about f inch from fore backwards, and about \ inch from within outwards. The 3dial surface is pitted with a number of orifices which lead into crypts the interior. The outer surface, which has a fibrous covering, is ated to the superior constrictor of the pharynx, some loose tissue tervening, and lateral to the superior constrictor is the medial erygoid muscle. Two of the tonsillar arteries, the tonsillar and sending palatine, lie between the superior constrictor and medial erygoid. The cervical portion of the facial artery in its course lies little below the outer aspect of the tonsil. The internal carotid tery is situated about 1 inch from it on its outer and posterior aspect. Arteries.—(1) The tonsillar and ascending palatine branches of e facial; (2) the ascending pharyngeal branch from the external rotid; (3) the dorsalis linguae branches from the lingual; (4) the


Fig. 819. —Section through a Crypt of the Tonsil.

iser palatine offsets of the greater palatine artery from the third rt of the maxillary; (5) tonsillar twigs from the internal carotid.

The veins form a plexus on the outer surface of the tonsil, from lich the blood passes into the pharyngeal plexus.

Lymphatics.—These pass to the superior deep cervical lymph mds.

Nerves.—The nerves are derived from (1) the glossopharyngeal, > the lesser palatine branches of the spheno-palatine ganglion, and ) the sympathetic.

Structure. —The tonsils are composed of lymphoid follicles. The follicles i ranged upon the sides of the crypts, which penetrate into the organ, these /pts being lined with mucous membrane covered by stratified squamous ithelium. Lymph corpuscles migrate from the follicles into the crypts, and

ome salivary corpuscles.

Development. —The tonsil of either side is developed from the epithelium the ventral part of the corresponding second visceral cleft. About the fourth 1 nth a depression, known as the sinus tonsillaris, makes its appearance. Solid




1356 A MANUAL OF ANATOMY

epithelial outgrowths or buds then extend from this sinus into the surroundinj mesoderm. These buds subsequently become hollow, the surface of the sinu becomes pitted, and so the crypts on the tonsil are formed. The mesoderm ii relation to the buds and crypts becomes pervaded with lymphoid cells, and ii this manner is formed the lymphoid tissue which constitutes the bulk of the tonsil The intratonsillar cleft indicates the position of the ventral angle of th< second lateral pouch.

The Nasal Cavity.

The nasal cavity extends from the anterior to the posterior aperture of the nose. Anteriorly it opens upon the face, and posteriorly int( the nasal part of the pharynx. The cavity is narrow above, bu


Fig. 820.—Sagittal Section through the Nasal Cavity, Mouth, Pharynx, (Esophagus, and Larynx.

The outer wall of the right nasal cavity is shown.


expanded below. It is divided into right and left halves by the nasal septum, and each half has two walls (outer and inner), a roof, and a floor. The lateral wall is rendered very irregular by three bony scrolls, disposed antero-posteriorly, which bulge into the fossa. These are the superior, middle, and inferior nasal conchae. They overhang deep channels, which are known as the meatus—superior, middle, and inferior respectively.

The superior meatus is confined to the back part of the outer wall,












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1357


id lies between tlie supeiior and middle conchae. It is short and clique, and opening into it there are the spheno-palatine foramen, hich leads from the pterygo-palatine fossa, and the posterior ethoidal sinus, by one or more openings. Above and behind the Lpenor concha is a depression, called the spheno-ethmoidal recess, to which the sphenoidal sinus opens.

The middle meatus is situated between the middle and inferior >nchae, is directed from behind forwards, and is overhung by the iddle concha. Anteriorly it describes a bend, and passes upwards ider coyer of the front part of the middle concha, to be continued to the infundibulum , which leads from the frontal sinus of the corre>onding side. The openings into the middle meatus are (1) the fundibulum, leading from the frontal sinus, with the opening of the iterior ethmoidal sinus * (2) the opening of the maxillary sinus;


Frontal Sinus


Orifice of Naso-lacrimal Duct


Vestibule


Fig. 821.—The Lateral Wall of the Right Nasal Cavity.

The superior and middle conchae and part of the inferior concha have

been removed.

id (3) one or two openings of the middle ethmoidal sinus. These irious openings are concealed by the middle concha. When this is moved a deep curved groove, called the hiatus semilunaris, is seen rected downwards and backwards from the lower end of the inndibulum. Behind and above this hiatus there is a round promince, called the bulla ethmoidalis (see Fig. 821). The opening of e anterior ethmoidal sinus is situated in the vertical portion of the atus semilunaris, and the opening of the maxillary sinus, which is small size, is placed in its horizontal portion, whilst the middle hmoidal sinus opens above the bulla ethmoidalis. In front of the iddle meatus is the region known as the atrium, which communicates teriorly with the vestibule, situated just within the ala of the nostril. The inferior meatus is situated below the inferior concha. Openl into its anterior part, under cover of the inferior concha, is the





A MANUAL OF ANATOMY


1358


lower orifice of the naso-lacrimal duct, which is provided with an im perfect mucous fold, called the lacrimal fold. The orifice is abou ij inches from the anterior nasal aperture. Quite often the superio nasal concha bifurcates posteriorly, and thus encloses a fourth o highest meatus.

The inner wall forms the nasal septum.

The roof, which is narrow, is horizontal in its central part, th anterior portion being sloped downwards and forwards, and th posterior portion downwards and backwards.


Sphenoidal Sinus


Perpendicular Plate of Ethmoid


Frontal Sinus


Nasal Bone


1 Septal Process of Lower Nasal Cartilage


Horizontal Plate of Palatine Bone (in section)


Septal Cartilage


Vomero-nasal Cartilage


Vomer


Palatine Process of Maxilla (in section)


Fig. 822.—The Osseous and Cartilaginous Nasal Septum (Right

Lateral View).


The floor is smooth, and at its anterior and inner part is the incisoi foramen, into which a funnel-shaped portion of the mucous membrane extends. This region represents the wide communication whicl existed in early life between the nasal and buccal cavities.

Each nasal cavity is divided into three regions—vestibular, olfactory, and respiratory. The vestibular region, or vestibule, form: the anterior and lower part near the nostril. It is covered by skin which is provided with hairs or vibrissce. The olfactory region i: situated superiorly, and corresponds to the superior concha and th<


/








THE HEAD AND NECK


1359


er third of the nasal septum. The respiratory region comprises middle and inferior conchae, the middle and inferior meatus, and corresponding part of the septum.

The Nasal Mucous Membrane. —With the exception of the vestibule, ch is lined with skin, the nasal cavity is provided with a highly sular and sensitive mucous membrane. It is continuous through the terior nasal apertures with the mucous membrane of the nasal part the pharynx; with that of the naso-lacrimal duct, lacrimal sac,

. lacrimal canaliculi, and thence with the conjunctiva; and with t of the various air-sinuses which communicate with the nasal ity. It is thick and spongy over the conchae, especially along the er borders of the middle and inferior conchae, and also on the nasal turn, but over the floor, atrium, and meatus it is comparatively


Fig. 823. _ The Nerves of the Nasal Septum (Hirschfeld and

Leveille).


n. It is freely provided with acinous glands, and contains a certain

ount of lymphoid tissue. •

The epithelium varies in different regions. In the vestibular ion, where the lining membrane is skin, it is of the stratified squamous 'iety; in the respiratory region, as well as in the air-sinuses, it is itified, columnar, ciliated epithelium; and in the olfactory region s non-ciliated columnar epithelium.

Olfactory Mucous Membrane. —In the olfactory region the mucous mbrane is thick and pulpy, and has a yellowish-brown colour, 3 to pigment in the epithelial cells. It contains a copious plexus olfactory nerve-fibres, and many serous glands, which are known the nasal glands (Bowman s glands). The epithelium is thick, and, as 5 been shown, is of the non-ciliated columnar variety, its free surface ng covered by a delicate limiting membrane. The cells of whic








1360


A MANUAL OF ANATOMY


it is composed are of three kinds: (1) Long columnar nucleated cel called the supporting cells, the deep end of each of which is prolong into a branched process. (2) Between these supporting cells the are the olfactory cells, which are elongated and spindle-shaped. Ea contains an almost spherical nucleus, and has a superficial and a de process or pole. The superficial pole extends through the limiti

membrance to the free surface, and pi jects slightly in the form of a tuft delicate hair - like filaments called t olfactory hairs. The deep pole , which a delicate varicose filament, exten towards the mucosa, where it becom continuous with one of the nerve-fibr of the olfactory plexus. (3) In the de part of the epithelium there are in sor places conical cells, the broad ends which rest upon the basement membra (see Fig. 824).

Olfactory Nerves. —These are from f teen to twenty in number on each sic After leaving the inferior surface of t olfactory bulb, they pass through t foramina in the corresponding half of t cribriform plate of the ethmoid bor and so reach the upper part of the nas cavity invested by prolongations of t membranes of the brain. Within t nasal cavity they are arranged in t\ groups, inner and outer. The nerves the inner group are distributed to the mucous membrane of the nas septum over about its upper third. The nerves of the outer group a distributed to the mucous membrane in the region of the superi concha and olfactory sulcus. The nerves form a copious plexus the mucous membrane, and the filaments which issue from this plex become continuous, as has been shown, with the deep poles of t olfactory cells. The olfactory nerves have no medullary sheath.

Nerves of Ordinary Sensation:

1. Upper nasal branches of the

spheno-palatine ganglion.

2. Nasal branches of the nerve of

the pterygoid canal.

3. Lower nasal branches of the

greater palatine nerve.

The upper nasal branches of the spheno-palatine ganglion enter the superi meatus through the spheno-palatine foramen, and are distributed to the muco membrane (1) over the superior and middle conchae, (2) over the upper ai back part of the nasal septum, and (3) within the posterior ethmoidal sinus.

Branches from the nerve of the pterygoid canal pierce the floor of that can; and are distributed to the mucous membrane over the back part of the roof the nasal cavity and the adjacent part of the septum.


