MINISTRY OF PUBLIC HEALTH OF UKRAINE Higher State Educational Establishment of Ukraine “Ukranian Medical Stomatological Academy”

"Approved" at the meeting of the Department of Human Anatomy «29»_08__2017 Minutes №1 Head of the Department Professor O.O. Sherstjuk ______

METHODICAL GUIDANCE for students' self-directed work at practical sessions (when preparing for and during the practical session)

Academic subject Human Anatomy Module №3 «The heart. Vessels and nerves of the head, the neck, the trunk, extremities» Year of study І-II Faculty foreign students' training faculty, specialty «Medicine»

Poltava – 2017 MINISTRY OF PUBLIC HEALTH OF UKRAINE Higher State Educational Establishment of Ukraine “Ukranian Medical Stomatological Academy”

Department of Human Anatomy

Composed by: N.L. Svinthythka, Associate Professor at the Department of Human Anatomy, PhD in Medicine, Associate Professor V.H. Hryn, Associate Professor at the Department of Human Anatomy, PhD in Medicine, Associate Professor A.V. Pilugin, Associate Professor at the Department of Human Anatomy, PhD in Medicine, Associate Professor A.L. Katsenko, Lecturer at the Department of Human Anatomy Schedule of classes for students of foreign students' training faculty, specialty “Medicine” on module №3 "Heart. The vessels and nerves of the head, neck, trunk and extremities "

№ Topic hours 1 Anatomy of the heart: external structure, the cardiac chambers, wall 2 structure of the heart. 2 Anatomy of the heart: vessels and nerves of the heart, the conducting 2 system of the heart. 3 Circles of blood circulation. The pericardium. Topography of the heart. 2 4 The aorta. The branches of aortic arch. The common carotid artery. 2 The internal carotid artery. 5 The external carotid artery. 2 6 The subclavian artery. The axillary artery. 2 7 Blood supply of the brain and spinal cord. Anastomoses. Clinical 2 aspects. 8 Arteries of upper extremity. 2 9 Thoracic aorta. Parietal and paired visceral branches of abdominal 2 aorta. 10 Unpaired visceral branches of abdominal aorta. 2 11 Iliac arteries. Arteries of the thigh. 2 12 Arteries of lower extremity. 2 13 General characteristic of venous system. System of vena cava 2 superior. Veins of head and neck. 14 System of vena cava superior. Veins of upper extremities and chest. 2 15 System of vena cava inferior. Veins of lower extremities, pelvis and 2 abdominal cavity. 16 System of portal vein. Fetal circulation. 2 17 Immune system. Organs of haemopoesis. Central part of the immune 2 system. The red bone marrow. The thymus. 18 Peripheral part of the immune system. The lymph nodes. The spleen. 2 The tonsils. The lymphoid nodules. 19 Lymphatic vessels and nodes of the lower limb, pelvis and abdomen. 2 20 Lymphatic vessels and nodes of the head and neck. 2 21 Submodule on Cardiovascular system and immune system. Situational 2 problems. 22 General characteristics of the peripheral nervous system. The spinal 2 nerves. The posterior rami of the spinal nerves. The anterior rami of the spinal nerves. The cervical plexus. 23 The brachial plexus. 2 24 The intercostal nerves. The lumbar plexus. 2 25 The sacro-coccygeal plexus. 2 26 Cranial nerves. The origination, the general features, the featured 2 nuclei, the point of arise, the escape point, the related branches and the responsibility areas of the oculomotor, trochlear and abducent nerves. 27 The origination, the general features, the featured nuclei, the point of 2 arise, the escape point, the related branches and the responsibility areas of the trigeminal nerve. Nervous pathway of the trigeminal nerve. 28 The facial nerve. The intermediate nerve. The origination, the general 2 features, the featured nuclei, the point of arise, the escape point, the related branches and the responsibility areas. 29 The glossopharyngeal nerve. The related branches and the 2 responsibility areas. 30 The vagus nerve. The origination, the general features, the featured 2 nuclei, the point of arise, the escape point, the related branches and the responsibility areas. 31 The accessory, hypoglossal nerves. The related branches and the 2 responsibility areas. 32 Submodule on peripheral nervous system. The spinal and cranial 2 nerves. Situation problems. 33 Introduction in vegetative nervous system. Sympathetic part of 2 autonomic nervous system. 34 Parasympathetic part of autonomic nervous system. 2 35 Autonomic innervation of organs. Autonomic ganglions of head and 2 neck, pelvis, abdomen. 36 Synthetic classes: vascularization and innervation of the chest cavity, 2 abdominal cavity and the pelvic cavity. 37 Vascularization and innervation of organs of head and neck. 38 Synthetic classes: vascularization and innervation of the limbs. 2 39 Practical skills from the training material module 3 «Heart. Vessels 2 and nerves of the head, neck, chest cavity and extremities». 40 Case-control material of the module 1 «Anatomy of the locomotor 2 apparatus». Step 1. Practical skills. 41 Case-control material of the module 2 «Splanchnology. Central 2 nervous system and sense organs». Step 1. Practical skills. 42 Final semester certification (exam). 2 Topic 1. Anatomy of the heart: external structure, the cardiac chambers, wall structure of the heart. 1. Relevance of the topic. The heart is a hollow contractile muscular organ that lies within the pericardium in the mediastinum in the thorax. The heart is responsible for pumping blood through the pulmonary and systemic circulations. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of tissues which form the walls of the heart Cardiology Find the auscultatory points for the heart valves. What are the components of the components of the conducting system of heart 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Cor (Greek. cardia) Heart Ventriculus cordis dexter/sinister Ventricle right / left Auricula dextra, sinistrа Right / left auricle Anulus fibrosus dexter/sinister Right / left fibrous rings M. papillaris Papillary muscle Trabeculae carneae Trabeculae carneae 4.2. Theoretical questions for the class: 1. Surfaces and borders of the heart. 2. Structure of the walls of the heart. 3. Chambers of the heart, structure of the right atrium. 4. Structure of the left atrium. 5. Structure of the right ventricle. 6. Structure of the left ventricle. 7. Structure of interventricular septum. 4.3. Practical task pertaining to the topic and to be completed during the class: on the preparations, tables, models to study the external structure of the heart, its shape, position, heart chambers, structure of the heart, heart valves, heart wall structure. Content of the topic. The heart, slightly larger than a clenched fist, is a double self-adjusting muscular pump, the parts of which work in unison to propel blood to the body. The right side of the heart receives poorly oxygenated blood from the body through the superior vena cava (SVC) and inferior vena cava (IVC) and pumps it through the pulmonary trunk to the lungs for oxygenation. The left side of the heart receives well-oxygenated blood from the lungs through the pulmonary veins and pumps it into the aorta for distribution to the body. The heart has four chambers: right and left atria and right and left ventricles. The atria are receiving chambers that pump blood into the ventricles—the discharging chambers. The synchronous pumping actions of the heart's two atrioventricular (AV) pumps (right and left chambers) constitute the cardiac cycle. The cycle begins with a period of ventricular relaxation (diastole) and ends with a period of ventricular contraction (systole). Two heart sounds—resulting from valve closures—can be heard with a stethoscope: a "lub" sound as the atria transfer blood to the ventricles and a "dub" sound as the ventricles contract and propel blood from the heart. The heart sounds are produced by the snapping shut of the one-way valves that normally keep blood from flowing backward during contractions of the heart. The wall of each chamber of the heart consists of three layers from superficial to deep: • Epicardium, a thin external layer (mesothelium) formed by the visceral layer of serous pericardium. • Myocardium, a thick middle layer composed of cardiac muscle. • Endocardium, a thin internal layer (endothelium and subendothelial connective tissue) or lining membrane of the heart that also covers its valves. When the ventricles contract, they produce a wringing motion because of the spiral orientation of the cardiac muscle fibers in the myocardium. This motion propels the blood from the heart. The muscle fibers are anchored to the fibrous skeleton of the heart. The fibrous framework of dense collagen forms four fibrous rings, which surround the orifices of the valves, right and left fibrous trigones, formed by connecting the rings, and the membranous parts of the interatrial and interventric- ular septa. The fibrous skeleton of the heart: • Keeps the orifices of the atrioventricular (AV) and semilunar valves patent and from being overly distended by the volume of blood pumping through them. • Provides attachments (origin and insertion) for the leaflets and cusps of the valves. • Provides attachment (origin and insertion) for the myocardium. • Forms an electrical "insulator" by separating the myenterically conducted impulses of the atria and ventricles so that they contract independently, and by surrounding and providing passage for the initial part of the AV bundle. The heart and roots of the great vessels within the pericardial sac are related anteriorly to the sternum, costal cartilages, and the medial ends of the 3rd through 5th ribs on the left side. The heart and pericardial sac are situated obliquely, about two-thirds to the left and one-third to the right of the median plane. The heart has an apex, base, three surfaces, and four borders. The apex of the heart: • Is formed by the left inferolateral part of the left ventricle. • Is located posterior to the left 5th intercostal space in adults, usually 9 cm from the median plane. • Is where maximal pulsation of the heart (apex beat) occurs and underlies the site where the "heartbeat" may be observed or palpated on the thoracic wall. The base of the heart: • Is the heart's posterior aspect (opposite the apex) as it lies in the thorax. • Is formed mainly by the left atrium, with a lesser contribution by the right atrium. • Faces posteriorly toward the bodies of vertebrae T6 through T9, and is separated from them by the pericardium, oblique pericardial sinus, esophagus, and aorta. • Extends superiorly to the bifurcation of the pulmonary trunk and inferiorly to the coronary groove (sulcus). • Receives the pulmonary veins on the right and left sides of its left atrial portion and the superior and inferior venae cavae at the upper and lower ends of its right atrial portion. The three surfaces of the heart are the: • Anterior (sternocostal) surface, formed mainly by the right ventricle. • Diaphragmatic (inferior) surface, formed mainly by the left ventricle and partly by the right ventricle; the diaphragmatic surface is related to the central tendon of the diaphragm. • Pulmonary (left) surface, formed mainly by the left ventricle; it occupies the cardiac area of the left lung. The four borders of the heart are the: • Right border (vertical, slightly convex), formed by the right atrium and extending between the SVC and IVC. Inferior border (nearly horizontal), formed mainly by the right ventricle and only slightly by the left ventricle Left border (oblique, nearly vertical), formed mainly by the left ventricle and slightly by the left auricle Superior border, formed by the right and left atria and auricles in an anterior view; the ascending aorta and pulmonary trunk emerge from the superior border, and the SVC enters its right side. Posterior to the aorta and pulmonary trunk and anterior to the SVC, the superior border forms the inferior boundary of the transverse pericardial sinus. Right Atrium. This chamber forms the right border of the heart and receives venous blood from the SVC and IVC and the coronary sinus. The earlike right auricle is a small, conical muscular pouch that projects from the right atrium, increasing the capacity of the atrium as it overlaps the ascending aorta. The primordial atrium is represented in the adult by the right auricle. The definitive atrium is enlarged by incorporation of most of the embryonic venous sinus (L. sinus venosus). The coronary sinus lies in the posterior part of the coronary groove and receives blood from the cardiac veins. The coronary sinus is also a derivative of the embryonic venous sinus. The part of the venous sinus incorporated into the primordial atrium becomes the smooth-walled sinus venarum of the adult right atrium. The separation between the primordial atrium - the adult auricle - and the si- nus venarum - the derivative of the venous sinus - is indicated externally by the terminal groove and internally by the terminal crest. The interior of the right atrium has • A smooth, thin-walled posterior part - the sinus venarum - which the SVC, IVC, and coronary sinus open, bringing poorly oxygenated blood into the heart. • A rough, muscular wall composed of pectinate muscles (L. musculi pectinati). • The opening of the SVC into its superior part, at the level of the right third costal cartilage. • The opening of the IVC into the inferior part, almost in line with the SVC at approximately the level of the 5th costal cartilage. • The opening of the coronary sinus between the right AV orifice and IVC orifice. • A right AV orifice through which the right atrium discharges the poorly oxygenated blood into the right ventricle. • The interatrial septum, separating the atria, has an oval, thumbprint-sized depression, the oval fossa (L. fossa ovalis), a remnant of the foramen ovale and its valve in the fetus. Right Ventricle. The right ventricle forms the largest part of the anterior surface of the heart, a small part of the diaphragmatic surface, and almost the entire inferior border of the heart. Superiorly the right ventricle tapers into an arterial cone—the conus arteriosus (infundibulum) that leads into the pulmonary trunk. The interior of the right ventricle has irregular muscular elevations called trabeculae carneae. A thick muscular ridge, the supraventricular crest, separates the ridged muscular wall of the inflow part of the chamber from the smooth wall of the conus arteriosus or outflow part of the right ventricle. The inflow part of the right ventricle receives blood from the right atrium through the right AV orifice, located posterior to the body of the sternum at the level of the 4th and 5th intercostal spaces. The right AV orifice is surrounded by a fibrous