4. Anterior ethmoidal nerve.

5. Branches of the anterior superi

dental nerve.

6. Long spheno-palatine nerve.

7. Infra-orbital nerve.



Olfactory _ Hairs ||


Peripheral

Process


Supporting

Cell


Olfactory li Cell ha


Nerve Fibre V. Process


Fig. 824.— Cells of Olfactory Mucous Membrane

(SCHULTZE, FROM QuAIN’S

‘ Anatomy ’)•












THE HEAD AND NECK


1361


Lower nasal branches arise from the greater palatine branch of the sphenolatine ganglion as that nerve traverses the greater palatine canal. They ter the nasal cavity through foramina in the perpendicular plate of the latine bone, and are distributed to the mucous membrane over the greater rt of the inferior concha, and the corresponding parts of the middle and ferior meatus.

The branches from the anterior ethmoidal nerve are two, septal and lateral, le septal branch is distributed to the mucous membrane over the anterior and >per part of the septum, and the lateral branch to that over the anterior irtions of the middle and inferior conchae, and over the outer wall in front these.

Upper nasal branches of the anterior superior dental nerve are distributed to e mucous membrane over the anterior part of the inferior meatus and the !jacent part of the floor of the nasal cavity.

The infra-orbital branch of the trigeminal supplies the vestibule.

Anterior Ethmoidal Arterv


Fig. 825. —The Arteries of the Nasal Septum (Hirschfeld and

Leveille).

It will be noticed that, with the exception of the anterior ethmoidal branch of te naso-ciliary, all the nerves of the nasal cavity are derived from the maxillary vision of the trigeminal nerve.

The long spheno-palatine nerve arises from the spheno-palatine ganglion, id enters the nasal cavity through the spheno-palatine foramen. It then osses the roof, and so reaches the septum, upon which it descends with a rward inclination, occupying the groove on the outer surface of the vomer.

then passes downwards to the anterior part of the hard palate, the left nerve aversing the anterior incisive canal, and the right nerve the posterior incisive nal. As the long spheno-palatine nerve lies upon the nasal septum it furnishes anches to its mucous membrane.

Arteries of the Nasal Cavity. —These are derived from the following sources:

1. The spheno-palatine. 4. The anterior ethmoidal.

2. The greater palatine. 5 - The posterior ethmoidal.

3. The artery of the pterygoid canal. 6. The superior labial.

The spheno-palatine artery is the principal artery of the nasal cavity. Arising am the third part of the maxillary, it enters the cavity through the sphenoilatine foramen. Most of its branches are distributed to the outer wall; but

86






1362


A MANUAL OF ANATOMY


one, called the posterior septal branch, accompanies the long spheno-palati nerve. This branch gives offsets to the septum, and enters the incisive forame where it anastomoses with a branch of the greater palatine artery, which ascen from the palate in the incisive canal.

The greater palatine artery arises from the third part of the maxillary. . it traverses the greater palatine canal it gives off two or three branches whi accompany the lower nasal branches of the greater palatine nerve throu, foramina in the perpendicular plate of the palate bone, to be distributed to t back part of the inferior concha and the adjacent parts of the middle and i ferior meatus.

The artery of the pterygoid canal, arising from the third part of the maxillai traverses the pterygoid canal, and furnishes a few twigs which accompany t branches of the corresponding nerve, and supply the back part of the roof the nasal cavity and the adjacent part of the septum.

The anterior and posterior ethmoidal arteries are branches of the ophthalm The anterior ethmoidal enters the nasal cavity along with the anterior ethmoid


Posterior Lateral Nasal Branches


Anterior EthmoiiJal


Posterior Ethmoidal

Posterior Septal Branch (cut) Spheno-palatine


Ascending Branch of Greater Palatine


Soft Palate


Fig. 826. —-The Arteries of the Lateral Wall of the Right Nasal Cavity, (after Hirschfeld and Leveille).

nerve, and furnishes branches to the anterior and upper part of the septur the front part of the outer wall, and the anterior portions of the middle ar inferior conchae. The posterior ethmoidal gives nasal branches which enter tl nasal cavity through some of the foramina in the cribriform plate of the ethmoii and are distributed to the roof and upper part of the septum.

The superior labial artery, a branch of the facial, gives off a septal branc, which supplies the anterior part of the septum and the columna nasi.

The veins form a free plexus, especially over the inferior concha and tl lower margin and back part of the middle concha. The vessels which can away the blood from the plexus correspond to the various arteries, and the principal destination is threefold—namely, (1) the pterygoid plexus, (2) th superior ophthalmic vein, and (3) the anterior facial vein. The ethmoidal vein which open into the superior ophthalmic vein, communicate with the intracrani; anterior meningeal veins and with the commencement of the anterior faci< vein by means of twigs which pass through minute apertures in the front* process of the maxilla, and, it may be, through a small foramen in the nas; bone. In those cases where the foramen caecum is pervious it transmits a









THE HEAD AND NECK 1363

issary vein which passes between the intracranial superior sagittal sinus 3 the veins of the roof of the nasal cavity.

The lymphatics of the atrium and vestibule pass to the submandibular lymph nds. The principal lymphatics pass to (1) the retropharyngeal glands; (2) the ip facial lymph glands; and (3) the superior deep cervical lymph glands, e lymphatics of the air-sinuses end in a similar manner.

The lymphatics of the nasal fossae communicate with lymphatic spaces ich are related to the olfactory nerve-filaments; and these lymphatic spaces turn communicate with the intracranial, subdural, and subarachnoid spaces.


Development of the Nose (pp. 83-88).


The cavity of the mouth in the embryo is separated from the lower surface the fore-brain and its derivatives by a layer of mesoderm which thickens titinuously. The nasal cavities are developed in this mesodermal layer, and as are not parts of the common mouth cavity', they open into this cavity by ertures which lengthen as the mesoderm thickens, and of which the greater rtions are secondarily closed by the palate folds, the unclosed parts forming e definite posterior nasal apertures.

The first indications of the olfactory organ are the two olfactory areas, ley consist of thickened ectoderm, and are placed on the ventral aspect of e anterior cerebral vesicle, on either side of the mesial nasal process of the mto-nasal process, and on the cephalic side of the orifice of the stomodaeum ig. 54).

Each olfactory area soon becomes depressed and forms the olfactory pit. le depression is due to the growth of mesoderm; on the inner and outer sides is forms inner and outer nasal folds respectively, continuous in front but open hind. The outer fold is the longer, and the maxillary process, growing inards across this, comes into contact with the inner fold, with which it fuses, bus the pit becomes a shallow fossa. Its posterior end is closed by the junction maxillary and inner nasal processes, and the epithelial fusion between these akes the hucco-nasal membrane, separating it from the mouth. The membrane oses what is, potentially, a primitive posterior naris ; it is stretched as this ■ows, and finally breaks and disappears. .

The subsequent development of the proportionately full-sized cavity from tis small beginning has been described on p. 85, etc., to which the reader is


ferred. . .

The lower conchal mass is present at an early stage, being made by the mmal projection of the lower edge of the outer nasal fold. It is added to by idition of maxillary mesoderm as the fossa increases in length backwards, le middle and upper nasal conchce become evident later as the cavity grows ey are present by the end of the second month. The upper mass is described derived from the upper part of the inner wall, migrating across the roof, ie ontogenetic evidence of this is very doubtful. The cartilaginous bases of ie masses are derived from the cartilaginous capsule. In foetal life there is marked tendency for the two upper masses to show longitudinal subdivisions, ving the appearance of the presence of half a dozen or more conchae, but the Dpearance is deceptive, as these are only surface formations, and are usua y

st by the time of birth. . , „ ,

The maxillary sinus can be recognized in the third month as a depression l the outer wall. It extends very slowly, so that at birth it only makes a ivity a few millimetres wide in the inner part of the maxilla.

A cartilaginous nasal capsule is built Up round the two cavities as t ey ctend up. It is deficient below, where the elongated aperture is placed, e s lateral plate has its lower edge turned in to make the cartilaginous asis o ie lower nasal concha. The other nasal conchae are based on ingrowths from s inner aspect. It presents the septal cartilage centrally, forme m e 1C lesoderm between the two cavities. The vomer develops as a paire ossi ca on in the mesoderm along the lower or free edge of the septal cartilage.


1364


A MANUAL OF ANATOMY


palatine bone ossifies on the deep surface of the capsule, and the maxilla structures superficially. The premaxilla and incisive part of the palate devel in the region of the primitive palate. The capsule is in contact with the bo of the sphenoid above and behind, and a wing-like process here, the orbi sphenoidal process, is related with the lesser wing.


Fig. 827.


The two upper figures show the lower aspects of the projecting heads of embry of 4 mm. and 7 mm. (From reconstruction models.) The change position of the olfactory region is due to the growth of the telencephah in the 7 mm. specimen. This not only advances the front of the he; beyond the site of the olfactory fields, but also, as a result of increase breadth, turns them more on to the lower aspect. A and B in the low figures are sections through the olfactory fields of the two embryos, showii formation of olfactory pits and fronto-nasal process. C and D are diagrar rnatic sections to illustrate the further changes. The maxillary process are indicated by interrupted lines to show where they will come into po: tion, as in D. ONF, INF, lateral and medial nasal folds; FNP, fronto-nas process.

The Paranasal Sinuses. —The frontal, ethmoidal, sphenoidal, and maxilla! sinuses are developed as evaginations of the nasal mucous membrane, whi( extend into spaces formed by absorption within the respective bones. The ma toid air-cells are developed as evaginations of the tympanic mucous membran which is continuous with the nasal mucous membrane through the pharyngt tympanic tube and nasal part of the pharynx.

Olfactory Organ. —The true olfactory organ is situated in the upper par or olfactory region, of each nasal cavity. The olfactory epithelium, which cove:




THE HEAD AND NECK 1365

ie mucous membrane of this region, is developed from the upper part of the orresponding olfactory pit.

External Nose. —The dorsum and tip of the nose, and the columna nasi, are eveloped from the portion of the mesial nasal process which lies between the lobular processes. The upper and lower nasal cartilages are derived from the irtilaginous core of the corresponding lateral nasal process. The anterior asal aperture of each side represents, as stated, the external orifice of the



Fig. 828. —Antero-posterior Sections of Heads of Embryos of

16 and 28 Mm.


corresponding olfactory pit, but it is modified by secondary extensions of maxillary mesoderm round its margins.

The Vomero-nasal Organ (Organ of Jacobson). —The vomero-nasal organ is rudimentary in man, but is well developed in reptiles.* It takes the form of a blind pouch, which is situated in the lower and anterior part of the nasal septum on either side. The minute orifice

  • There is some doubt as to whether the rudimentary structure of man is

really vestigial of that of the lower forms.



















1366


A MANUAL OF ANATOMY


of the pouch lies above the recess or depression of mucous membrane which projects slightly into the upper end of the incisive canal. Th pouch extends upwards and backwards in the nasal septum for a ver short distance, and ends in a blind extremity. The vomero-nas; (subvomerine) cartilage lies underneath it. The vomero-nasal orga does not seem to perform any function in man. In those animal: however, in which it is well developed it receives two nerves, one c which is olfactory, the other being derived from the spheno-palatiu ganglion. Moreover, its epithelial lining is similar to that of the o factory region of the nasal cavity, inasmuch as it contains olfactor cells, the deep poles of which are continuous with olfactory filaments In such animals it acts as a supplementary organ of smell.


Fig. 829.—View, from below and behind, of the Roof of the Mouth of an Embryo of 16 Mm. (Sixth Week).

Showing the palate folds reaching the fronto-nasal process, the evident shaj of this process, though covered by a layer of maxillary mesoderm, and tl growth of the labial extension of the mesoderm, only just meeting its fello in the middle line. This will become much thicker and vertically deepe hiding the fronto-nasal form altogether. The interrupted lines indicathe extension upward of the upper level of the posterior nasal apertures.

Development of the Vomero-nasal Organ. —This organ is developed as diverticulum of a portion of the ectoderm of the olfactory pit. The diverticulu: projects upwards and backwards into a recess situated laterally within tl lower and anterior part of the septal nasal cartilage just above the upper er of the incisive canal; it marks the meeting of the paraxial and visceral mesodern in the septum.

The Pharynx.

The pharynx is situated behind the posterior nasal apertures, tl oropharyngeal isthmus, and larynx, and it extends from the basik region of the base of the skull to the level of the lower border of tl cricoid cartilage of the larynx, where it becomes continuous with tl oesophagus. It is a musculo-aponeurotic tube about 5 inches lon| and it attains its greatest width between the base of the skull an



THE HEAD AND NECK


1367


e hyoid bone. Below the latter level it narrows, and is flattened )m before backwards, so as to assume the form of a transverse cleft, cept during the act of deglutition.

Relations. —Posteriorly it rests upon the bodies and discs of the rvical vertebrae as low as the sixth, and the prevertebral muscles vered by the prevertebral fascia. Between it and the last-named scia is the retropharyngeal space, which is occupied by connective ssue, but this is so loosely arranged that no obstacle is offered to Le movement of the tube, and a post-pharyngeal abscess can readily ffuse itself. Anteriorly it communicates with (1) the nasal cavities trough the posterior nasal apertures, (2) the pharyngo-tympanic


Sinus of Morgagni


Lateral Pterygoid Muscle Styloid Process


Superior Constrictor - .4 _ Muscle


Middle Constrictor Muscle


Inferior Constrictor Muscle


--Head of Mandible

-Spheno-mandibu lar Ligament

.Ramus of Mandible

_,Stylo-phar. Muse.

.Stylo-hyoid Lig.

f_Medial Pterygoid

Muscle

__.Greater Horn of

Hyoid Bone

-’Angle of Mandible

Ah--- .-Median Pharyngeal

Ms Raphe


Fig. 830.


Oesophagus


-The Posterior Wall of the Pharynx and Adjacent

Structures.


ubes, (3) the buccal cavity through the oropharyngeal isthmus, and 4) the larynx. On this aspect its attachments are effected by means )f the constrictor muscles in its walls. Laterally it is related to the irincipal bloodvessels and nerves of the neck, and comes into contact vith the styloid muscles and the process from which they arise. Superiorly it is attached to the basilar region of the base of the skull.

r nferiorly it is continuous with the oesophagus. .

The wall of the pharynx consists of the following four strata,

rom without inwards: (1) the pharyngeal portion of the buccopharyngeal fascia, (2) the muscular coat, (3) the pharyngo-basi ar
ascia, and (4) the mucous coat.








1368


A MANUAL OF ANATOMY


Bucco-pharyngeal Fascia.—This is an offshoot of the prevertebrs layer of the deep cervical fascia along the medial aspect of the carotii sheath. In front it becomes continuous with the fascia covering th buccinator muscle. In association with this fascial stratum there ar many veins upon the posterior and lateral walls of the pharynx, whicl constitute the pharyngeal venous plexus.

Muscular Coat.—This is composed on either side of the three cou strictor muscles—inferior, middle, and superior—the stylo-pharyngeus

and the palato-pharyngeus (including th salpingo-pharyngeus).

Inferior Constrictor— Origin .—(i) The sid of the cricoid cartilage at its posterior part (2) the inferior horn of the thyroid cartilage and (3) the outer surface of the lamin behind the oblique line.

Insertion .—The median raphe on the pos terior wall of the pharynx, where it meet its fellow of the opposite side.

The lower fibres of the muscle are hori zontal, but the upper fibres pass upward and backwards more and more obliquel} and the highest fibres of the two muscle meet in the raphe to form a peak, which i about an inch below the basilar part of th occipital bone. The lower border of th muscle overlaps the upper end of the oesc phagus. The recurrent laryngeal nerve an inferior laryngeal artery pass upwards be


Fig. 831.—Scheme to show neath the lower border behind the cricc


Planes in Composition of Pharyngeal Wall, with Relation of Mus

SUP., MID., INF., upper, middle, and lower constrictors. Sinus of Morgagni is the interval be


thyroid joint. The upper border, which i very oblique, overlaps the lower portion c cles to Mucous Mem- the middle constrictor, and the interne brane (Dotted Line). laryngeal nerve and the superior laryngee

artery, on their way to pierce the thyro-hyoi membrane, pass between the two muscle anteriorly.

, . . . Middle Constrictor— Origin. —(1) The oute

and Skull base; the tube border of the greater horn of the hyoid bon is seen coming through over its entire length, (2) the lesser horr this. and (3) the hyoid extremity of the style

hyoid ligament.

Insertion .—The median raphe on the posterior wall of the pharym where it meets its fellow of the opposite side.

The muscle is fan-shaped, and its fibres consequently diverg very much as they pass round to reach the raphe. The inferior fibre descend very obliquely, and are overlapped by the upper fibres c the inferior constrictor, the internal pharyngeal nerve and superic laryngeal artery passing to the thyro-hyoid membrane between th




THE HEAD AND NECK


1369


0 muscles anteriorly. The middle fibres pass more or less transrsely. The superior fibres ascend obliquely, and reach the basilar rt of the occipital bone. They overlap the lower portion of the perior constrictor, and the stylo-pharyngeus muscle and glossoaryngeal nerve pass between the two. The lingual artery lies perficial to the muscle at the greater horn of the hyoid bone.

Superior Constrictor— Origin. —(1) The lower third of the posterior rder of the medial pterygoid plate, and the pterygoid hamulus ocess of the sphenoid bone; (2) the posterior aspect of the pterygo


Fig. 832. _Dissection showing the Cheek, Pharynx, Submandibular

Region, and Larynx (Right View).

landibular ligament, along which it meets the buccinator muscle, ]) the posterior extremity of the mylo-hyoid line of t e mandibe, I-) the mucous membrane of the mouth; and (5) the side o e ongue.

Insertion .—The median raphe on the posterior wall of the pharynx diere it meets its fellow of the opposite side. A few °f t e ig es bres are inserted into the pharyngeal tubercle on the under sur ace

f the basilar part of the occipital bone. .

The muscle is four-sided. The fibres for the most part pass horiontally, but the lower fibres radiate in a downward direction, whi st he upper fibres curve backwards and upwards. The lower portion





1370


A MANUAL OF ANATOMY


of the muscle is overlapped by the upper part of the middle constricto the stylo-pharyngeus muscle and glosso-pharyngeal nerve passir between the two. Between the upper, concave border and the bas of the skull there is an interval occupied by the pharyngo-basik fascia, which is here stronger than elsewhere, and so compensates f( the absence of muscular fibres. This interval is semilunar, and known as the sinus of Morgagni.

Nerve-supply of the Constrictor Muscles.—The nerves are derive from the pharyngeal plexus, which is formed by the pharyngeal branc


Fig. 833. —Sagittal Section through the Nasal Cavity, Mouth, Pharynx, (Esophagus, and Larynx.

The outer wall of the right nasal cavity is shown.


of the vagus, the pharyngeal branches of the glosso-pharyngeal, an sympathetic filaments. The motor fibres of the plexus are derive from the pharyngeal branch of the vagus, but their ultimate source i the cranial root of the accessory nerve. The inferior constrictor musd also receives twigs from (1) the external laryngeal branch of tb superior laryngeal nerve, and (2) the recurrent laryngeal nerve as i passes beneath the lower border of the muscle.