ring (part of fibrous skeleton of heart) that resists the dilation that might otherwise result from blood being forced through it. The tricuspid valve guards the right AV orifice. The bases of the valve cusps are attached to the fibrous ring around the orifice. Tendinous cords (L. chordae tendineae) attach to the free edges and ventricular surfaces of the anterior, posterior, and septal cusps—much like the cords attaching to a parachute. Because the cords are attached to adjacent sides of two cusps, they prevent separation of the cusps and their inversion when tension is applied to the cords throughout ventricular contraction (systole); that is, the cusps of the tricuspid valve are prevented from prolapsing (being driven into right atrium) as ventricular pressure rises. Thus, regurgitation of blood (backward flow of blood) from the right ventricle into the right atrium is blocked by the valve cusps. The papillary muscles form conical projections with their bases attached to the ventricular wall and tendinous cords arising from their apices. There are usually three papillary muscles (anterior, posterior, and septal) in the right ventricle that correspond in name to the cusps of the tricuspid valve. The papillary muscles begin to contract before contraction of the right ventricle, tightening the tendinous cords and drawing the cusps together. Contraction is maintained throughout systole. This prevents ventricular blood from passing back (regurgitating) into the right atrium. The interventricular (IV) septum—composed of membranous and muscular parts—is a strong, obliquely placed partition between the right and left ventricles, forming part of the walls of each. The superoposterior membranous part of the IV septum is thin and is continuous with the fibrous skeleton of the heart. The muscular part of the IV septum is thick and bulges into the cavity of the right ventricle because of the higher blood pressure in the left ventricle. The septomarginal trabecula (moderator band) is a curved muscular bundle that runs from the inferior part of the interventricular septum to the base of the anterior papillary muscle. This trabecula is important because it carries part of the right bundle of the AV bundle of the conducting system of the heart, which takes a "short cut" across the chamber of the ventricle to reach the anterior papillary muscle. The right AV orifice is large enough to admit the tips of three fingers. When the right atrium contracts, blood is forced through this orifice into the right ventricle, pulegg the cusps of the tricuspid valve aside like curtains. The inflow of blood into the right ventricle (inflow tract) enters posteriorly, and the outflow of blood into the pulmonary trunk (outflow tract) leaves superiorly and to the left. Conse quently, the blood takes a U-shaped path through the right ventricle. The inflow (AV) orifice and outflow (pulmonary) orifice are approximately 2 cm apart. The pulmonary valve at the apex of the conns arteriosus is at the level of the left 3rd costal cartilage. Each of the semilunar cusps of the pulmonary valve (anterior, right, and left), is concave when viewed superiorly. The pulmonary sinuses are the spaces at the origin of the pulmonary trunk between the dilated wall of the vessel and each cusp of the pulmonary valve. The blood in the pulmonary sinuses prevents the cusps from sticking to the wall of the pulmonary trunk and failing to close. Left Atrium. This heart chamber forms most of the base of the heart. The valveless pairs of right and left pulmonary veins enter the left atrium. The left auricle forms the superior part of the left border of the heart and overlaps thepulmonary trunk. The interior of the left atrium has • A larger smooth-walled part and a smaller muscular auricle containing pectinate muscles. • Four pulmonary veins (two superior and two inferior) entering its posterior wall. • A slightly thicker wall than that of the right atrium. • An interatrial septum that slopes posteriorly and to the right. • A left AV orifice through which the left atrium discharges the oxygenated blood it receives into the left ventricle. The smooth-walled part of the left atrium is formed by absorption of parts of the embryonic pulmonary veins, whereas the rough-walled part, mainly in the auricle, represents the remains of the left part of the primordial atrium. Left Ventricle. This chamber forms the apex of the heart, nearly all of its left (pulmonary) surface and border, and most of the diaphragmatic surface. Because ar- terial pressure is much higher in the systemic than in the pulmonary circulation, the left ventricle performs more work than the right ventricle. The interior of the left ventricle has • A double-leaflet mitral valve that guards the left AV orifice. • Walls that are twice as thick as that of the right ventricle. • A conical cavity that is longer than that of the right ventricle. • Walls that are covered with thick muscular ridges—trabeculae carneae—that are more numerous than in the right ventricle. • Anterior and posterior papillary muscles that are larger than those in the right ventricle because this ventricle works harder. • A superoanterior outflow part formed by the smooth-walled aortic vestibule leading to the aortic orifice. • An aortic orifice that lies in its right posterosuperior part and is surrounded by a fibrous ring to which the right, posterior, and left cusps of the aortic valve are attached. The mitral valve closing the orifice between the left atrium and left ventricle has two cusps, anterior and posterior. "Mitral" derives from the valve's resemblance to a bishop's miter (headdress). The mitral valve is located posterior to the sternum at the level of the 4th costal cartilage. Each of its cusps receives tendinous cords from more than one papillary muscle. These muscles and their cords support the mitral valve, allowing the cusps to resist the pressure developed during contractions (pumping) of the left ventricle. The cords become taut, preventing the cusps from being forced (prolapsed) into the left atrium. The ascending aorta, approximately 2.5 cm in diameter, begins at the aortic orifice. The aortic valve, obliquely placed, is located posterior to the left side of the sternum at the level of the 3rd intercostal space. Superior to each valve, dilations of the aortic wall form aortic sinuses. Materials for self-check: A. Tasks for self-check: on the preparations, tables, models to study the external structure of the heart, its shape, position, heart chambers, structure of the heart, heart valves, heart wall structure. B. Choose the correct answer. 1. Contraction of a great vessel reduced blood derivation from the left ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein. B. Pulmonary trunk, C. Aorta. D. Superior vena cava. E. Inferior vena cava. 2. Blood pressure rise in aorta increased the load of the cardiac muscle. The muscular wall of which region of the heart reacts to irritation? A. Left ventricle. B. Left atrium. C. Right ventricle. D. Right atrium. E. Venous sinus. 3. Blood pressure rise in a great vessel, which carries blood to lungs, increased the load of the cardiac muscle. The muscular wall of which region of the heart reacts to irritation? A. Right ventricle. B. Left ventricle. C. Right atrium. D. Left atrium. E. Venous sinus. 4. Examining a teenager a doctor detected a congenital heart disease - patent ductus arteriosus. What structures docs the duct join in the period of prenatal development? A. Right and left atriums. B. Right and left ventricles. C. Aorta and inferior vena cava. D. Pulmonary trunk and aorta. E. Pulmonary trunk and superior vena cava. 5. Usually, if a patient has essential hypertension, his left cardiac border is shifted to the left. Due to which chambers of heart or vessels does it happen? A. Left atrium. B. Left ventricle. C. Left ventricle and left atrium. D. Arch of aorta E. Pulmonary trunk. 6. During the ultrasonic examination of the heart, a doctor observes semilunar cusps. What happens to them at diastole (relaxation) of ventricles? A. Interlock, closing the lumen of vessels. B. Turn out into the lumen of vessels. C. Turn out into the lumen of ventricles. D. Press to the vessels walls. E. Press to the ventricle walls. 7. An inflammatory process in endocardium (endocarditis) is diagnosed. Which structure of heart is damaged in case of this pathology? A. Myocardium. B. Conducting system of heart. C. Coronary artery. D. Cardiac bursa. E. Cardiac valve. 8. A patient has significant enlargement of the left atrium, enlarged liver. Which structure of heart is damaged? A. Valva tricuspidalis. B. Valva aortae. C. Valva bicuspidalis. D. Valva pulmonalis. E. Auricula sinistra. 9. During the period of prenatal development in the vascular system of a fetus an arterial duct functions, which turns into lig. arteriosum after birth. What vessels does it join? A. Pulmonary trunk and aorta. B. Right and left atrium. C. Aorta and inferior vena cava. D. Pulmonary trunk and superior vena cava. E. Aorta and superior vena cava. 10. A patient has symptoms of arterial duct nonclosure. Which vessels does it join? A. Aorta and pulmonary trunk. B. Aorta and inferior vena cava. C. Aorta and superior vena cava. D. Pulmonary artery and superior vena cava. E. Pulmonary artery and inferior vena cava. References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 2. Anatomy of the heart: vessels and nerves of the heart, the conducting system of the heart. 1. Relevance of the topic. Information about vessels, nerves and conducting system of the heart is important for understanding of the work of the heart. The knowledges of the structure of the heart, its topography required for students in the studying of many clinical disciplines, such as therapy, surgery and others. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of tissues which form the walls of the heart Cardiology Call the function and influence on heart activity of the sympathetic and parasympathetic innervation

4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Truncus pulmonalis Pulmonary trunk Arteria coronaria sinistra / dextra Coronary artery left / right Bifurcatio trunci pulmonalis Bifurcation of pulmonary trunk Arteria pulmonalis Pulmonary artery 4.2. Theoretical questions for the class: 1. Coronary arteries: origin, branches, regions of supplying. 2. Veins of the heart, regions of venous drainage. 3. Structure of conducting system of the heart. 4. Nerves of the heart, nervous plexuses. 4.3. Practical task pertaining to the topic and to be completed during the class: on the preparations, tables, models to study vessels of the heart, conducting system of the heart. Content of the topic. Arterial Supply Of the Heart. The coronary arteries — the 1st branches of the aorta — supply the myocardium and epicardium. The right and left coronary arteries arise from the corresponding aortic sinuses at the proximal part of the ascending aorta, just superior to the aortic valve. The coronary arteries supply both the atria and ventricles; however, the atrial branches are usually small. The right coronary artery (RCA) arises from the right aortic sinus of the ascending aorta and runs in the coronary groove (sulcus). Near its origin, the RCA usually gives off an ascending sinuatrial (SA) nodal branch that supplies the sinuatrial (SA) node — the mass of specialized cardiac muscle fibers that normally act as the "pacemaker" of the cardiac conducting system. The RCA then descends in the coronary groove and gives off the right marginal branch that supplies the right border of the heart as it runs toward (but does not reach) the apex of the heart. After giving off this branch, the RCA turns to the left and continues in the coronary groove on the posterior aspect of the heart. At the crux (cross) of the heart, the junction of the septa and walls of the four heart chambers, the RCA gives rise to the AV nodal branch, which supplies the AV node, a circumscribed mass of modified cardiac muscle fibers that gives rise to the AV bundle of the conduction system of the heart. The RCA then gives off the large posterior interventricular (IV) artery that descends in the posterior IV groove toward the apex of the heart. The posterior IV artery supplies both ventricles and sends perforating IV septal branches to the IV septum. Near the apex of the heart, the RCA anastomoses with the circumflex and anterior IV branches of the left coronary artery. Typically, the RCA supplies: • The right atrium. • Most of right ventricle. • Part of left ventricle (diaphragmatic surface). • Part of IV septum (usually posterior third). • The SA node (in approximately 60% of people). • The AV node (in approximately 80% of people). The left coronary artery (LCA) arises from the left aortic sinus of the ascending aorta and passes between the left auricle and pulmonary trunk in the coronary groove. In approximately 40% of people, the SA nodal branch arises from the circumflex branch of the LCA and ascends on the posterior surface of the left atrium to the SA node. At the left end of the coronary groove—located just left of the pulmonary trunk—the LCA divides into two branches, an anterior IV branch (left anterior descending branch, LAD branch) and a circumflex branch. The anterior IV branch passes along the IV groove to the apex of the heart. Here it turns around the inferior border of the heart and anastomoses with the posterior IV branch of the right coronary artery. The anterior IV branch supplies both ventricles and the IV septum. In many people, the anterior IV artery gives rise to a lateral (diagonal) branch, which descends on the anterior surface of the heart. The smaller circumflex branch of the LCA follows the coronary groove around the left border of the heart to the posterior surface of the heart. The left marginal artery, a branch of the circumflex branch, follows the left margin of the heart and supplies the left ventricle. The circumflex branch of the LCA terminates on the posterior aspect of the heart and often anastomoses with the posterior IV branch of the RCA. Typically, the LCA supplies: • The left atrium. • Most of left ventricle. • Part of right ventricle. • Most of IV septum (usually its anterior two-thirds), including the AV bundle of conducting tissue, through its perforating IV septal branches. • The SA node (in approximately 40% of people). Venous Drainage of the Heart. The heart is drained mainly by veins that empty into the coronary sinus, and partly by small anterior cardiac veins that empty directly into the right atrium and the other heart chambers (smallest cardiac veins). The coronary sinus, the main vein of the heart, is a wide venous