Action.—The constrictor muscles are concerned in the act of d( glutition. The superior constrictor and upper portion of the midd] constrictor act upon the nasal part of the pharynx—that is, the con













THE HEAD AND NECK


I 37 i


irtment of the pharynx which lies above the soft palate—and is in mmunication with the nasal cavities through the posterior nasal jertures. They narrow the nasal part of the pharynx in the lateral rection, and this movement, in conjunction with the action of the ilato-pharyngeal arch, shuts off the cavities, thus preventing relrgitation into and through the nasal cavities. The lower portion of ie middle constrictor and the inferior constrictor diminish the calibre the oral part of the pharynx. Coming into action during the second age of deglutition, they grasp the bolus of food and press it downwards to the oesophagus. The constrictor muscles contract rapidly, and order from above downwards.

For a description of the stylo-pharyngeus and palato-pharyngeus uscles (including the salpingo-pharyngeus), see pp. 1323 and 1352.

Pharyngo-basilar Fascia (Pharyngeal Aponeurosis).—This is situated Tween the muscular coat and the mucosa. Interiorly it is weak and distinct, but superiorly it acquires greater firmness and density, specially where it is attached to the basi-occipital, the apex of the strous part of the temporal bone, the adjacent portion of the pharyngounpanic tube, and the medial pterygoid plate of the sphenoid bone.

receives an accession of strength in the median line from a strong

imdle of fibres which descends from the pharyngeal tubercle on the nder surface of the basilar process of the occipital bone, and which irms the raphe of the pharynx.

Interior of the Pharynx.—The mucous membrane, which forms ie deepest stratum in the pharyngeal wall, is of a papillary laracter, and has the following important continuations: (1) with ie mucous membrane of the pharyngo-tympanic tube, and thence ith that of the tympanic cavity; (2) with that of the nasal cavities irough the posterior nares; (3) with that of the cavity of the mouth irough the oropharyngeal isthmus; (4) with that of the larynx through ie superior laryngeal aperture; and (5) with that of the oesophagus, d its upper and back part it is richly provided with lymphoid tissue, i be noticed presently, and in the submucous tissue there are many cinous glands of a mucous character.

The soft palate projects into the cavity of the pharynx in a downward and backward direction, and divides it into two regions, upper nd lower. The upper region is known as the nasal part of the pharynx, nd is in communication with the nasal cavities and pharyngo-tympanic iibes. It also communicates with the lower region. by means of tie pharyngeal isthmus. The lower region is subdivided into two arts, oral and laryngeal. The buccal part is limited above by the 3 ft palate, and below by the inlet of the larynx, and it communicates dth the cavity of the mouth through the oropharyngeal isthmus, he laryngeal part is situated behind the larynx, with which it ommunicates, as well as with the oesophagus interiorly.

The Nasal Part of the Pharynx.—This is entirely respiratory in motion, and is therefore always patent. It measures a little more fan an inch from above downward, and about 2 inches from side to


^372


A MANUAL OF ANATOMY


side, while from before backward it is about f inch. It is bounded front by the posterior nasal apertures and the posterior border of t] vomer; behind, by the vertebral column; above, by the basilar pa of the occipital and part of the body of the sphenoid; and below 1 the soft palate, which can be elevated and depressed. Four openin communicate with it. The anterior wall has the oval openings the posterior nasal apertures leading from the nasal cavities, ai separated from each other by the posterior border of the vomer. Ea< opening in the recent state measures about i inch from above dow wards, and about \ inch from side to side. Through it, on the out wall of the corresponding nasal cavity, are seen the posterior par


Posterior Border of the Vomer


Tubal Elevation


Right Posterior Nasal Aperture / Levator Palati


Salpingo pharyngeus


Musculus Uvulas Palatopharyngeus


1 WL— . Tensor Palati


- Medial Pterygoid Uvula

- Root of Tongue


-pL -Epiglottis

_ Wall of Pharynx

_ Pyriform Fossa .. Arytenoideus Obliquus . Arytenoideus Transversus

A Crico-arytenoideus Posterior


CEsophagus


Fig. 834.—The Pharynx opened from Behind.

of the middle and inferior nasal conchae, covered by mucous membram and above and below the inferior nasal concha are seen the posteri( parts of the middle and inferior meatus. The orifice of the pharyng' tympanic tube is situated on each lateral wall behind and external 1 the corresponding posterior nasal aperture, and on the same lev as the posterior end of the inferior nasal concha. It is somewhc triangular, and has, above and behind, a prominent round bordf formed of cartilage covered by lymphoid tissue, called the tub . elevation. Behind the tubal elevation there is a deep pouch on tl lateral wall of the nasal part of the pharynx, called the pharynge recess (fossa of Rosenmuller), which is a secondary widening of til











THE HEAD AND NECK


1373


of of the primitive pharynx. The mucous membrane extending

tween the pharyngeal recesses at the upper and back part has a

imber of folds containing a large amount of lymphoid tissue, which institute the naso-pharyngeal tonsil. When enlarged, this mass is ible to obstruct the orifices of the pharyngo-tympanic tubes, and ten the posterior nasal apertures, and is known as adenoids. At le lower part of the naso-pharyngeal tonsil there may be seen a small edian recess, called the pharyngeal bursa, which leads upwards and ickwards towards the pharnygeal tubercle on the basilar part of the xipital bone.

The mucous membrane is covered by ciliated columnar epithelium.

The Oral Part of the Pharynx.—This part is situated between the )ft palate and the inlet of the larynx. Anteriorly it communicates ith the cavity of the mouth, through the oropharyngeal isthmus, elow which the root of the tongue forms its anterior wall. Each iteral wall shows the palato-pharyngeal arch, the interval between le two arches corresponding to the pharyngeal isthmus. In front E each arch is a triangular depression which lodges the tonsil.

Laryngeal Part of the Pharynx.—This part is situated behind the trynx. Anterior to it there are the epiglottis, the inlet of the larynx, n either side of which is a recess called the pyriform fossa, and the osterior parts to the arytenoid and cricoid cartilages, with the muscles dated to them. It communicates with the larynx anteriorly and tie oesophagus interiorly.

The mucous membrane of the buccal and laryngeal portions is Dvered by stratified squamous epithelium.

Blood-supply.—The arteries of the pharynx are derived from the scending pharyngeal branch of the external carotid, the ascending alatine and tonsillar branches of the cervical part of the facial artery, nd the greater palatine and pharyngeal branches of the maxillary.

The veins form a copious pharyngeal plexus, which is disposed pon the lateral and posterior walls of the pharynx. It communicates uperiorly with the pterygoid venous plexus, and receives tributaries 'om the soft palate, tonsils, and pharyngo-tympanic tubes. Interiorly tie blood is conveyed from it into the internal jugular vein.

Lymphatics.—The lymphatic vessels from the upper part of the harynx pass to the deep facial lymph glands, which are associated rith the lateral walls of the tube, and those from the remaining part ass to the upper group of deep cervical lymph glands. Some of the ^mphatics from the upper part pass to the retropharyngeal lymph lands of its own side, each of which lies upon the upper part of the orresponding longus capitis muscle.

development of the Pharynx and of the Pharyngeal Pouches or Visceral Grooves

and Visceral Arches (see Chapter II.).

The pharynx is developed from the anterior or cephalic part of the fore-gut.

On the ventral wall or floor of this part certain grooves are found at an arly stage running more or less transversely, and separated from one another •y thick and transversely directed masses of mesoderm; these are the visceral


1374


A MANUAL OF ANATOMY


arches, and the grooves are known as visceral grooves (clefts). Each groo\ runs out to the lateral part of the cavity, where it terminates in a deepe pharyngeal pouch, which can again be divided into dorsal and ventral part: each of these being the seat of distinct developments. On the outer aspect < the embryo the arches are visible, except in the case of the fifth and sixth, an the external grooves between them, lined with ectoderm, are at first in conta( with the entodermal linings of the corresponding lateral pharyngeal pouche: This contact is soon lost, save in the case of the first (external meatus).

As growth proceeds, the arches (and grooves) are placed (see Fig. 835) moi obliquely as they are followed back. They run medially into a central long tudinal prominence, the hypobranchial eminence, especially in the case of tt


Fig. 835.—A, external pharyngeal arches, 4 mm. B, floor of early pharyn exposed from above. C, shows on left the adult formations, their arc! origins being indicated on right. D, indicates remnants of skeletal structure of arches. Visceral arches are numbered in Roman figures. M, R, Meckel and Reichert's bars. On left, in C, the forward growth of third arch : shown not only in tubo-tympanic part, but in back of tongue, across tonsi fossa, and in pharyngeal extension to palate.

third and fourth, and in front of this is the little tuberculum impar, centrall placed in the first groove. The opening of the pulmonary outgrowth is sagittall placed just behind the eminence.

The arches and grooves are numbered from before backwards, the numbe of each groove being that of the arch just in front of it. The first is often terme the mandibular arch, as the lower jaw forms in it; its upper and outer part lie under the head region in front of the ear, and from here a maxillary proC6£ grows forwards from it below the eye to form the upper arcade of the mouth, There are,six arches and five grooves. The first four arches are distinc (see Fig. 49A). The fifth is rudimentary, and is buried with its groove at the bottoy of the fourth pouch. The sixth forms the immediate boundary on each sid of the pulmonary opening. The first four grooves are distinct, the fifth i







THE HEAD AND NECK 1375

uded in the fourth, and no definite groove limits the caudal part of the th arch.

The widest part of the cavity is opposite the second arch. Here is formed ! tubo-tympanic recess from which the tympanic cavity and tube are differentid as the result of forward growth of the third arch over the second. This wth goes over the region of the large second lateral pouch, but leaves the sal or outer part of this in the tympanic cavity, while its ventral part remains the pharyngeal wall and becomes the fossa in which the tonsil will develop, e growth forward of the third arch comes up against the first arch to some

ent, and obliterates its groove so far, but the dorsal part of the first pouch

aains in the tympanic cavity (Fig. 835, C).

The hypobranchial eminence forms the main epiglottic mass; the third arch ning from this becomes the pharyngo-epiglotiic fold, and the fourth forms s ary-epiglottic fold. The third pouch marks the pyriform fossa, while the irth is lost, occasionally indicated as a depression beside the lower margin the cricoid. The sixth arches are joined with an upward growth of the fourth form a paired mass standing up behind the epiglottis; this mass (arytenoid inences) is separated from the epiglottis by a transversely disposed cleft, bounded erally by the ary-epiglottic folds, and hides the sagittal opening from view d makes the supraglottic part of the larynx. The tongue is developed in front the hypobranchial eminence, the tuberculum impar being enlarged to form 5 front part of the organ, while paired growths from the front of the eminence d (?) the central parts of the second arches make its back part behind the bus terminalis.

The ventral part of the third pouch gives origin to the bud from which the miUS is formed. A similar bud from the fourth pouch develops into an ithelial mass embedded in the back of the lobe of the thyroid. The thyroid md proper is formed from a central entodermal downgrowth which takes ice early just behind the tuberculum impar; the situation of this is therefore irked in the adult by the foramen caecum, which is formed by the two masses at make the back of the tongue meeting each other at an angle, and being us applied to the front portion of the organ.

The third pouch and the constituents of the fourth pouch complex give off rtain outgrowths which separate from them through atrophy of the pharynal connection, and which may be divided into dorsal and ventral bodies. Ventral dies from the third pouch make the thymus, shifting caudally; from the irth, make a ‘ rudimentary thymus 5 which remains applied to. the back of e thyroid lobe; from the fifth rudiment, constitute an ‘ ultimo-branchial dy’ which remains in the same situation. Dorsal bodies: from the third, e lower parathyroid, carried down with the thymus; from the fourth, upper rathyroid, remaining more or less in situ ; no dorsal body from the fifth has t been found in human embryos.

At a later stage each visceral arch presents the following four elements:

) an artery; (2) a visceral myotome or muscle-segment; (3) a nerve (or nerves); d (4) a rod of cartilage. The artery is known as a visceral arch artery, and it one of the primitive aortic arches, establishing communications between the rresponding primitive ventral and dorsal aortas.

Myotomes of Visceral Arches. —The visceral myotome in each arch gives rise certain muscles. The myotome of the first arch furnishes (1) the. anterior lly of the digastric ; (2) the mylo-hyoid; and (3) the muscles of mastication— tmely, (a) masseter, ( b ) temporalis, (c) lateral pterygoid, and (d) medial pterygoid.

The myotome of the second arch furnishes (1) the posterior belly of the digastric; ) the stylo-hyoid; and (3) the stapedius. From this myotome are also derived .e muscles Of expression on the face and epicranial region, as well as the platysma. iese muscles migrate during ontogeny over the neighbouring areas.

The myotome of the third arch furnishes the stylo-pharyngeus, and the middle •nstrictor of the pharynx may be regarded as derived from it.

The myotome of the fourth arch (and perhaps that of the fifth arch) may be garded as furnishing the inferior constrictor of the pharynx.


A MANUAL OF ANATOMY


1376

Nerves of Visceral Arches—First or Mandibular (Oral) Arch. —The comm

nerve of this arch is the trigeminal nerve. The mandibular division belongs the mandibular process of the arch, and to its muscles, and the lower teeth one side; the maxillary division belongs to the maxillary process of the arch, a to the upper teeth of one side. The ophthalmic division is not concerned in i supply of the arch; it is a distinct nerve phylogenetically, only supplying parax formations.

Second or Hyoid Arch. —The nerve of this arch and of the first pharyng( pouch is the facial nerve. The auditory nerve may be included.

Third or Thyro-hyoid Arch. — The nerve of this arch and of the secoi pharyngeal pouch is the glosso-pharyngeal nerve.

Fourth Arch. —The nerve of this arch is the superior laryngeal nerve, whi is a branch of the vagus.

Sixth Arch. —The nerve of this arch is the recurrent laryngeal nerve, which a branch of the vagus.

The bar of cartilage in each arch is developed in the mesenchyme, whi forms the core of the arch.

Metamorphoses of the Visceral Arches.

First Visceral or Mandibular Arch. —This arch is situated, as stated, betwe the first pharyngeal pouch and the stomodaeum or primitive oral cavity. ] artery is the first primitive aortic arch; its nerve is the mandibular divisi of the trigeminal nerve; its cartilaginous bar is known as Meckel’s cartilage. T ventral end of this cartilage meets its fellow of the opposite side, and is join to it by connective tissue. The dorsal end is related to the periotic cartilagino capsule, and furnishes an offshoot, called the manubrium.

1. The upper or dorsal end of Meckel’s cartilage, becoming ossified, grv rise to the malleus, and probably the incus.

2. The lower or ventral end of Meckel’s cartilage is ossified in the incis portion of the mandible.

3. The part of Meckel’s cartilage between the upper and lower ends disappea: The membranous investment of the lower or mandibular portion of this part grv rise to the chief part of one-half of the body of the mandible, and the lower h of the ramus as high as the mandibular foramen. The membranous investme of the upper portion, between the periotic cartilaginous capsule and the mandibul foramen, forms the spheno-mandibular ligament.

4. The maxillary process, aided by part of the fronto-nasal process —namel the globular and lateral nasal processes —gives rise to the maxilla (see Develo ment of the Skull).

5- The upper end of the first arch on its superficial surface gives rise to t tragus, and part of the helix of the pinna.

Second or Hyoid Arch. —This arch is situated, as stated, between the fii and second pharyngeal pouches. Its artery is the second primitive aortic arcl its nerve is the facial nerve, with the chorda tympani; and its cartilaginous b is called the hyoid bar, or cartilage of Reichert. This bar ventrally is connect with its fellow of the opposite side by a transverse copula, forming part of t body of the hyoid bone.

The second bar becomes transformed into the following structures:

1. The upper or dorsal segment of the hyoid bar gives rise to the head, net and limbs of the stapes, the foot-piece of that ossicle perhaps being develop* from the cartilaginous capsule of the labyrinth within the fenestra vestibuli.

2. The succeeding segment of the hyoid bar gives rise to (a) the tympar hyal, and (b) the stylo-hyal, which collectively constitute the styloid process the temporal bone.

3. The next portion of the hyoid bar becomes converted into fibrous tissr and forms the stylo-hyoid ligament, which sometimes exists as an epi-hyal born

4. The lower or ventral segment of the hyoid bar gives rise to the cerato-hyt or lesser horn of the hyoid bone.


THE HEAD AND NECK


1377


The second, arch also gives rise superiorly to the antihelix, antitragus , and ule of the pinna; and inferiorly, along with the third arch, possibly helps to

m one-half of the posterior third of the tongue.

Third or Thyro-hyoid Arch— This arch is situated between the second and rd pharyngeal pouches. Its artery is the third primitive aortic arch; its nerve

he glosso-pharyngeal nerve; and its cartilaginous bar is known as the thyro)id bar. This bar is connected ventrally with its fellow by a copula.

A large portion of the thyro-hyoid bar disappears, but its lower or ventral ment gives rise to the thyro-hyal or greater horn of the hyoid bone. The i-hyal or body of the hyoid bone is developed from the copula.

Fourth and Fifth Visceral Arches. —The artery of the fourth arch is the fourth mitive aortic arch, and its nerve is the superior laryngeal nerve, which is a ,nch of the vagus. The artery of the fifth arch is the fifth primitive aortic h, and its nerve a small and transient branch of the vagus. The greater •tions of these two arches disappear; but the lower or ventral ends of their tilaginous bars are by some regarded as giving rise to a small part of the lina of the thyroid cartilage. The lower musculature of the pharynx comes m the cells of the fourth arch, as does also the crico-thyroid .

Sixth Visceral Arch. —The artery of this arch is the sixth primitive aortic h. Its nerve is the recurrent laryngeal. The sixth arch itself, being unferentiated, leaves no traces behind it, but the internal intrinsic muscles of ! larynx are formed from its cells.

The metamorphoses of the pharyngeal pouches have been already described connection with these pouches.

The first external furrow, corresponding to the first internal pharyngeal ich, gives rise, as stated, to the external auditory meatus, and the walls of

upper part of this furrow become differentiated into the component parts

the pinna.

Sinus Cervicalis and Cervical Fistula. —The first or mandibular and second hyoid arches increase more rapidly in all directions than the succeeding hes. The third and fourth visceral arches therefore become overlapped the second or hyoid arch, and now lie at the bottom of a depression. This Dression is called the sinus cervicalis. The lining membrane of the sinus is med by the ectodermic coverings of the overlapped visceral arches. The us is, as a rule, transitory, the second arch atrophying rapidly, and the rd external groove disappearing, while the third arch flattens. The fourth

h is partly covered from behind, a ‘ placodal duct ' being enclosed for a short

le. Otherwise there is no ‘ closing of a cervical sinus ’ in man such as has m described in lower forms.

Morphology of the Visceral Arches and Clefts.— In aquatic animals — e.g., ihes and Amphibia at an early stage, but only in Perennibranchiata pernentlv—these are called the branchial or gill-arches and clefts. The clefts lge in number from five to eight, and they differ from those of Mammals I Birds, inasmuch as they are complete clefts, the closing membrane being sent. They therefore establish free communications between the exterior 1 the fore-part of the alimentary canal, or throat, for the entrance and exit water.

The functional branchial arches are those which are post-oral, commencing

h the second. The second branchial or gill-arch is not, however, a real

tnchial arch in the functional sense, but is opercular, giving rise on either e to the operculum or gill-cover. The real branchial or gill-arches, properly called functionally, are those which succeed to the second, of which the third 1 fourth are conspicuous. I he mucous membrane of the real branchial -hes is folded into parallel lamellae, which are placed close together, and s freely furnished with capillary bloodvessels, the blood being derived from ^ branchial-arch arteries. These lamellae constitute the branchiae or gills. Aquatic respiration consists in the passage of currents of water containing pgen through the complete gill-clefts into the pharyngeal part of the foret. As the water bathes the branchiae, or gills, its oxygen is taken up into the

87


A MANUAL OF ANATOMY


1378

blood within the branchial capillaries, and the carbon dioxide of the capillc blood is yielded up to the water. Thereafter the water is expelled throu the gill-clefts, and is immediately replaced by a fresh current of respiratc water. The branchiae, or gills, of aquatic animals therefore correspond functi( ally to the lungs of Mammals and Birds, whose respiration is aerial.