channel that runs from left to right in the posterior part of the coronary groove. The coronary sinus receives the great cardiac vein — the main tributary of the sinus — at its left end and the middle and small cardiac veins at its right end. The left posterior vein and left marginal vein also open into the coronary sinus. The smallest cardiac veins (L. venae cordis minimae) are minute vessels that begin in the capillary beds of the myocardium and open directly into the chambers of the heart, chiefly the atria. Although called veins, they are valveless communications with the capillary beds of the myocardium and may carry blood from the heart chambers to the myocardium; thus, they provide a collateral circulation to the heart musculature. Conducting System of the Heart. The impulse-conducting system — which coordinates the cardiac cycle —consists of cardiac muscle cells and highly specialized conducting fibers for initiating impulses and conducting them rapidly through the heart. Nodal tissue initiates the heartbeat and coordinates the contractions of the four heart chambers. The sinuatrial (SA) node gives off an impulse about 70 times per minute in most people. The SA node — the pacemaker of the heart — is located anterolaterally just deep to the epi-cardium at the junction of the SVC and right atrium. The atrioventricular (AV) node is a smaller collection of nodal tissue located in the posteroinferior region of the interatrial septum near the opening of the coronary sinus. The signal generated by the SA node passes through the walls of the right atrium propagated by the cardiac muscle (myogenic conduction), which transmits the signal rapidly from the SA node to the AV node. The AV node then distributes the signal to the ventricles through the atrioventricular (AV) bundle—a group of modified cardiac muscle fibers. Sympathetic stimulation speeds up the rate at which impulses are generated and conducted. Parasympathetic stimulation slows down the rate at which impulses are generated and conducted. The AV bundle, the only bridge between the atrial and ventricular myocardium, passes from the AV node through the fibrous skeleton of the heart and along the membranous part of the IV septum. At the junction of the membranous and muscular parts of the septum, the AV bundle divides into right and left bundle branches. The bundles proceed on each side of the muscular IV septum deep to the endocardium and then ramify into subendocardial branches (Purkinje fibers), which extend into the walls of the respective ventricles. The subendocardial branches of the right bundle stimulate the muscle of the IV septum, the anterior papillary muscle (through the septomarginal trabecula or moderator band), and the wall of the right ventricle. The subendocardial branches of the left bundle stimulate the IV septum, the anterior and posterior papillary muscles, and the wall of the left ventricle. Summary of conducting system of heart: • The SA node initiates an impulse that is rapidly conducted to cardiac muscle fibers in the atria, causing them to contract. • The impulse spreads by myogenic conduction that rapidly transmits the impulse from the SA node to the AV node. • The signal is distributed from the AV node through the AV bundle and the right and left bundle branches, which pass on each side of the IV septum to supply subendocardial branches to the papillary muscles and the walls of the ventricles. INNERVATION OF THE HEART. The heart is supplied by autonomic nerve fibers from superficial and deep cardiac plexuses. These nerve networks lie anterior to the bifurcation of the trachea, posterior to the ascending aorta, and superior to the bifurcation of the pulmonary trunk. The sympathetic supply of the heart is from presynaptic fibers with cell bodies in the intermediolateral cell columns (lateral horns) of the superior five or six thoracic segments of the spinal cord, and from postsynaptic sympathetic fibers with cell bodies in the cervical and superior thoracic paravertebral ganglia of the sympathetic trunks. The postsynaptic fibers end in the SA and AV nodes and in relation to the terminations of parasympathetic fibers on the coronary arteries. Sympathetic stimulation of the nodal tissue increases the heart's rate and the force of its contractions. Sympathetic stimulation (indirectly) produces dilation of the coronary arteries by inhibiting their constriction. This supplies more oxygen and nutrients to the myocardium during periods of increased activity. The parasympathetic supply of the heart is from presynaptic fibers of the vagus nerves (CN X). The postsynaptic parasympathetic fibers also end in the SA and AV nodes and directly on the coronary arteries. The cell bodies of the postsynaptic fibers constitute intrinsic ganglia in the vicinity of these structures. Stimulation of parasympathetic nerves slows the heart rate, reduces the force of the heartbeat, and constricts the coronary arteries, saving energy between periods of increased demand. Materials for self-check: A. Tasks for self-check: examine the topography of the heart, vessels, conducting system, innervation of the heart using the diagrams, models and cadaver preparations. B. Choose the correct answer. 1. A 58-year-old patient is admitted to a cardiological clinic with acute persistent pain in substernal area, which does not reduce after the second taking of nitroglycerine. Electrocardiogram shows that he has big necrosis of the posterior surface of the heart. The diagnosis is transmural myocardial infarction of the posterior wall of the heart. Acute occlusion of which vessel led to this disease? A. Right coronary artery. B. Coronary sinus. C. Right pulmonary artery. D. Left coronary artery. E. Left common carotid artery. 2. A patient has an infarction the anterior wall of the left ventricle. Blood circulation of which vessel is damaged? A. Anterior interventricular branch the left coronary artery. B. Atrioventricular branches of the right coronary artery. C. Circumflex branch of the left coronary artery. D. Posterior interventricular branch of the right coronary artery. E. Left marginal branch of the left coronary artery. 3. Examining a patient ischemic disease a doctor detected deterioration of venous blood flow in the one of a cardiac vein, which passes through the anterior interventricular sulcus. Which vein is this? A. V. cordis parva. B. V. cordis media. C. V. cordis magna. D. V. posterior ventriculi sinistri. E. V. obliqua atrii sinistri. 4. During the period of prenatal development in the vascular system of a fetus an arterial duct functions, which turns into lig. arteriosum after birth. What vessels does it join? A. Pulmonary trunk and aorta. B. Right and left atrium. C. Aorta and inferior vena cava. D. Pulmonary trunk and superior vena cava. E. Aorta and superior vena cava. 5. A patient has symptoms of arterial duct nonclosure. Which vessels does it join? A. Aorta and pulmonary trunk. B. Aorta and inferior vena cava. C. Aorta and superior vena cava. D. Pulmonary artery and superior vena cava. E. Pulmonary artery and inferior vena cava. 6. A patient has ischemic disease and extensive myocardial infraction of the posterior wall of the right ventricle diagnosed. Blood circulation of which artery basin is violated? A. Posterior interventricular branch of the right coronary artery. B. Anterior interventricular branch of the left coronary artery. C. Circumflex branch of the left coronary artery. D. Pericardiacophrenic artery. E. A trial branches of the left coronary artery. 7. A patient has anteroapical myocardial infarction caused by thrombosis of a vessel of heart. Which vessel is it? A. Pericardiacophrenic artery. B. Posterior intcrventricular branch of the right coronary artery. C. Circumflex branch of the left coronary artery. D. Anterior interventricular branch of the left coronary artery. E. Atrial branches of the left coronary artery. 8. During examination, a patient has myocardial infarction of the anterior septum diagnosed. Blood circulation of which vessel of heart is violated? A. Anterior interventricular branch of the left coronary artery. B. Posterior interventricular branch of the right coronary artery. C. Circumflex branch of the left coronary artery. D. Atrial branches of the left coronary artery. E. Pericardiacophrenic artery. 9. A patient has infarction of the posterior part of the interventricular septurn diagnosed. Blood circulation of which vessel is violated? A. R. interventricular posterior. B. R. marginalis dexter. C. R. atrialis intermedius. D. R. circumflexus. E. R. marginalis sinister. 10. A 52-year-old patient was admitted to a hospital with complaints of unbearable substernal pain, asphyxia. Examination has shown myocardial infarction of the anterior wall of the left ventricle. Which artery of heart is damaged? A. Anterior interventricular branch of the left coronary artery. B. Posterior interventricular branch of the right coronary artery. C. Right coronary artery. D. Circumflex branch of the left coronary artery. E. Pericardiacophrenic artery. References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 3. Circles of blood circulation. The pericardium. Topography of the heart. 1. Relevance of the topic. Topography of the heart and big vessels are important for the internists for auscultation of the heart. The knowledges of the structure of the heart, its topography required for students in the studying of many clinical disciplines, such as therapy, surgery and others. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of tissues which form the walls of the heart

Cardiology Call the function and influence on heart activity of the sympathetic and parasympathetic innervation, find places of the auscultation, borders of the heart Radiology To determine the position of the X-ray examination of the heart 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Truncus pulmonalis Pulmonary trunk Vena pulmonalis Pulmonary vein Aorta Aorta Pericardium Pericardium A. carotis communis Common carotid artery 4.2. Theoretical questions for the class: 1. Structure of the fibrous pericardium. 2. Structure of serous pericardium. 3. Pericardial sinuses. 4. Projections of the heart on the wall of the body. 4.3. Practical task pertaining to the topic and to be completed during the class: specify projections of the borders of the heart and vessels on the anterior surface of the chest, layers of pericardium and its structures. Content of the topic. The pericardium is a fibroserous sac that encloses the heart and the roots of the great blood vessels. It lies within the middle mediastinum. Fibrous Pericardium The fibrous pericardium is the fibrous part of the sac. It is strong and limits unnecessary movements of the heart. It fuses above with the walls of the great blood vessels (ascending aorta, pulmonary trunk, superior and inferior venae cavae, and the pulmonary veins). It is firmly attached below to the central tendon of the diaphragm. It is attached anteriorly to the sternum by the sternopericardial ligaments. Serous Pericardium The serous pericardium has parietal and visceral layers. The parietal layer lines the fibrous pericardium and is reflected around the roots of the great vessels to become continuous with the visceral layer that closely covers the heart (epicardium). The pericardial cavity is the slitlike space between the parietal and visceral layers. The pericardial fluid is a small amount of fluid normally present in the pericardial cavity to act as a lubricant to facilitate cardiac movements. Pericardial Sinuses The transverse sinus is a passage on the posterior surface of the heart that lies between the reflection of serous pericardium around the ascending aorta and pulmonary trunk and the reflection around the great veins. The oblique sinus is a recess formed by the reflection of the serous pericardium around the venae cavae and the four pulmonary veins. Surface anatomy of the heart and great vessels The heart and great vessels are approximately in the middle of the thorax, surrounded laterally and posteriorly by the lungs and bounded anteriorly by the sternum and the central part of the thoracic cage. The apex beat is an impulse that results from the apex being forced against the anterior thoracic wall when the left ventricle contracts. The location of the apex beat varies in position and may be located in the 4th or 5th intercostal spaces, 6 to 10 cm from the midline of the thorax. The outline of the heart can be traced on the anterior surface of the thorax by using these guidelines: • The superior border of heart corresponds to a line connecting the inferior border of the 2nd left costal cartilage to the superior border of the 3rd right costal cartilage. • The right border of the heart corresponds to a line drawn from the 3rd right costal cartilage to the 6th right costal cartilage; this border is slightly convex to the right. • The inferior border of the heart corresponds to a line drawn from the inferior end of the right border to a point in the 5th intercostal space close to the left midclavicular line; the left end of this line corresponds to the location of the apex of the heart and the apex beat. • The left border of the heart corresponds to a line connecting the left ends of the lines representing the superior and inferior borders. • The pulmonary, aortic, mitral, and tricuspid valves are located posterior to the sternum; however, the sounds produced by them are best heard at the auscultatory areas illustrated: pulmonary (P), aortic (A), mitral (M), tricuspid (T). Clinicians' interest in the surface anatomy of the heart and the location of the valves results from their need to listen to the valve sounds. Because the auscultatory areas are wide apart, the sounds produced at any given valve may be clearly distinguished from those produced at other valves. Blood tends to carry the sound in the direction of its flow. Each area is situated superficial to the chamber or vessel into which the blood has passed and in a direct line with the valve orifice. Materials for self-check: A. Tasks for self-check: specify projections of the borders of the heart and vessels on the anterior surface of the chest, layers of pericardium and its structures. B. Choose the correct answer: 1. In a patient revealed pericarditis (an accumulation of serous fluid in the sinuses of the pericardial space). Specify the pericardial sinuses. A. Sinus transversus verticalis. B. Dexter et sinister sinus pericardii. C. Sinus transversus pericardii et sinus rectus. D. Sinus obliquus pericardii et sinus superior. E. Sinus transversus pericardii et sinus obliquus pericardii. 