The Pharyngo-tympanic Tube.

The pharyngo-tympanic tube (Eustachian tube) leads from t tympanic cavity to the nasal part of the pharynx, and is about i| inct in length. It is directed forwards, inwards, and slightly downwan and is composed of two parts, bony and cartilaginous. The bo or postero-lateral part is about \ inch long, and is situated in the anj between the petrous and squamous parts of the temporal bone. T cartilaginous or antero-medial part is about 1 inch in length, and 1 on the groove between the greater wing of the sphenoid and the api< portion of the petrous part of the temporal bone. It is at first narro but gradually enlarges, so as to resemble a trumpet. The narrow( part of the whole tube is at the junction of the bony and cartilaginc parts; this is the isthmus, and the widest part is at the pharyng< orifice. The roof, inner wall, and upper part of the outer wall of t cartilaginous part consist of a triangular plate of cartilage, the margi of which are slightly rolled towards each other. The floor and mt of the outer wall are formed of a dense fibrous membrane. T pharyngeal orifice of the tube is expanded, and is situated on the late: wall of the nasal part of the pharynx behind, and external to, t corresponding posterior nasal aperture, and on the same level as t posterior end of the inferior nasal concha. It is somewhat triangul; and above and behind is the tubal elevation, already described, form by the thick margin of the cartilage, and posterior to this is the phar) geal recess.

The tube is lined with mucous membrane, which is continue with that of the tympanic cavity on the one hand, and of the na part of the pharynx on the other. It is thin in the bony part of t tube, but in the cartilaginous part it is thick, and contains mucc glands and lymphoid tissue. It is covered by stratified columr ciliated epithelium.

Muscles connected with the Pharyngo-tympanic Tube. —The leva palati has an origin from the lower margin of the cartilage of the tul the tensor palati from the outer side of the cartilage, and the salpinj pharyngeus is attached to the lower and front part of the tube. Duri deglutition the orifice of the tube is opened.

Arteries are derived from the artery of the pterygoid canal, fr( the third part of the maxillary, and the ascending pharyngeal bran of the external carotid.

Nerves. —The nerves come from the tympanic plexus on the ini wall of the tympanic cavity, and the nerve of the pterygoid canal.

Development. —From the tubo-tympanic recess of the primitive phary modified and narrowed by forward growth of the third arch (Fig. 835, C).


THE HEAD AND NECK


1379


The Larynx.

The larynx is the upper part of the respiratory passage, being )dified in structure so as to enable it to act as the organ of voice, is situated in the median line of the neck above the trachea, and it s opposite the fourth, fifth, and sixth cervical vertebrae. Superiorly opens into the laryngeal portion of the pharynx, and interiorly into e trachea. It is covered in front by the integument and the deep rvical fascia, and the laryngeal portion of the pharynx lies behind On either side it is in relation with the upper part of the lobe the thyroid gland, the sterno-hyoid, omo-hyoid, sterno-thyroid, d thyro-hyoid muscles, and the common carotid artery.


Epiglottis

Superior Horn of Thyroid . —

Cartilage / .

Cuneiform Cartilage _i_ Comiculate Cartilage !j—


Axytenoideus Obliquus — Arytenoideus Transversus--'

Crico-arytenoideus Posterior Crico-thyroid Joint


Cricoid Cartilage—— " Trachea


Wu>. •••


SEI!

ll '!)

f 1 »•

tail,

(1 Ml

‘lull


?ig. 836. —The Intrinsic Muscles of the Larynx (Posterior View).


Structure.—The larynx consists of a framework of cartilages, some which are connected by joints and ligaments; it is provided with ecial muscles, spoken of as intrinsic ; and it is lined with mucous embrane.

Cartilages are nine in number, three being single and three arranged pairs. The single cartilages are The epiglottis, the thyroid, and the icoid; and the three arranged in pairs are the arytenoid, corniculate, id the cuneiform.

The epiglottis is a leaf-like plate of yellow elastic fibro-cartilage, tiich is placed between the base of the tongue and the inlet of the rynx. Its lower part forms a stalk which is attached to the receding igle of the thyroid cartilage, just below the thyroid notch on its







1380


A MANUAL OF ANATOMY


upper border, by means of a fibro-elastic band, called the thyr epiglottic ligament. Above it has a broad, round, free margin. Ea< lateral border is free above, but its lower part is contained within t] ary-epiglottic fold of mucous membrane. The anterior or lingu surface is free over its upper part, where it faces the base of the tongr and is covered by mucous membrane. This membrane is prolong! on to the base of the tongue as the glosso-epiglottic fold, which medially placed. It is also prolonged from the sides of the epiglotl on to the lateral walls of the pharynx as the pharyngo-epiglottic fold On either side of the glosso-epiglottic fold, between it and each pharyng epiglottic fold, there is a depression or fossa, which is known as t] vallecula. Lower down than these folds the anterior surface is co nected to the back of the upper border of the body of the hyoid boi by an elastic, semilunar membrane, called the hyo-epiglottic ligamer


Thyroid Notch


- Superior Horn of Thyoid Cartilage

Superior Thyroid Tubercle

• Oblique Line of Lamina Laryngeal Prominence ' Inferior Thyroid Tubercle

' Inferior Horn


Cricoid Cartilage Crico-thyroid Ligament


Fig. 837.—The Thyroid and Cricoid Cartilages of the Larynx

(Anterior View).


Above the upper border of the thyroid cartilage the anterior surfa< is attached to the back of the body of the hyoid bone and of the thyr hyoid membrane by dense connective tissue. The posterior or lary geal surface is free over its whole extent, and is covered by mucoi membrane. It is concave from side to side, and concavo-convt from above downwards. The lower convexity forms the tuberc (cushion). When the mucous membrane is removed, the epiglott presents a number of small glandular pits.

Development.— The epiglottis is developed from the hinder part of the hyp branchial eminence.

Thyroid Cartilage. —This cartilage is composed of two flat quadi lateral laminae false), which meet in front by their anterior border but diverge widely behind. The angular projection formed by the union is called the laryngeal prominence (pomum Adami). The unic is confined to about the lower half of each anterior border, and the




THE HEAD AND NECK


1381

left superiorly a deep triangular cleft called the thyroid notch. The ►sterior border, of greater length than the anterior, is round, and yes attachment to fibres of the palato-pharyngeus and stylo-pharynus muscles. At either extremity it is prolonged into a projection, e superior horn and inferior horn respectively. The superior horn yes attachment to the lateral thyro-hyoid ligament, and the inferior irn, which is slightly incurved, is faceted on its inner aspect to ticulate with the cricoid cartilage. The superior border is for the ost part convex, and near its back part is a slight eminence, called e superior thyroid tubercle. The inferior border is almost horizontal, id has an eminence about the junction of the posterior third with the terior two-thirds, called the inferior thyroid tubercle. It gives tachment to the median portion of the crico-thyroid ligament and e crico-thyroid muscle. The outer surface of the lamina is marked


Laryngeal Prominence


Fig. 838.—The Thyroid and Cricoid Cartilages of the Larynx

(Lateral View).


an oblique line, which extends downwards and forwards from the perior to the inferior tubercle. This line gives insertion to the irno-thyroid, and origin to the thyro-hyoid muscles. It divides the ter surface into two unequal parts—an anterior three-fourths and posterior fourth, the latter giving origin to fibres of the inferior nstrictor muscle. The inner surface of the lamina is smooth, slightly ncave, and covered by mucous membrane. In the median line, hind the laryngeal prominence, there is a vertical depression known the receding angle. Beginning just below the thyroid notch on e upper border and passing downwards, this region gives attach^nt to the following structures: the thyro-epiglottic. ligament, the stibular ligaments, and the vocal ligaments, in association with which 5 the fibres of the thyro-arytenoid muscles.

Development of the Thyroid Cartilage. —The thyroid cartilage represents ' ventral portions of the skeletal cartilages of the fourth (and ? fifth) visceral lies of either side, which become united by a median plate.



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A MANUAL OF ANATOMY


Cricoid Cartilage.—The cricoid cartilage is situated below tl thyroid cartilage, and forms the lower part of the larynx. It bea some resemblance to a signet-ring, and it consists of two parts—s anterior arch and a posterior lamina.

The arch is narrow from above downwards as well as from sic to side. The inferior border is horizontal, and is connected with tl first ring of the trachea by a fibro-elastic membrane. The superi border is connected with the inferior border of thyroid cartilage t the crico-thyroid ligament.

The lamina is quadrilateral, broad, and deep. Its depth is owii to the rapid elevation of the superior border of the arch as it pass backwards. The inferior border is connected laterally with the fir

ring of the trachea by a fibro-elastic membran and medially, where the tracheal rings are d ficient, to the same membrane. The superi border has a median notch, and on either side «  this an oval convex facet for articulation wil the base of the arytenoid cartilage. The posteri surface is divided into two depressed areas by median vertical ridge, which gives attachment the longitudinal muscular fibres of the oesophagi! The depressed area on either side of this medic vertical ridge gives origin to the crico-arytenoidei posterior.

The outer surface of the cricoid cartilage pr sents posteriorly a circular facet for articulatic with the inferior horn of the lamina of the thyroid cartilage. Tl upper sloping border of this part gives attachment along its inn margin to the lateral portion of the crico-vocal membrane.

The internal surface of the cricoid cartilage is lined with the mucoi membrane of the larynx.

Development. —The cricoid cartilage, like the rings of the trachea, is develop! in the mesoderm of the respiratory tube, in the sixth arch.

Arytenoid Cartilages.—These cartilages are placed above the crico cartilage posteriorly. Each has the form of a three-sided pyrami and measures about -J inch in height, and about J inch in width the base. The apex looks upwards, and is curved in a backward at inward direction. It is surmounted by the corniculate cartilag The base looks downwards, and is slightly concave and faceted articulate with the superior border of the cricoid cartilage posteriori Two of the three angles of the base project. The anterior ang] somewhat pointed, is directed straight forwards to form the voc process. It gives attachment to the vocal ligament. The extern angle, thick and somewhat round, has an inclination backwards well as outwards, and is known as the muscular process. Anterior it gives insertion to the crico-arytenoideus lateralis, and posterior to the crico-arytenoideus posterior. The surfaces are antero-laten


For Articulation with Arytenoid Cartilage


Fig. 839.— The Cricoid Cartilage of the Larynx (Posterior View).



THE HEAD AND NECK


1383


sterior, and medial. The antero-lateral surface, a little above the cal process, attaches to the vestibular ligament, and above and

eral to the vocal process the thyro-arytenoideus muscle. The

sterior surface is triangular and concave, and gives attachment to portion of the arytenoideus transversus. The medial surface faces

fellow of the opposite side, and is covered by mucous membrane,

forms the posterior part of the lateral boundary of the rima glottidis. le borders are anterior, posterior, and lateral. The anterior border parates the medial from the antero-lateral surface, and terminates low in the vocal process. The posterior border separates the medial )m the posterior surface. The lateral border separates the antero-lateral )m the posterior surface, and ends below in the muscular process.

The thyroid and cricoid cartilages usually retain their cartilaginous con:ion up to about the twentieth year. In the case of the thyroid cartilage fification proceeds from the inferior horn, there being a special osseous nucleus the region of the laryngeal prominence.


Fig. 840. —The Right Arytenoid Cartilage and Corniculate Cartilage (Lateral Aspect Enlarged).

The anterior part and lower margin of the cricoid cartilage remain cartipnous for some time, but the remainder undergoes ossification simultaneously ith the thyroid cartilage.

Ossification of the arytenoid cartilages takes place at a later date than in e case of the two preceding cartilages.

Corniculate cartilages (cartilages of Santorini) are two small, somehat conical nodules of yellow elastic cartilage which cap the apical arts of the arytenoid cartilages, their direction being backwards and iwards. Each lies within the ary-epiglottic fold of mucous membrane.

Cuneiform cartilages are two nodules of yellow elastic cartilage, Inch are situated, one on either side, in the ary-epiglottic fold of iucous membrane at its back part, not far from the corniculate irtilages.

Development. —The arytenoid cartilages are formed in the sixth arches, id the ary-epiglottic folds from the fourth. The corniculate cartilages are I shoots of the arytenoid cartilages. The cuneiform cartilages are derived from

ie epiglottis.


1384


A MANUAL OF ANATOMY


Ligaments 0! the Larynx—Thyro-hyoid Membrane.—This is

broad membranous sheet, which passes between the superior borde of the thyroid cartilage and the back of the upper border of the bod of the hyoid bone, as well as the deep border of each greater horr Its central and lateral portions are strong, and are composed large! of elastic tissue. The central portion is known as the median thy re hyoid ligament, its lower attachment being to the border of the thyroii cartilage. The lateral portions, round and cord-like, are very elastic and are known as the lateral thyro-hyoid ligaments. Each extend from the superior horn of the thyroid cartilage to the tip of the greate horn of the hyoid bone, and enclosed within it, towards its upper pail there is a small nodule of cartilage called the cartilago triticea Between the upper median portion of the thyro-hyoid membrane ari( the concave posterior surface of the body of the hyoid bone there i a synovial bursa. It is to be noted that the superior attachment 0


the thyro-hyoid membrane is such as to enable the upper part of the thyroid cartilage, when raised, to be received within the outline 0: the hyoid bone. The central portion of the membrane is subcutaneous but on either side it is covered by the thyro-hyoid muscle. Beneatf the posterior border of this muscle the internal laryngeal nerve anc superior laryngeal artery pierce the membrane.

Crico-vocal Membrane.—This membrane is composed of an anterioi and two lateral portions. The anterior portion or crico-thyroid ligameni portion, elastic and triangular, is attached by its base to the lowei border of the thyroid, and by its apex to the upper border of the cricoid, close to the mid-line. It is subcutaneous in the median line except that it is crossed by the crico-thyroid branch of the superioi thyroid arteries. Through this portion laryngotomy may be performed. The lateral part of the crico-vocal membrane is connectec
















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1385

elow with the upper border of the lateral part of the cricoid cartilage, uperiorly it is not connected with the thyroid cartilage, but passes eep to its lamina into the larynx, where it expands in an inward irection, and extends from the back of the lamina of the thyroid artilage in its lower part, close to the receding angle, to the under spect of the vocal process of the arytenoid cartilage. Between these oints it becomes continuous with the vocal ligament. The lateral ortion of the crico-thyroid membrane (within the lamina of the thyroid artilage) is covered by the crico-arytenoideus lateralis and thyrorytenoideus.

Vestibular Ligaments (Superior Thyro-arytenoid Ligaments).—These Drm two small fibrous bands, one at either side, which lie within the dds of mucous membrane, called the vestibular folds (false vocal cords). Lach is attached in front to the receding angle of the thyroid cartilage mmediately below the attachment of the thyro-epiglottic ligament, nd behind to the antero-lateral surface of the arytenoid cartilage little above the vocal process.

Vocal Ligaments (Inferior Thyro-arytenoid Ligaments).—These nportant ligaments, covered by mucous membrane, constitute the ocal folds (true vocal cords), and each is continuous with the upper •art of the expanded lateral portion of the crico-vocal membrane. Lach is composed of yellow elastic tissue, and with its fellow is attached 1 front to the receding angle of the thyroid cartilage at its centre nd behind to the vocal process of the arytenoid cartilage. Its inner order, which is covered by mucous membrane, is free and clearly efined. In its front part there is a very small nodule of elastic artilage.

Crico-thyroid Joint.—This belongs to the class of synovial joints.

'he articular surfaces are the facet on the inner surface of the inferior orn of the thyroid cartilage, and that on the outer surface of the ricoid cartilage posteriorly. The joint is surrounded by a capsular gament, and this is lined with a synovial membrane. The moveaents allowed are as follows: (1) rotation of the thyroid cartilage round n axis passing transversely through both joints; and (2) gliding, in diich the cricoid moves upwards and backwards, or downwards and Drwards, this movement partaking somewhat of a swinging character.

The recurrent laryngeal nerve ascends close behind the cricohyroid joint before entering the larynx.

Crico-arytenoid Joint.—This belongs to the class of synovial oints. The articular surfaces are the convex facet on the superior 'order of the cricoid cartilage posteriorly, and the concave under urface of the base of the arytenoid cartilage. The joint is surrounded y a capsular ligament, and this is lined with a synovial membrane, he movements allowed are as follows: (1) rotation, in which the rytenoid cartilage rotates on a nearly vertical axis, the effect being 0 invert or evert the vocal process; and (2) gliding in a lateral direction,

1 which one cartilage moves inwards towards its fellow, or outwards way from its fellow.


1386


A MANUAL OF ANATOMY


The corniculate cartilages are usually connected to the arytenoit cartilages by fibrous tissue, but in some cases there is a synovia articulation.

Prelaryngeal Lymph Glands.—One or two glands may lie upon tin median portion of the crico-vocal membrane in the interval betweei


Root of Tongue



Epiglottis


Ary-epiglottic Fold


Vestibular Fold Ventricle Vocal Fold Cuneiform Cartilage


Vocal Process of Arytenoid Cartilage


the crico-thyroid muscles. Thei afferent vessels are derived fron

(1) the infraglottic portion of th larynx, the lymphatics from whicl pierce the crico-vocal membrane

(2) the beginning of the trachea and (3) the upper part of the isthmu of the thyroid gland. Their efferen vessels pass either to the inferio deep cervical lymph glands, or t< the pretracheal glands as an inter mediate gland-station.

The Cavity of the Larynx.—Tb inlet of the larynx is situated be hind and below the epiglottis. I is triangular, being wide in fron and narrow behind, and its plan is sloped obliquely downwards an( backwards. Above and in front i n ls bounded by the epiglottis, am behind by the fold of mucous membrane which stretches between the arytenoid cartilages. On either side are the prominent ary-epiglottic folds, which extend from the tips of the arytenoid cartilages to the sides of the epiglottis and contain muscular fibres. Each of these folds, close to the arytenoid cartilage, contains the corniculate cartilage, which gives rise to a slight elevation, and a little in front of this another slight elevation is produced by the cuneiform cartilage. Between the arytenoid cartilage and the back part of the aryepiglottic fold medially and the back


Rima Glottidis Corniculate Cartilage

Fig. 842. — The Inlet of the Larynx and Adjacent Parts.


Epiglottis


Vestibule


Lamina of Thyroid Cartilage Middle Part


Cricoid Cartilage


Lower Part


Trachea


part of the lamina of the thyroid Fig. 843. —Vertical Transvers cartilage laterally there is a depression, Section of the Larynx, shov opening upwards, called the pyriform ing the Posterior Surface c

fossa. This is important, because unless Organ^Marshaix) ALF ° F ™ an instrument intended for the interior (Marshall).

of the larynx is kept carefully to the mid-line it will enter the foss and be pressed against its floor, just below the mucous membrane ( which the internal laryngeal nerve passes on its way to the larynx.