2. Ultrasound scan of pregnant woman revealed violations in the cardiovascular system of the fetus, venous duct function. Determine, what vessels does venous duct connect? A. Umbilical vein and inferior vena cava B. Pulmonary trunk and aorta C. Pulmonary trunk and inferior vena cava D. Umbilical vein and aorta E. Umbilical vein and umbilical artery 3. The patient, 32 years old, was diagnosed mitral valve insufficiency. What part of the heart this valve is located? A. Between the left atrium and the left ventricle. B. Between the right atrium and the right ventricle. C. Between the left and right atrium. D. Between the left and right ventricle. E. Where there is the output of the aorta. 4. The patient, 30 years old, was diagnosed tricuspid valve insufficiency. What part of the heart this valve is located? A. Between the left atrium and the left ventricle. B. Between the right atrium and the right ventricle. C. Between the left and right atrium. D. Between the left and right ventricle. E. Where there is the output of the aorta. 5. During examination of the child revealed a cleft oval foramen. What part of the heart is the foramen located? A. Between the right atrium and the right ventricle. B. Between the left and right atrium. C. Between the left atrium and the left ventricle. D. Between the left and right ventricles. E. In the area of the mitral valve. References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 4. The aorta. The branches of aortic arch. The common carotid artery. The internal carotid artery. 1. Relevance of the topic. Aorta is a bigest vessel in the human body, from it arises greater circulation. The internal carotid artery is involved in the blood supply of the brain and its membranes, the date artery is anastomozing with the branches of the external carotid artery. Knowledge of the internal carotid artery and its branches is necessary for students in the future in diagnosis in clinics neurosurgery, nerve and eye diseases. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the big arterious vessels Cardiology Describe the relevant areas of blood supply of the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Aorta; pars ascendens aortae aorta; descending aorta Sinus aortae, bulbus aortae aortic sinus; aortic bulb Arteria carotis communis; Bifurcatio common carotid artery; carotid bifurcation carotidis Arcus aortae; Truncus brachiocephalicus; aortic arch; brachiocephalic trunc; Arteria carotis externa external carotid artery

4.2. Theoretical questions for the class: 1. Parts of aorta, branches of the arch of aorta. 2. Common carotid arteries. 3. Parts of the internal carotid artery. 4. Branches of petrous and cavernous parts of internal carotid artery. 5. Branches of cerebral part of internal carotid artery. 4.3. Practical work (tasks) that are executed on employment: specify place of origin of aorta, its parts, branches of arch of aorta. Find differences in place of origin of right and left common carotid arteries, parts and division of common carotid artery. Show on cadaver preparations, tables point of origin of internal carotid artery, its parts, branches of each part, regions of supplying. Content of the topic. The AORTA is the main trunk of a series of vessels which convey the oxygenated blood to the tissues of the body for their nutrition. It commences at the upper part of the left ventricle, where it is about 3 cm. in diameter, and after ascending for a short distance, arches backward and to the left side, over the root of the left lung; it then descends within the thorax on the left side of the vertebral column, passes into the abdominal cavity through the aortic hiatus in the diaphragm, and ends, considerably diminished in size (about 1.75 cm. in diameter), opposite the lower border of the fourth lumbar vertebra, by dividing into the right and left common iliac arteries. Hence it is described in several portions, viz., the ascending aorta, the arch of the aorta, and the descending aorta, which last is again divided into the thoracic and abdominal aortae. The Arch of the Aorta (Arcus Aortae; Transverse Aorta) — The arch of the aorta begins at the level of the upper border of the second sternocostal articulation of the right side, and runs at first upward, backward, and to the left in front of the trachea; it is then directed backward on the left side of the trachea and finally passes downward on the left side of the body of the fourth thoracic vertebra, at the lower border of which it becomes continuous with the descending aorta. It thus forms two curvatures: one with its convexity upward, the other with its convexity forward and to the left. Its upper border is usually about 2.5 cm. below the superior border to the manubrium sterni. Branches. The branches given off from the arch of the aorta are three in number: the brachiocephalic trunk, the left common carotid, and the left subclavian. The brachiocephalic trunk (truncus Brachiocephalicus) is the largest branch of the arch of the aorta, and is from 4 to 5 cm. in length. It arises, on a level with the upper border of the second right costal cartilage, from the commencement of the arch of the aorta, on a plane anterior to the origin of the left carotid; it ascends obliquely upward, backward, and to the right to the level of the upper border of the right sternoclavicular articulation, where it divides into the right common carotid and right subclavian arteries. The Common Carotid Artery (A. Carotis Communis). The common carotid arteries differ in length and in their mode of origin. The right begins at the bifurcation of the brachiocephalic artery behind the sternoclavicular joint and is confined to the neck. The left springs from the highest part of the arch of the aorta to the left of, and on a plane posterior to the brachiocephalic artery, and therefore consists of a thoracic and a cervical portion. The INTERNAL CAROTID ARTERY supplies the anterior part of the brain, the eye and its appendages, and sends branches to the forehead and nose. It is remarkable for the number of curvatures that it presents in different parts of its course. It occasionally has one or two flexures near the base of the skull, while in its passage through the carotid canal and along the side of the body of the sphenoid bone it describes a double curvature and resembles the italic letter S. Course and Relations. In considering the course and relations of this vessel it may be divided into four portions: cervical (on neck), petrous (in carotid canal of temporal bone), cavernous (in cavernous sinus), and cerebral (on the brain). Branches. The cervical portion of the internal carotid gives off no branches. Those from the other portions are: From the Petrous Portion Caroticotympanic. Artery of the Pterygoid Canal. From the Cavernous Portion Cavernous. Anterior Meningeal. Ophthalmic. From the Cerebral Portion Anterior Cerebral. Middle Cerebral. Posterior Communicating. Choroidal.

1. The caroticotympanic branch (ramus caroticotympanicus; tympanic branch) is small; it enters the tympanic cavity through a minute foramen in the carotid canal, and anastomoses with the anterior tympanic branch of the maxillary, and with the stylomastoid artery. 2. The artery of the pterygoid canal (a. canilis pterygoidei [Vidii]; Vidian artery) is a small, inconstant branch which passes into the pterygoid canal and anastomoses with a branch of the maxillary artery. 3. The cavernous branches are numerous small vessels which supply the hypophysis, the semilunar ganglion, and the walls of the cavernous and inferior petrosal sinuses. Some of them anastomose with branches of the middle meningeal. 4. The anterior meningeal branch (a. meningea anterior) is a small branch which passes over the small wing of the sphenoid to supply the dura mater of the anterior cranial fossa; it anastomoses with the meningeal branch from the posterior ethmoidal artery. 5. The ophthalmic artery (a. ophthalmica) arises from the internal carotid, just as that vessel is emerging from the cavernous sinus, on the medial side of the anterior clinoid process, and enters the orbital cavity through the optic foramen, below and lateral to the optic nerve. It then passes over the nerve to reach the medial wall of the orbit, and thence horizontally forward, beneath the lower border of the Obliquus superior, and divides it into two terminal branches, the frontal and dorsal nasal. As the artery crosses the optic nerve it is accompanied by the nasociliary nerve, and is separated from the frontal nerve by the Rectus superior and Levator palpebrae superioris. 6. The anterior cerebral artery (a. cerebri anterior) arises from the internal carotid, at the medial extremity of the lateral cerebral fissure. It passes forward and medialward across the anterior perforated substance, above the optic nerve, to the commencement of the longitudinal fissure. Here it comes into close relationship with the opposite artery, to which it is connected by a short trunk, the anterior communicating artery. From this point the two vessels run side by side in the longitudinal fissure, curve around the genu of the corpus callosum, and turning backward continue along the upper surface of the corpus callosum to its posterior part, where they end by anastomosing with the posterior cerebral arteries. 7.The middle cerebral artery (a. cerebri media), the largest branch of the internal carotid, runs at first lateralward in the lateral cerebral or Sylvian fissure and then backward and upward on the surface of the insula, where it divides into a number of branches which are distributed to the lateral surface of the cerebral hemisphere. 8.The posterior communicating artery (a. communicans posterior) runs backward from the internal carotid, and anastomoses with the posterior cerebral, a branch of the basilar. From its posterior half are given off a number of small branches, the postero-medial ganglionic branches, which, with similar vessels from the posterior cerebral, pierce the posterior perforated substance and supply the medial surface of the thalami and the walls of the third ventricle. The anterior choroidal (a. chorioidea; choroid artery) is a small but constant branch, which arises from the internal carotid, near the posterior communicating artery. Passing backward and lateralward between the temporal lobe and the cerebral peduncle, it enters the inferior horn of the lateral ventricle through the choroidal fissure and ends in the choroid plexus. It is distributed to the hippocampus, fimbria, tela chorioidea of the third ventricle, and choroid plexus. Materials for self-check: A. Tasks for self-check: specify place of origin of aorta, its parts, branches of arch of aorta. Find differences in place of origin of right and left common carotid arteries, parts and division of common carotid artery. Show on cadaver preparations, tables point of origin of internal carotid artery, its parts, branches of each part, regions of supplying. B. Choose the correct answer. 1. A 56-year-old patient has worked for 28 years at a chemical plant in a workshop with harmful productions conditions. He often has hemorrhages of the nasal cavity mucosa. Which arteries involved? A. Anterior and posterior ethmoidal B. Supraorbital. C. Ciliary. D. Anterior cerebral. E. Ophthalmic. 2. An 18-year-old man was admitted to a hospital after a car accident. In the traumathology center numerous traumas of soft tissues of the face in the region of the medial angle of eye ac¬companied by profuse bleeding were detected. What arterial anastomosis is formed in this region? A. A. carotis externa et a. carotis interna. B. A. carotis externa et a. subclavia. C. A. carotis interna et a. subclavia. D. A. subclavia et a. ophthalmica. E. A. carotis interna et a. ophthalmica. 3. A 80 year-old patient had hemorrhage of the brain and was taken to the hospital. The place of hemorrhage was revealed on the lateral hemispheres surfaces during the medical examination. What artery was injured? A. The middle cerebral artery B. The anterior cerebral artery C. The posterior cerebral artery D. The anterior communicating artery E. The posterior communicating artery 4. A 70 year-old patient had hemorrhage of the brain and was taken to the hospital. The place of hemorrhage was revealed on the lateral hemispheres surfaces during the medical examination. Artery running along the lateral sulcus and giving numerous branches was damaged. What artery was injured? A. The middle cerebral artery B. The anterior cerebral artery C. The posterior cerebral artery D. The anterior communicating artery E. The posterior communicating artery 5. Which triangle of the neck is situated common carotid artery? A. Omotrapezoid B. Omoclavicular C. Submental D. Submandibular E. Carotid 6. What are the boundaries of the carotid triangle? A. Anterior belly of digastric, superior belly of omohyoid, sternocleidomastoid B. Posterior belly of digastric, inferior belly of omohyoid, sternocleidomastoid C. Posterior belly of digastric, sternocleidomastoid D. Posterior belly of digastric, superior belly of omohyoid, sternocleidomastoid E. Anterior belly of digastric, thyrohyoid, sternocleidomastoid 7. An injured man has bleeding from branches of carotid artery. For a temporary arrest of bleeding it is necessary to press the carotid artery to the tubercle of a cervical vertebra. Which vertebra is it? A. VI B. V C. IV D. III E. II 8. A patient with inflammation of the cells of the ethmoid bone (ethmoiditis) was identified violations of the blood supply. Branches of what artery is supplied by the ethmoid labyrinth? A. A. cerebri anterior. B. A. infraorbitalis. C. A. facialis. D. A. ophthalmica. E. A. transversa facei. 9. Specify the terminal branches of the common carotid artery. A. Subclavian artery B. Maxillary artery C. Internal and external carotid arteries D. Axillary artery E. Vertebral artery 10. Specify the level of bifurcation of the common carotid artery. A. The body of the mandible B. The upper edge of the thyroid cartilage C. The lower edge of the thyroid cartilage D. Arch of cricoid cartilage E. The first tracheal cartilage ring References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 5. The external carotid artery. 1. Relevance of the topic. External carotid artery supplies external tissues of the head. Anterior group of its branches supplies region of the face – the point of attention of the stomatologist. External carotid artery supplies external tissues of the head. Middle and posterior groups of branches are supply the internal organs of the head and neck – neighbouring to the workregion of the stomatologist. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the arterious vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Arteria maxillaris Maxillary artery A. tympanica Tympanic artery A. alveolaris inferior/ superior Alveolar artery lower / upper A. facialis Facial artery A. lingualis Lingual artery A. temporalis superficialis Superficial temporal artery 4.2. Theoretical questions for the class: 1. Origin of external carotid artery, groups of branches. 2. Superior thyroid artery. 3. Lingual artery. 4. Cervical part of facial artery. 5. Facial part of facial artery. 6. Posterior branches of external carotid artery. 7. Ascending pharyngeal and superficial temporal arteries. 8. Mandibular portion of maxillary artery. 9. Pterygoid portion of maxillary artery. 10. Pterygopalatine portion of maxillary artery. 4.3. Practical task pertaining to the topic and to be completed during the class: specify point of origin of external carotid artery, name groups of branches of external carotid artery, branches in each groups, their arteries and regions of supplying. Content of the topic. The EXTERNAL CAROTID ARTERY begins opposite the upper border of the thyroid cartilage, and, taking a slightly curved course, passes upward and forward, and then inclines backward to the space behind the neck of the mandible, where it divides into the superficial temporal and maxillary arteries. At its origin, this artery is more superficial, and placed nearer the middle line than the internal carotid, and is contained within the carotid triangle. Branches. The branches of the external carotid artery may be divided into three sets. Anterior: Superior Thyroid (1) Lingual (2) Facial (3) Posterior: Occipital (4) Posterior auricular (5) Sterno-cleido-mastoideus (6) Medial: Ascending pharyngeal (7) Superficial Temporal (8) Maxillary (9) The superior thyroid artery (a. thyreoidea superior) arises from the external carotid artery just below the level of the greater cornu of the hyoid bone and ends in the thyroid gland. Branches. It distributes twigs to the adjacent muscles, and numerous branches to the thyroid gland, anastomosing with its fellow of the opposite side, and with the inferior thyroid arteries. The branches to the gland are generally two in number; one, the larger, supplies principally the anterior surface; on the isthmus of the gland it anastomoses with the corresponding artery of the opposite side: a second branch descends on the posterior surface of the gland and anastomoses with the inferior thyroid artery. Besides the arteries distributed to the muscles and to the thyroid gland, the branches of the superior thyroid are: • Hyoid. • Superior Laryngeal. • Sternocleidomastoid. • Cricothyroid. The Hyoid Branch (ramus hyoideus; infrahyoid branch) is small and runs along the lower border of the hyoid bone beneath the Thyreohyoideus and anastomoses with the vessel of the opposite side. The Sternocleidomastoid Branch (ramus sternocleidomastoideus; sternomastoid branch) runs downward and lateralward across the sheath of thecommon carotid artery, and supplies the Sternocleidomastoideus and neighboring muscles and integument; it frequently arises as a separate branch from the external carotid. The Superior Laryngeal Artery (a. laryngea superior), larger than either of the preceding, accompanies the internal laryngeal branch of the superior laryngeal nerve, beneath the Thyreohyoideus; it pierces the hyothyroid membrane, and supplies the muscles, mucous membrane, and glands of the larynx, anastomosing with the branch from the opposite side. The Cricothyroid Branch (ramus cricothyreoideus) is small and runs transversely across the cricothyroid membrane, communicating with the artery of the opposite side. The lingual artery (a. lingualis) arises from the external carotid between the superior thyroid and facial; it first runs obliquely upward and medialward to the greater cornu of the hyoid bone; it then curves downward and forward, forming a loop which is crossed by the hypoglossal nerve, and passing beneath the Digastricus and Stylohyoideus it runs horizontally forward, beneath the Hyoglossus, and finally, ascending almost perpendicularly to the tongue, turns forward on its lower surface as far as the tip, under the name of the profunda linguae. Branches. The branches of the lingual artery are: • Hyoid. • Sublingual. • Dorsales linguae. • Profunda linguae. The Hyoid Branch (ramus hyoideus; suprahyoid branch) runs along the upper border of the hyoid bone, supplying the muscles attached to it and anastomosing with its fellow of the opposite side. The Arteria Dorsales Linguae (rami dorsales linguae) consist usually of two or three small branches which arise beneath the Hyoglossus; they ascend to the back part of the dorsum of the tongue, and supply the mucous membrane in this situation, the glossopalatine arch, the tonsil, soft palate, and epiglottis; anastomosing with the vessels of the opposite side. The Sublingual Artery (a. sublingualis) arises at the anterior margin of the Hyoglossus, and runs forward between the Genioglossus and Mylohyoideus to the sublingual gland. It supplies the gland and gives branches to the Mylohyoideus and neighboring muscles, and to the mucous membrane of the mouth and gums. One branch runs behind the alveolar process of the mandible in the substance of the gum to anastomose with a similar artery from the other side; another pierces the Mylohyoideus and anastomoses with the submental branch of the facial artery. The Arteria Profunda Linguae (deep lingual artery) is the terminal portion of the lingual artery; it pursues a tortuous course and runs along the under surface of the tongue, below the Longitudinalis inferior, and above the mucous membrane; it lies on the lateral side of the Genioglossus, accompanied by the lingual nerve. At the tip of the tongue, it is said to anastomose with the artery of the opposite side, but this is denied by Hyrtl. In the mouth, these vessels are placed one on either side of the frenulum linguae. The facial artery (a. facialis) arises in the carotid triangle a little above the lingual artery and, sheltered by the ramus of the mandible, passes obliquely up beneath the Digastricus and Stylohyoideus, over which it arches to enter a groove on the posterior surface of the submaxillary gland. It then curves upward over the body of the mandible at the antero-inferior angle of the Masseter; passes forward and upward across the cheek to the angle of the mouth, then ascends along the side of the nose, and ends at the medial commissure of the eye, under the name of the angular artery. This vessel, both in the neck and on the face, is remarkably tortuous: in the former situation, to accommodate itself to the movements of the pharynx in deglutition; and in the latter, to the movements of the mandible, lips, and cheeks. Branches.—The branches of the artery may be divided into two sets: those given off in the neck (cervical), and those on the face (facial). Cervical branches: • Ascending Palatine. • Tonsillar • Glandular • Submental • Muscular Facial branches: • Inferior Labial. • Superior Labial. • Lateral Nasal. • Angular • Muscular The Ascending Palatine Artery (a. palatina ascendens) arises close to the origin of the facial artery and passes up between the Styloglossus and Stylopharyngeus to the side of the pharynx, along which it is continued between the Constrictor pharyngis superior and the Pterygoideus internus to near the base of the skull. It divides near the Levator veli palatini into two branches: one follows the course of this muscle, and, winding over the upper border of the Constrictor pharyngis superior, supplies the soft palate and the palatine glands, anastomosing with its fellow of the opposite side and with the descending palatine branch of the maxillary artery; the other pierces the Constrictor pharyngis superior and supplies the palatine tonsil and auditory tube, anastomosing with the tonsillar and ascending pharyngeal arteries. The Tonsillar Branch (ramus tonsillaris) ascends between the Pterygoideus internus and Styloglossus, and then along the side of the pharynx, perforating the Constrictor pharyngis superior, to ramify in the substance of the palatine tonsil and root of the tongue. The Glandular Branches (rami glandulares; submaxillary branches) consist of three or four large vessels, which supply the submaxillary gland, some being prolonged to the neighboring muscles, lymph nodes, and integument. The Submental Artery (a. submentalis) the largest of the cervical branches, is given off from the facial artery just as that vessel quits the submaxillary gland: it runs forward upon the Mylohyoideus, just below the body of the mandible, and beneath the Digastricus. It supplies the surrounding muscles, and anastomoses with the sublingual artery and with the mylohyoid branch of the inferior alveolar; at the symphysis menti it turns upward over the border of the mandible and divides into a superficial and a deep branch. The superficial branch passes between the integument and Quadratus labii inferioris, and anastomoses with the inferior labial artery; the deep branch runs between the muscle and the bone, supplies the lip, and anastomoses with the inferior labial and mental arteries. The Inferior Labial Artery (a. labialis inferior; inferior coronary artery) arises near the angle of the mouth; it passes upward and forward beneath the Triangularis and, penetrating the Orbicularis oris, runs in a tortuous course along the edge of the lower lip between this muscle and the mucous membrane. It supplies the labial glands, the mucous membrane, and the muscles of the lower lip; and anastomoses with the artery of the opposite side, and with the mental branch of the inferior alveolar artery. The Superior Labial Artery (a. labialis superior; superior coronary artery) is larger and more tortuous than the inferior. It follows a similar course along the edge of the upper lip, lying between the mucous membrane and the Orbicularis oris, and anastomoses with the artery of the opposite side. It supplies the upper lip, and gives off in its course two or three vessels which ascend to the nose; a septal branch ramifies on the nasal septum as far as the point of the nose, and an alar branch supplies the ala of the nose. The Lateral Nasal branch is derived from the facial as that vessel ascends along the side of the nose. It supplies the ala and dorsum of the nose, anastomosing with its fellow, with the septal and alar branches, with the dorsal nasal branch of the ophthalmic, and with the infraorbital branch of the maxillary. The Angular Artery (a. angularis) is the terminal part of the facial; it ascends to the medial angle of the orbit, imbedded in the fibers of the angular head of the Quadratus labii superioris, and accompanied by the angular vein. On the cheek it distributes branches which anastomose with the infraorbital; after supplying the lacrimal sac and Orbicularis oculi, it ends by anastomosing with the dorsal nasal branch of the ophthalmic artery. The Muscular Branches in the neck are distributed to the Pterygoideus internus and Stylohyoideus, and on the face to the Masseter and Buccinator. The anastomoses of the facial artery are very numerous, not only with the vessel of the opposite side, but, in the neck, with the sublingual branch of the lingual, with the ascending pharyngeal, and by its ascending palatine and tonsillar branches with the palatine branch of the maxillary; on the face, with the mental branch of the inferior alveolar as it emerges from the mental foramen, with the transverse facial branch of the superficial temporal, with the infraorbital branch of the maxillary, and with the dorsal nasal branch of the ophthalmic. Posterior group: The occipital artery (a. occipitalis) arises from the posterior part of the external carotid, opposite the facial, near the lower margin of the posterior belly of the Digastricus, and ends in the posterior part of the scalp. It gives: muscular, auricular, meningeal branches. The posterior auricular artery (a. auricularis posterior) is small and arises from the external carotid, above the Digastricus and Stylohyoideus, opposite the apex of the styloid process. It ascends, under cover of the parotid gland, on the styloid process of the temporal bone, to the groove between the cartilage of the ear and the mastoid process, immediately above which it divides into its auricular and occipital branches. The sternocleidomastoid artery supplies the sternocleidomastoid muscle. Middle group: The ascending pharyngeal artery (a. pharyngea ascendens) arises from the back part of the external carotid and ascends vertically between the internal carotid and the side of the pharynx, to the under surface of the base of the skull, lying on the Longus capitis. Pass blod to pharynx, soft palate, auditive tube, tympanic cavity, palatine tonsil. The superficial temporal artery (a. temporalis superficialis), appears, from its direction, to be the continuation of that vessel. It begins in the substance of the parotid gland, behind the neck of the mandible, and corsses over the posterior root of the zygomatic process of the temporal bone; about 5 cm. above this process it divides into two branches, a frontal and a parietal. The maxillary artery (a. maxillaris), the larger of the two terminal branches of the external carotid, arises behind the neck of the mandible, and is at first imbedded in the substance of the parotid gland; it passes forward between the ramus of the mandible and the sphenomandibular ligament, and then runs, either superficial or deep to the Pterygoideus externus, to the pterygopalatine fossa. It supplies the deep structures of the face, and may be divided into mandibular, pterygoid, and pterygopalatine portions. The first or mandibular portion passes horizontally forward, between the ramus of the mandible and the sphenomandibular ligament, where it lies parallel to and a little below the auriculotemporal nerve; it crosses the inferior alveolar nerve, and runs along the lower border of the Pterygoideus lateralis. The second or pterygoid portion runs obliquely forward and upward under cover of the ramus of the mandible and insertion of the Temporalis, on the superficial (very frequently on the deep) surface of the Pterygoideus lateralis; it then passes between the two heads of origin of this muscle and enters the fossa. The third or pterygopalatine portion lies in the pterygopalatine fossa in relation with the sphenopalatine ganglion. The branches of this vessel may be divided into three groups, corresponding with its three divisions. Branches of the First or Mandibular Portions: • anterior tympanic • deep auricular • middle meningeal • inferior alveolar The Anterior Tympanic Artery (a. tympanica anterior; tympanic artery) enters the tympanic cavity through the petrotympanic fissure, and anastomosing with the artery of the pterygoid canal and with the caroticotympanic branch from the internal carotid. The Deep Auricular Artery (a. auricularis profunda) ascends in the substance of the parotid gland, behind the temporomandibular articulation, pierces the cartilaginous or bony wall of the external acoustic meatus, and supplies its cuticular lining and the outer surface of the tympanic membrane. It gives a branch to the temporomandibular joint. The Middle Meningeal Artery (a. meningea media; medidural artery) is the largest of the arteries which supply the dura mater. It ascends between the sphenomandibular ligament and the Pterygoideus lateralis, and between the two roots of the auriculotemporal nerve to the foramen spinosum of the sphenoid bone, through which it enters the cranium. The branches of the middle meningeal artery are distributed partly to the dura mater, but chiefly to the bones; they anastomose with the arteries of the opposite side, and with the anterior and posterior meningeal. The Inferior Alveolar Artery (a. alveolaris inferior; inferior dental artery) descends to the mandibular foramen on the medial surface of the ramus of the mandible. It runs along the mandibular canal in the substance of the bone, accompanied by the nerve, and opposite the first premolar tooth divides into two branches, incisor and mental. The incisor branch is continued forward beneath the incisor teeth as far as the middle line, where it anastomoses with the artery of the opposite side; the mental branch escapes with the nerve at the mental foramen, supplies the chin, and anastomoses with the submental and inferior labial arteries. Near its origin the inferior alveolar artery gives off a lingual branch which descends with the lingual nerve and supplies the mucous membrane of the mouth. As the inferior alveolar artery enters the foramen, it gives off a mylohyoid branch which runs in the mylohyoid groove, and ramifies on the under surface of the Mylohyoideus. The inferior alveolar artery and its incisor branch during their course through the substance of the bone give off a series of branches which correspond in number to the roots of the teeth: these enter the minute apertures at the extremities of the roots, and supply the pulp of the teeth. Branches of the Second or Pterygoid Portion: • deep temporal • pterygoid • masseteric • buccinator The Deep Temporal Branches, two in number, anterior and posterior, ascend between the Temporalis and the pericranium; they supply the muscle, and anastomose with the middle temporal artery; the anterior communicates with the lacrimal artery by means of small branches which perforate the zygomatic bone and great wing of the sphenoid. The Pterygoid Branches (rami pterygoidei), irregular in their number and origin, supply the Pterygoidei. The Masseteric Artery (a. masseterica) is small and passes lateralward through the mandibular notch to the deep surface of the Masseter. It supplies the muscle, and anastomoses with the masseteric branches of the facial and with the transverse facial artery. The Buccinator Artery (a. buccinatoria; buccal artery) is small and runs to the outer surface of the Buccinator, to which it is distributed, anastomosing with branches of the facial and with the infraorbital. Branches of the Third or Pterygopalatine Portion: • posterior superior alveolar • infraorbital • descending palatine • artery of the pterygoid canal • pharyngeal • sphenopalatine The Posterior Superior Alveolar Artery (a. alveolaris superior posterior; alveolar or posterior dental artery) is given off from the maxillary, frequently in conjunction with the infraorbital just as the trunk of the vessel is passing into the pterygopalatine fossa. Descending upon the tuber maxilla, it divides into numerous branches, some of which enter the alveolar canals, to supply the molar and premolar teeth and the lining of the maxillary sinus, while others are continued forward on the alveolar process to supply the gums. The Infraorbital Artery (a. infraorbitalis) appears, from its direction, to be the continuation of the trunk of the maxillary, but often arises in conjunction with the posterior superior alveolar. It runs along the infraorbital groove and canal with the infraorbital nerve, and emerges on the face through the infraorbital foramen. While in the canal, it gives off (a) orbital branches which assist in supplying the Rectus inferior and Obliquus inferior and the lacrimal sac, and (b) anterior superior alveolar branches which descend through the anterior alveolar canals to supply the upper incisor and canine teeth and the mucous membrane of the maxillary sinus. On the face, some branches pass upward to the medial angle of the orbit and the lacrimal sac, anastomosing with the angular branch of the facial artery; others run toward the nose, anastomosing with the dorsal nasal branch of the ophthalmic; and others run downward and anastomose with the facial, transverse facial, and buccinator arteries. The four remaining branches arise from that portion of the maxillary which is contained in the pterygopalatine fossa. The Descending Palatine Artery (a. palatina descendens) descends through the pterygopalatine canal, and, emerging from the greater palatine foramen, runs forward in a groove on the medial side of the alveolar border of the hard palate to the incisive canal; the terminal branch of the artery passes upward through this canal to anastomose with the sphenopalatine artery. Branches are distributed to the gums, the palatine glands, and the mucous membrane of the roof of the mouth; while in the pterygopalatine canal it gives off twigs which descend in the lesser palatine canals to supply the soft palate and palatine tonsil, anastomosing with the ascending palatine artery. The Artery of the Pterygoid Canal (a. canalis pterygoidei; Vidian artery) passes backward along the pterygoid canal with the corresponding nerve. It is distributed to the upper part of the pharynx and to the auditory tube, sending into the tympanic cavity a small branch which anastomoses with the other tympanic arteries. The Pharyngeal Branch is very small; it runs backward through the pharyngeal canal with the pharyngeal nerve, and is distributed to the upper part of the pharynx and to the auditory tube. The Sphenopalatine Artery (a. sphenopalatina; nasopalatine artery) passes through the sphenopalatine foramen into the cavity of the nose, at the back part of the superior meatus. Here it gives off its posterior lateral nasal branches which spread forward over the conchae and meatuses, anastomose with the ethmoidal arteries and the nasal branches of the descending palatine, and assist in supplying the frontal, maxillary, ethmoidal, and sphenoidal sinuses. Crossing the under surface of the sphenoid the sphenopalatine artery ends on the nasal septum as the posterior septal branches; these anastomose with the ethmoidal arteries and the septal branch of the superior labial; one branch descends in a groove on the vomer to the incisive canal and anastomoses with the descending palatine artery. Materials for self-check: A. Tasks for self-check: specify point of origin of external carotid artery, name groups of branches of external carotid artery, branches in each groups, their arteries and regions of supplying. B. Choose the correct answer. 1. A victim of a car accident has a contused wound in temporal region. During medical examination a fracture of zygomatic bone and symptoms of intra-cranial hemorrhage are observed. Which artery might be damaged in this region? A. Superficial temporal. B. Middle meningeal. C. Anterior meningeal. D. Maxillary. E. Facial. 2. After the injury of temporal region, a patient got epidural hematoma. Which artery is damaged? A. Deep temporal. B. Middle meningeal. C. Deep auriculary. D. Superior tympanic. E. Inferior tympanic. 3. A patient was admitted to a hospital with an open fracture of the ramus mandible and profuse bleeding in the fracture site. Which artery is damaged? A. A. palatina ascendens. B. A. temporalis media. C. A. facialis. D. A. lingualis. E. A. alveolaris inferior. 4. A patient has epidural hematoma in the temporal region. Which artery is damaged? A. Medial meningeal. B. Medial cerebral. C. Posterior communicating. D. Anterior meningeal. E. Anterior cerebral. 5. A patient who got into a car accident has bleeding from soft tissues in front of the angle of the mandible. Which vessel must be ligated to stop the bleeding? A. A. lingualis. B. A. carotis interna. C. A. temporalis superficial. D. A. alveolaris inferior. E. A. facialis. 6. A patient has bleeding in the region of the upper lip. Which artery is damaged? A. A. lingualis. B. A. maxillaris. C. A. facialis. D. A. temporalis superficialis. E. A. angularis. 7. An 18-year-old man was admitted to a hospital after a car accident. In the traumathology center numerous traumas of soft tissues of the face in the region of the medial angle of eye ac¬companied by profuse bleeding were detected. What arterial anastomosis is formed in this region? A. A. carotis externa et a. carotis interna. B. A. carotis externa et a. subclavia. C. A. carotis interna et a. subclavia. D. A. subclavia et a. ophthalmica. E. A. carotis interna et a. ophthalmica. 8. A 30-year-old patient was hospitalized due to bleeding of the facial artery. What place on the face has to be pressed to stop bleeding? A. The mandible’s edge B. The mental process C. The mandible’s branch D. The nose’s back E. The molar bone 9. An injured man has bleeding from branches of carotid artery. For a temporary arrest of bleeding it is necessary to press the carotid artery to the tubercle of a cervical vertebra. Which vertebra is it? A. VI B. V C. IV D. III E. II 10. Which triangle of the neck is situated carotid artery? A. Omotrapezoid B. Omoclavicular C. Submental D. Submandibular E. Carotid References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 6. The subclavian artery. The axillary artery. 1. Relevance of the topic. Branches of the subcluvian artery together with the internernal carotid artery – are the main sourse of the blood supply of the brain. External branches of the subclavian artery supply the tissues of the neck. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the arterious vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Arteria subclavia subclavian artery Arteria vertebralis vertebral artery Rr. spinales spinal branches Arteria basilaris The basilar artery A. cerebri posterior Posterior cerebral artery A. epigastrica superior The superior epigastric artery Arteria axillaris axillary artery 4.2. Theoretical questions for the class: 1. Topography of the subclavian artery, its division on the parts. 2. Branches of the first part of subclavian artery. 3. Branches of the second part of subclavian artery. 4. Branches of the third part of the subclavian artery. 5. Topography of the axillary artery, its division on the parts. 6. Branches of the first and second parts of axillary artery. 7. Branches of the third part of axillary artery. 8. Anastomosises between the cerebral branches of the internal carotid artery and branches of vertebral artery. 4.3. Practical task pertaining to the topic and to be completed during the class: specify topography, division of the subclavian and axillary arteries on the parts. Find branches of each part, regions of supplying. Find anastomoses between the cerebral branches of the internal carotid artery and branches of vertebral artery on cadaver preparations. Content of the topic. Subclavian artery. The artery which supplies the upper extremity continues as a single trunk from its commencement down to the elbow; but different portions of it have received different names, according to the regions through which they pass. That part of the vessel which extends from its origin to the outer border of the first rib is termed the subclavian; beyond this point to the lower border of the axilla it is named the axillary; and from the lower margin of the axillary space to the bend of the elbow it is termed brachial; here the trunk ends by dividing into two branches the radial and ulnar. The Subclavian Artery (A. Subclavia) – On the right side the subclavian artery arises from the brachiocephalic trunk behind the right sternoclavicular articulation; on the left side it springs from the arch of the aorta. The two vessels, therefore, in the first part of their course, differ in length, direction, and relation with neighboring structures. In order to facilitate the description, each subclavian artery is divided into three parts. The first portion extends from the origin of the vessel to the medial border of the Scalenus anterior; the second lies behind this muscle; and the third extends from the lateral margin of the muscle to the outer border of the first rib, where it becomes the axillary artery. Branches. The branches of the subclavian artery are: 1. Vertebral. – 1stpart 2. Thyrocervical. – 1stpart 3. Internal thoracic. – 1stpart 4. Costocervical. – 2ndpart 5. Transverse artery of the neck. – 3rdpart 1. The vertebral artery (a. vertebralis) is the first branch of the subclavian, and arises from the upper and back part of the first portion of the vessel. It ascends through the foramina in the transverse processes of the upper six cervical vertebrae it then winds behind the superior articular process of the atlas and, entering the skull through the foramen magnum, unites, at the lower border of the pons, with the vessel of the opposite side to form the basilar artery. The branches of the vertebral artery may be divided into two sets: those given off in the neck, and those within the cranium. Cervical branches: spinal branches - (rami spinales) enter the vertebral canal through the intervertebral foramina and supply the metter of the spinal cord, vertebrae; muscular branches - are given off to the deep muscles of the neck. Cranial branches: The Meningeal Branch (ramus meningeus; posterior meningeal branch) springs from the vertebral opposite the foramen magnum, ramifies between the bone and dura mater in the cerebellar fossa, and supplies the falx cerebelli. The Posterior Spinal Artery (a. spinalis posterior; dorsal spinal artery) arises from the vertebral, at the side of the medulla oblongata; passing backward, it descends to the lower part of the medulla spinalis. The Anterior Spinal Artery (a. spinalis anterior; ventral spinal artery) is a small branch, which arises near the termination of the vertebral, and, descending in front of the medulla oblongata, unites with its fellow of the opposite side at the level of the foramen magnum. The single trunk, thus formed, descends on the front of the medulla spinalis. The Posterior Inferior Cerebellar Artery (a. cerebelli inferior posterior) the largest branch of the vertebral, winds backward around the upper part of the medulla oblongata, over the inferior peduncle to the under surface of the cerebellum. The Medullary Arteries (bulbar arteries) are several minute vessels which spring from the vertebral and its branches and are distributed to the medulla oblongata. The Basilar Artery (a. basilaris) so named from its position at the base of the skull, is a single trunk formed by the junction of the two vertebral arteries: it extends from the lower to the upper border of the pons, lying in its median groove, under cover of the arachnoid. It ends by dividing into the two posterior cerebral arteries. Has next branches: The pontine branches (rami ad pontem; transverse branches) are a number of small vessels which come off at right angles from either side of the basilar artery and supply the pons and adjacent parts of the brain. The internal auditory artery (a. auditiva interna; auditory artery), a long slender branch, arises from near the middle of the artery; it accompanies the acoustic nerve through the internal acoustic meatus, and is distributed to the internal ear. The anterior inferior cerebellar artery (a. cerebelli inferior anterior) passes backward to be distributed to the anterior part of the under surface of the cerebellum. The superior cerebellar artery (a. cerebelli superior) arises near the termination of the basilar. It passes lateralward, winds around the cerebral peduncle, and, arriving at the upper surface of the cerebellum. The posterior cerebral artery (a. cerebri posterior) pass lateralward, parallel to the superior cerebellar artery, and receiving the posterior communicating from the internal carotid, it winds around the cerebral peduncle, and reaches the tentorial surface of the occipital lobe of the cerebrum, where it breaks up into branches for the supply of the temporal and occipital lobes. 