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1387


The cavity of the larynx begins at the inlet, and ends on a level with he lower border of the cricoid cartilage. It is divided into three ompartments by means of two antero-posterior folds of mucous nembrane, which project into it from each lateral wall. The upper >air of folds are called the vestibular cords, and the lower pair the r ocal folds. The upper compartment is known as the vestibule of he larynx, and it extends as low as the vestibular folds. It is wider bove than below, and its anterior depth exceeds the posterior. The niddle part is situated between the vestibular folds above and the meal folds below. On either side is a recess, called the sinus of the arynx (ventricle). This is bounded above by a vestibular fold, and >elow by a vocal fold. Its outer wall is covered by fibres of the hyro-arytenoid muscle. At the anterior part of the sinus there is


Fig. 844. —Sagittal Section of the Larynx and Trachea, showing the Vocal Folds and Sinus of the Right Side.


1 small valvular aperture, which leads to a diverticulum of the ventricle, called the saccule of the larynx. This extends upwards Detween the vestibular fold and the lamina of the thyroid cartilage, reaching as high as the upper border of the latter. On its medial aspect there are some muscular fibres, which are known as the compressor sacculi laryngis.

The lower part of the larynx is compressed from side to side above, but becomes circular inferiorly, where it opens into the trachea.

The vestibular folds (false vocal cords) are two folds of mucous membrane, which extend at either side from the receding angle of the thyroid cartilage immediately below the attachment of the thyroepiglottic ligament to the antero-lateral surface of the arytenoid cartilage a little above the vocal process. Each contains some fibrous









1388


A MANUAL OF ANATOMY


tissue, forming the vestibular ligament. The vestibular folds ar widely separated from each other by an interval known as the rim vestibuli [false glottis), so that the vocal folds are visible on lookin into the larynx from above.

The vocal folds (true vocal cords) are concerned in the productioi of the voice. They are prominent folds at either side, which ar rather less than an inch in length, and extend from the receding angl of the thyroid cartilage to the vocal process of each arytenoid cartilage Each cord consists of the vocal ligament, which is continuous with th upper part of the expanded lateral portion of the crico-vocal membrane

and is composed of yellow elastic


Thyroid Notch


Lamina of Thyroid Cartilage / JMljift fif

/J


Thyro-arytenoideus


Vocal Fold '


Crico-arytenoideus

Lateralis


Arytenoid Cartilage

Crico-arytenoideus Posterior


Arytenoideus


tissue. The mucous membran< covering the fold is thin, anc firmly adherent to the elastii tissue of the ligament, and it has ; characteristic pearly white colour The vocal folds are much nearei to each other than the false, s( that the latter are not visible when the larynx is viewed froir below.

Rima Glottidis.—The rima glottidis, or true glottis, is the narrov fissure by which the upper anc lower parts of the larynx communicate with each other, and il


Tig. 845. Dissection of the Larynx, fUp narrowest nart of f-fie ravhv showing the Muscles, Vocal Folds 1 + • narro ^ e ^ P art °* tne cavl y and Rima Glottidis (Superior 1S elongated from before backView) . wards, and is narrow in front at

. the receding angle of the thyroid

cartilage, but wider behind, where it is closed by the interarytenoid ° d °1 mucous membrane. It is divisible into an intermembranous, part and an inter cartilaginous part. The intermembranous part is nari ow, and is bounded on either side by the vocal cord. Its length is rather less than an inch, and it forms about two-thirds of the entire aperture. The intercartilaginous part is wider than the intermembranous part, and is bounded on either side by the inner aspect oi the base of the arytenoid cartilage. It is about J inch in length, an ^orms about one-third of the length of the entire aperture.

The shape of the rima glottidis is subject to alteration, and has to be considered under three conditions:

( I ) During quiet respiration it has the form of an elongated triangle, the apex being in front at the thyroid cartilage, and the base behind at the mterarytenoid fold of mucous membrane. (2) During a deep inspiration the rima is widely dilated, and assumes a diamond shape, the widest part being opposite the tips of the vocal processes of the aiytenoid cartilages, where the lateral angles of the diamond are placed, the posterior angle at the interarytenoid fold of mucous mem







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irane being truncated. (3) While talking, and especially in singing igh notes , the vocal folds become so closely approximated as to be ►ractically parallel, and the rima glottidis assumes the form of a narrow

hink.

Mucous Membrane of the Larynx.—This is continuous above with he mucous membrane of the pharynx, and below with that of the rachea. Above the level of the rima glottidis its subjacent attachment is loose on account of the presence of submucous areolar tissue, articularly near the ary-epiglottic folds, a condition which favours


Epiglottis and its Tubercle


Sinus of Larynx,


Vestibular Fold


Vocal Fold Cuneiform Cartilage Corniculate Cartilage ■""* __ Tip of Arytenoid Cartilage





r iG. 846. —The Inlet of the Larynx and the Rima Glottidis, as seen by the Aid of the Laryngoscope under Different Conditions.

(The Figures on the left side are copied from Czermak.)

A, Ordinary quiet inspiration C, Vocalization, especially in singing high notes

B, Very deep inspiration R.G. Rima glottidis


he occurrence of oedema, but over the laryngeal surface of the epiglottis it is firmly attached. Over the vocal folds it is very thin, md is so firmly connected to the vocal ligaments that oedema cannot >ass this point. The membrane is covered by ciliated columnar pithelium, except (1) near the margin of the ary-epiglottic folds, vhere it is of the stratified squamous variety, as in the laryngeal )ortion of the pharynx and the cavity of the mouth; and (2) over the X)cal folds, where it is also of the stratified squamous vaiiety. Bodies esembling the taste-buds of the tongue are met with on the laryngeal surface of the epiglottis, the inner surfaces of the arytenoid cartilages








1390


A MANUAL OF ANATOMY


and of the ary-epiglottic folds, and over the margins of the vestibula folds.

The mucous membrane contains a large number of acinous mucou glands, the ducts of which open freely on the surface, except over th vocal folds, where there are no glands. They are arranged in the follow ing groups: (i) epiglottic glands, which are very numerous, and occup; the pits on the laryngeal surface of the epiglottis; (2) arytenoid glands in front of the arytenoid cartilages, and in the adjacent portions 0 the ary-epiglottic folds; (3) along the vestibular folds; and (4) in th wall of the laryngeal saccule, where they are very numerous.

It is of practical importance to remember that an opening mad in the crico-thyroid space enters the larynx below the vocal folds


Epiglottis

Superior Horn of Thyroid Cartilage

Cuneiform Cartilage Corniculate Cartilage

Arytenoideus Obliquus Arytenoideus Transversus

Crico-arytenoideus Posterior Crico-thyroid Joint


Cricoid


Fig. 847. —The Intrinsic Muscles of the Larynx (Posterior View).

consequently, in those cases in which suffocation is threatened b} a foreign body impacted in the upper part of the larynx, the simpb operation of laryngotomy or incising the crico-thyroid space wil usually give relief.

Intrinsic Muscles. —-These are the muscles by which the cartilages are moved and the condition of the vocal folds determined. They art the crico-thyroideus, crico-arytenoideus posterior, crico-arytenoideus lateralis, thyro-arytenoideus, arytenoideus, and aryepiglotticus. The arytenoideus is a single muscle, but all the others are arranged ir pairs.

Crico-thyroideus — Origin .—The antero-lateral part of the cricoic cartilage.







THE HEAD AND NECK


I 39 i


Insertion .—The lower margin of the lamina of the thyroid cartilage, id the front of the inferior horn.

Nerve-supply .—The external laryngeal branch of the superior ryngeal nerve.

The fibres are directed upwards and backwards in a diverging Lanner, the posterior being horizontal and the anterior oblique, hese two sets of fibres are often distinct.

Action .—To approximate the front parts of the cricoid and thyroid irtilages in the following manner: the posterior horizontal fibres raw the cricoid cartilage backwards, and the anterior oblique fibres


Fig. 848.—The Intrinsic Muscles of the Larynx (Lateral View).

The greater part of the right lamina of the thyroid cartilage has

been removed.


levate the anterior part of the cricoid cartilage. As a result of this aovement the posterior part of the cricoid cartilage, carrying the .rytenoid cartilages on its upper border, is depressed and carried >ackward. Thus the vocal folds are put upon the stretch, and the uuscle is a tensor of the fold.

Between the two muscles anteriorly there is a triangular interval ibout ^ inch wide, in which the central portion of the crico-vocal nembrane is visible, this portion being crossed at its centre by the

rico-thyroid arch of arteries. In this region, just above the cricoid
artilage, laryngotomy may be performed.





















1392


A MANUAL OF ANATOMY


Crico-arytenoideus Posterior (see Fig. 847)— Origin. —The posterior

surface of the cricoid cartilage on one side of the median vertical ridge.

Insertion. —The posterior aspect of the muscular process of the arytenoid cartilage.

Nerve-supply. —The recurrent laryngeal nerve.

The fibres of the muscle are directed upwards and outwards, the highest being short and nearly horizontal, the middle being oblique, and the lowest almost vertical.

Action. —To draw the muscular process of the arytenoid cartilage backwards, thereby swinging the vocal process outwards, the result of which is to open the rima glottidis. The muscle is, therefore, a dilator of the rima glottidis.

The muscle is separated from its fellow by the median vertical ridge on the back of the cricoid cartilage.

Crico-arytenoideus Lateralis (see Fig. 848)— Origin— The lateral portion of the cricoid cartilage along its upper sloping border, extending as far back as the crico-arytenoid joint.

Insertion. —The anterior aspect of the muscular process of the arytenoid cartilage, and the adjacent portion of the antero-lateral surface.

Nerve-supply. —The recurrent laryngeal nerve.

The fibres of the muscle are directed backwards and upwards.

Action. —To draw the muscular process of the arytenoid cartilage forwards, thereby swinging the vocal process inwards, the result of which is to narrow the rima glottidis. The two muscles therefore approximate the vocal folds, and come into action in speaking. When the crico-arytenoidei posteriores et laterales act together they prevent rotation, and thus indirectly assist the arytenoideus in approximating the aryt