2. The thyrocervical trunk (truncus thyreocervicalis; thyroid axis) is a short thick trunk, which arises from the front of the first portion of the subclavian artery, close to the medial border of the Scalenus anterior, and divides almost immediately into three branches, the inferior thyroid – to thyroid gland, wall of the larynx (where make anastomoses with Superior thyroid), esophagus; suprascapular – goes to scapular notch to the dorsal muscles of the scapula; and ascending cervical – supplies deep muscles of the neck. 3. The internal thoracic artery (a. thoracica interna) arises from the under surface of the first portion of the subclavian, opposite the thyrocervical trunk. It descends behind the cartilages of the upper six ribs at a distance of about 1.25 cm. from the margin of the sternum, gives off anterior intercostal arteries (in upper six intercostal spaces), and at the level of the sixth intercostal space divides into the musculophrenic and superior epigastric arteries. On its way internal thoracic artery gives branches to anterior mediastinum, thymus, trachea, bronchi, mammary glands. 4. The costocervical trunk (truncus costocervicalis; superior intercostal artery) arises from the upper and back part of the subclavian artery, behind the Scalenus anterior on the right side, and medial to that muscle on the left side. Passing backward, it gives off the profunda cervicalis – to the posterior muscles of the neck, and, continuing as the highest intercostal artery, to the first and second intercostal spaces. 5. The transverse artery of the neck (a. transversa colli) pierces brachial plexus, goes along medial margin of scapula to its inferior angle. Supplies neighbouring muscles. Axillary artery. The axillary artery the continuation of the subclavian, commences at the outer border of the first rib, and ends at the lower border of the tendon of the Teres major, where it takes the name of brachial. To facilitate the description of the vessel it is divided into three portions; the first part lies above, the second behind, and the third below the Pectoralis minor. Branches of the first part are: 1. A. thoracica suprema – goes to m. subclavius, lesser and greater pectoral, m. serratus anterior. 2. A. thoracoacromialis – arise on the level of upper margin m. pectoralis minor, divides on branches, part of which goes upward and lateralward to acromion, another – to deltoid and pectoral muscles. Branches of the second part: 1. A. thoracica lateralis – descends on lateral wall of the chest and gives off branches to mammary gland and neighbouring muscles. Branches of third part: 1. A. subscapularis – arise on the level of lower margin of subscapular muscle, descends along this muscle and divides on branches: a. circumflexa scapule – to the dorsal surface of the scapula, and a. thoracodorsalis – goes along lateral margin of scapula. 2. A. circumflexa humeri posterior – goes around surgical neck of humerus from the back, supplies deltoid muscle. 3. A. circumflexa humeri anterior – goes around surgical neck of humerus from the front, gives branches to the muscles and shoulder joint. Materials for self-check: A. Tasks for self-check: specify topography, division of the subclavian and axillary arteries on the parts. Find branches of each part, regions of supplying. Find anastomoses between the cerebral branches of the internal carotid artery and branches of vertebral artery on cadaver preparations. B. Choose the correct answer. 1. A surgeon, accessing the organs of the thoracic cavity, made an incision on the anterior chest wall along one of the intercostal spaces. He carefully dissected the tissues of the anterior medial region of the intercostal space in order not to damage the artery situated in parallel to the edge of the breastbone, by 1-1.5 cm more lateral from it. Which artery is meant? A. Inferior phrenic. B. Anterior intercostal. C. Superior phrenic. D. Costocervical trunk. E. Internal thoracic. 2. A doctor examined a patient who got into a car accident. The patient has a fracture of the left clavicle and disorders of blood circulation in the extremity (radial artery pulsation is absent). What is the cause of blood circulation disorder? A. Compression of vertebral artery. B. Compression of axillary artery. C. Compression of subciavian vein. D. Compression of subciavian artery. E. Compression of axillary vein. 3. Specify parts of the vertebral artery. A. The cerebral part B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The cavernous and cerebral parts 4. Specify parts of the aorta. A. The cerebral part B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 5. Specify parts of the descending aorta. A. The thoracic and abdominal parts B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 6. In the performance of surgical intervention on the thyroid gland, the surgeon must select the upper and lower thyroid artery, which form in the gland arterial anastomoses. Branches from which major vessels are these arteries? A. A. carotis externa et a. subclavia B. A. carotis interna et a. subclavia C. A. carotis externa et a. carotis interna D. A. subclavia et truncus thyrocervicalis E A. subclavia et a. transversa colli 7. Specify the location of origin of the right subclavian artery: A. Descending aorta B. Brachiocephalic trunk C. Right common carotid artery D. Aortic arch E. Ascending aorta 8. Specify the location of origin of the left subclavian artery: A. Descending aorta B. Brachiocephalic trunk C. Right common carotid artery D. Aortic arch E. Ascending aorta 9. Specify the border between the subclavian and axillary arteries: A. Sternal end of the clavicle B. Acromial end of the clavicle C. The outer edge of the first rib D. The outer edge of the second rib E. Anterior scalene muscle 10. Specify the branches of the first division of subclavian artery: A. The internal thoracic artery, the vertebral artery, the thyrocervical trunk B. Costocervical trunk C. The transverse cervical artery D. The anterior cerebral artery E. The posterior cerebral artery

References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/ Topic 7. Blood supply of the brain and spinal cord. Anastomoses. Clinical aspects. 1. Relevance of the topic. Branches of the subcluvian artery together with the internernal carotid artery – are the main sourse of the blood supply of the brain. External branches of the subclavian artery supply the tissues of the neck. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the arterious vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Arteria subclavia Subclavian artery Arteria vertebralis Vertebral artery Rr. spinales Spinal branches Arteria basilaris The basilar artery A. cerebri posterior Posterior cerebral artery A. communicans posterior Posterior communicating artery Arteria cerebri media Middle cerebral artery A. cerebri anterior Anterior cerebral artery 4.2. Theoretical questions for the class: 1. Topography of the subclavian artery, its division on the parts. 2. Topography of the internal carotid artery, its division on the parts. 3. Anastomosises between the cerebral branches of the internal carotid artery and branches of vertebral artery. 4. Anastomosises between the cerebral branches of the internal carotid artery and branches of external carotid artery. 4.3. Practical task pertaining to the topic and to be completed during the class: specify topography, division of the internal carotid and subclavian arteries on the parts. Find branches of each part, regions of supplying. Find anastomoses between the cerebral branches of the internal carotid artery and branches of vertebral artery on cadaver preparations. Content of the topic. The INTERNAL CAROTID ARTERY supplies the anterior part of the brain, the eye and its appendages, and sends branches to the forehead and nose. It is remarkable for the number of curvatures that it presents in different parts of its course. It occasionally has one or two flexures near the base of the skull, while in its passage through the carotid canal and along the side of the body of the sphenoid bone it describes a double curvature and resembles the italic letter S. Course and Relations. In considering the course and relations of this vessel it may be divided into four portions: cervical (on neck), petrous (in carotid canal of temporal bone), cavernous (in cavernous sinus), and cerebral (on the brain). Branches. The cervical portion of the internal carotid gives off no branches. Those from the other portions are: 1. The caroticotympanic branch (ramus caroticotympanicus; tympanic branch) is small; it enters the tympanic cavity through a minute foramen in the carotid canal, and anastomoses with the anterior tympanic branch of the maxillary, and with the stylomastoid artery. 2. The artery of the pterygoid canal (a. canilis pterygoidei [Vidii]; Vidian artery) is a small, inconstant branch which passes into the pterygoid canal and anastomoses with a branch of the maxillary artery. 3. The cavernous branches are numerous small vessels which supply the hypophysis, the semilunar ganglion, and the walls of the cavernous and inferior petrosal sinuses. Some of them anastomose with branches of the middle meningeal. 4. The anterior meningeal branch (a. meningea anterior) is a small branch which passes over the small wing of the sphenoid to supply the dura mater of the anterior cranial fossa; it anastomoses with the meningeal branch from the posterior ethmoidal artery. 5. The ophthalmic artery (a. ophthalmica) arises from the internal carotid, just as that vessel is emerging from the cavernous sinus, on the medial side of the anterior clinoid process, and enters the orbital cavity through the optic foramen, below and lateral to the optic nerve. It then passes over the nerve to reach the medial wall of the orbit, and thence horizontally forward, beneath the lower border of the Obliquus superior, and divides it into two terminal branches, the frontal and dorsal nasal. As the artery crosses the optic nerve it is accompanied by the nasociliary nerve, and is separated from the frontal nerve by the Rectus superior and Levator palpebrae superioris. 6. The anterior cerebral artery (a. cerebri anterior) arises from the internal carotid, at the medial extremity of the lateral cerebral fissure. It passes forward and medialward across the anterior perforated substance, above the optic nerve, to the commencement of the longitudinal fissure. Here it comes into close relationship with the opposite artery, to which it is connected by a short trunk, the anterior communicating artery. From this point the two vessels run side by side in the longitudinal fissure, curve around the genu of the corpus callosum, and turning backward continue along the upper surface of the corpus callosum to its posterior part, where they end by anastomosing with the posterior cerebral arteries. 7. The middle cerebral artery (a. cerebri media), the largest branch of the internal carotid, runs at first lateralward in the lateral cerebral or Sylvian fissure and then backward and upward on the surface of the insula, where it divides into a number of branches which are distributed to the lateral surface of the cerebral hemisphere. 8. The posterior communicating artery (a. communicans posterior) runs backward from the internal carotid, and anastomoses with the posterior cerebral, a branch of the basilar. From its posterior half are given off a number of small branches, the postero-medial ganglionic branches, which, with similar vessels from the posterior cerebral, pierce the posterior perforated substance and supply the medial surface of the thalami and the walls of the third ventricle. The anterior choroidal (a. chorioidea; choroid artery) is a small but constant branch, which arises from the internal carotid, near the posterior communicating artery. Passing backward and lateralward between the temporal lobe and the cerebral peduncle, it enters the inferior horn of the lateral ventricle through the choroidal fissure and ends in the choroid plexus. It is distributed to the hippocampus, fimbria, tela chorioidea of the third ventricle, and choroid plexus The vertebral artery (a. vertebralis) is the first branch of the subclavian, and arises from the upper and back part of the first portion of the vessel. It ascends through the foramina in the transverse processes of the upper six cervical vertebrae it then winds behind the superior articular process of the atlas and, entering the skull through the foramen magnum, unites, at the lower border of the pons, with the vessel of the opposite side to form the basilar artery. The branches of the vertebral artery may be divided into two sets: those given off in the neck, and those within the cranium. Cervical branches: spinal branches - (rami spinales) enter the vertebral canal through the intervertebral foramina and supply the metter of the spinal cord, vertebrae; muscular branches - are given off to the deep muscles of the neck. Cranial branches: The Meningeal Branch (ramus meningeus; posterior meningeal branch) springs from the vertebral opposite the foramen magnum, ramifies between the bone and dura mater in the cerebellar fossa, and supplies the falx cerebelli. The Posterior Spinal Artery (a. spinalis posterior; dorsal spinal artery) arises from the vertebral, at the side of the medulla oblongata; passing backward, it descends to the lower part of the medulla spinalis. The Anterior Spinal Artery (a. spinalis anterior; ventral spinal artery) is a small branch, which arises near the termination of the vertebral, and, descending in front of the medulla oblongata, unites with its fellow of the opposite side at the level of the foramen magnum. The single trunk, thus formed, descends on the front of the medulla spinalis. The Posterior Inferior Cerebellar Artery (a. cerebelli inferior posterior) the largest branch of the vertebral, winds backward around the upper part of the medulla oblongata, over the inferior peduncle to the under surface of the cerebellum. The Medullary Arteries (bulbar arteries) are several minute vessels which spring from the vertebral and its branches and are distributed to the medulla oblongata. The Basilar Artery (a. basilaris) so named from its position at the base of the skull, is a single trunk formed by the junction of the two vertebral arteries: it extends from the lower to the upper border of the pons, lying in its median groove, under cover of the arachnoid. It ends by dividing into the two posterior cerebral arteries. Has next branches: The pontine branches (rami ad pontem; transverse branches) are a number of small vessels which come off at right angles from either side of the basilar artery and supply the pons and adjacent parts of the brain. The internal auditory artery (a. auditiva interna; auditory artery), a long slender branch, arises from near the middle of the artery; it accompanies the acoustic nerve through the internal acoustic meatus, and is distributed to the internal ear. The anterior inferior cerebellar artery (a. cerebelli inferior anterior) passes backward to be distributed to the anterior part of the under surface of the cerebellum. The superior cerebellar artery (a. cerebelli superior) arises near the termination of the basilar. It passes lateralward, winds around the cerebral peduncle, and, arriving at the upper surface of the cerebellum. The posterior cerebral artery (a. cerebri posterior) pass lateralward, parallel to the superior cerebellar artery, and receiving the posterior communicating from the internal carotid, it winds around the cerebral peduncle, and reaches the tentorial surface of the occipital lobe of the cerebrum, where it breaks up into branches for the supply of the temporal and occipital lobes. The cerebral arterial circle (of Willis), circulus arteriosus cerebri (Willisii) The cerebral arteries anastomose to form the arterial ring, which associates two major systems. These anastomoses provide redistribution of blood flow and compensation of restricted blood flow should it occur. The polygonal circle is formed of the following anastomoses: 1) the anterior cerebral arteries anastomose by means of the anterior communicating artery; 2) each internal carotid artery anastomoses with the respective posterior cerebral artery by means of posterior communicating arteries. The arterial circle is quite variable. Classic appearance constitutes 30-50% of occurrences; the circle may be open anteriorly and in 6-10% of occurrences, one of the posterior communicating branches may be absent. Intrinsic branching of the cerebral arteries The cerebral arteries form numerous anastomoses on the hemisphere surface forming thus the arterial network. The network gives radiating intrinsic branches to underlying structures. The branches are subdivided into: 1) the short cortical branches that supply the cerebral cortex; 2) the long cerebral branches that reach the white matter. The basal ganglia and the thalamus receive branches (the central arteries) from the inferior surface of brain. The intrinsic arteries form few anastomoses. Different sources communicate mainly via microcirculatory network. The network features inability to narrow or widen. Even transient ischemia may result in alteration of capillary endothelium and swelling of glial cells. This may interrupt blood How within the affected area (“circulation renewal failure” after ischemia). Clinical applications The cerebral arteries are susceptible to atherosclerotic lesions. Atherosclerosis causes rupture of blood vessels followed by hemorrhage. Apart from this, atherosclerosis causes obstruction of blood flow, which results in ischemia and necrosis. Slowly progressing atherosclerosis leads to atrophy of cerebral cortex and thus to mental disorders (especially in elderly individuals). Studying of atherosclerosis etiology is one of the greatest medical problems. Materials for self-check: A. Tasks for self-check: specify topography, division of the internal carotid and subclavian arteries on the parts. Find branches of each part, regions of supplying. Find anastomoses between the cerebral branches of the internal carotid artery and branches of vertebral artery on cadaver preparations. B. Choose the correct answer. 1. A 56-year-old patient has worked for 28 years at a chemical plant in a workshop with harmful productions conditions. He often has hemorrhages of the nasal cavity mucosa. Which arteries involved? A. Anterior and posterior ethmoidal B. Supraorbital. C. Ciliary. D. Anterior cerebral. E. Ophthalmic. 2. An 18-year-old man was admitted to a hospital after a car accident. In the traumathology center numerous traumas of soft tissues of the face in the region of the medial angle of eye accompanied by profuse bleeding were detected. What arterial anastomosis is formed in this region? A. A. carotis externa et a. carotis interna. B. A. carotis externa et a. subclavia. C. A. carotis interna et a. subclavia. D. A. subclavia et a. ophthalmica. E. A. carotis interna et a. ophthalmica. 3. A 80 year-old patient had hemorrhage of the brain and was taken to the hospital. The place of hemorrhage was revealed on the lateral hemispheres surfaces during the medical examination. What artery was injured? A. The middle cerebral artery B. The anterior cerebral artery C. The posterior cerebral artery D. The anterior communicating artery E. The posterior communicating artery 4. A 70 year-old patient had hemorrhage of the brain and was taken to the hospital. The place of hemorrhage was revealed on the lateral hemispheres surfaces during the medical examination. Artery running along the lateral sulcus and giving numerous branches was damaged. What artery was injured? A. The middle cerebral artery B. The anterior cerebral artery C. The posterior cerebral artery D. The anterior communicating artery E. The posterior communicating artery 5. Which triangle of the neck is situated common carotid artery? A. Omotrapezoid B. Omoclavicular C. Submental D. Submandibular E. Carotid 6. What are the boundaries of the carotid triangle? A. Anterior belly of digastric, superior belly of omohyoid, sternocleidomastoid B. Posterior belly of digastric, inferior belly of omohyoid, sternocleidomastoid C. Posterior belly of digastric, sternocleidomastoid D. Posterior belly of digastric, superior belly of omohyoid, sternocleidomastoid E. Anterior belly of digastric, thyrohyoid, sternocleidomastoid 7. An injured man has bleeding from branches of carotid artery. For a temporary arrest of bleeding it is necessary to press the carotid artery to the tubercle of a cervical vertebra. Which vertebra is it? A. VI B. V C. IV D. III E. II 8. A patient with inflammation of the cells of the ethmoid bone (ethmoiditis) was identified violations of the blood supply. Branches of what artery is supplied by the ethmoid labyrinth? A. A. cerebri anterior. B. A. infraorbitalis. C. A. facialis. D. A. ophthalmica. E. A. transversa facei. 9. Specify the terminal branches of the internal carotid artery: A. The superior thyroid artery, the lingual artery and the facial artery B. The ophthalmic, the anterior cerebral, middle cerebral, posterior communicating arteries C. The superficial temporal artery and the maxillary artery D. The ascending pharyngeal artery E. The occipital artery and the posterior auricular artery 10. A 20-year-old man was admitted to a hospital after a car accident. In the traumathology center numerous traumas of soft tissues of the face in the region of the medial angle of eye accompanied by profuse bleeding were detected. What arterial anastomosis is formed in this region? A. A. vertebralis et a. carotis interna. B. A. lingualis et a. subclavia. C. A. carotis interna et a. subclavia. D. A. facialis et a. ophthalmica. E. A. carotis interna et a. ophthalmica. 11. The narrowing of large vessel caused worsening of outflow of blood from the left ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein B. Pulmonary trunk C. Aorta D. Superior vena cava E. Inferior vena cava 12. The narrowing of large vessel caused worsening of outflow of blood from the right ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein B. Pulmonary trunk C. Aorta D. Superior vena cava E. Inferior vena cava 13. A 30-year-old man was admitted to a hospital after a car accident. In the traumathology center numerous traumas of soft tissues of the face in the region of the medial angle of eye accompanied by profuse bleeding were detected. What arterial anastomosis is formed in this region? A. The superior thyroid artery, the lingual artery and the facial artery B. The ophthalmic and the anterior cerebral arteries C. The superficial temporal artery and the maxillary artery D. The dorsal nasal artery and the angular artery E. The middle cerebral and posterior communicating arteries References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 8. Arteries of upper extremity. 1. Relevance of the topic. The arteries of the upper extremity: brachial, radial, ulnar blood supply muscles of the upper limb, joints, hand, participating part in forming deep and superficial palmar arch. Knowledge of the topography of the arteries of the upper extremity is important in the surgical clinic, and for common clinical practice. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the arterious vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Arteria brachialis Brachial artery A. profunda brachii Deep artery of the arm Arteria radialis Radial artery Arteria ulnaris Ulnar artery Arcus palmaris superficialis The superficial palmar arch 4.2. Theoretical questions for the class: 1. Topography of the brachial artery and its branches 2. Topography of the ulnar artery and its branches. 3. Topography of the radial artery and its branches. 4. Arteries of the hand. 5. Supplying of the elbow-joint. 6. Supplying of the radiocarpal joint. 4.3. Practical task pertaining to the topic and to be completed during the class: specify topography of the brachial artery and its branches. Find ulnar and radial arteries, their branches on cadaver preparations, models, tables. Describe its branches and relation to the tissues. Explain articular branches of the big arteries, their anastomosises. Content of the topic. The brachial artery commences at the lower margin of the tendon of the Teres major, and, passing down the arm, ends about 1 cm. below the bend of the elbow, where it divides into the radial and ulnar arteries. At first the brachial artery lies medial to the humerus; but as it runs down the arm it gradually gets in front of the bone, and at the bend of the elbow it lies midway between its two epicondyles. The branches of the brachial artery are: Profunda Brachii. Muscular, nutrient Superior Ulnar Collateral. Inferior Ulnar Collateral. The arteria profunda brachii (superior profunda artery) is a large vessel which arises from the medial and back part of the brachial, just below the lower border of the Teres major. It follows closely the radial nerve, running at first backward between the medial and lateral heads of the Triceps brachii, then along the groove for the radial nerve, where it is covered by the lateral head of the Triceps brachii, to the lateral side of the arm; there it pierces the lateral intermuscular septum, and, descending between the Brachioradialis and the Brachialis to the front of the lateral epicondyle of the humerus, ends by anastomosing with the radial recurrent artery. It gives branches to the Deltoideus and to the muscles between which it lies; it supplies an occasional nutrient artery which enters the humerus behind the deltoid tuberosity. A branch ascends between the long and lateral heads of the Triceps brachii to anastomose with the posterior humeral circumflex artery; a middle collateral branch descends in the middle head of the Triceps brachii and assists in forming the anastomosis above the olecranon; and, lastly, a radial collateral branch runs down behind the lateral intermuscular septum to the back of the lateral epicondyle of the humerus, where it anastomoses with the interosseous recurrent and the inferior ulnar collateral arteries. The superior ulnar collateral artery (a. collateralis ulnaris superior; inferior profunda artery), of small size, arises from the brachial a little below the middle of the arm; it frequently springs from the upper part of the a. profunda brachii. It pierces the medial intermuscular septum, and descends on the surface of the medial head of the Triceps brachii to the space between the medial epicondyle and olecranon, accompanied by the ulnar nerve, and ends under the Flexor carpi ulnaris by anastomosing with the posterior ulnar recurrent, and inferior ulnar collateral. It sometimes sends a branch in front of the medial epicondyle, to anastomose with the anterior ulnar recurrent. The inferior ulnar collateral artery (a. collateralis ulnaris inferior; anastomotica magna artery) arises about 5 cm. above the elbow. It passes medialward upon the Brachialis, and piercing the medial intermuscular septum, winds around the back of the humerus between the Triceps brachii and the bone, forming, by its junction with the profunda brachii, an arch above the olecranon fossa. As the vessel lies on the Brachialis, it gives off branches which ascend to join the superior ulnar collateral: others descend in front of the medial epicondyle, to anastomose with the anterior ulnar recurrent. Behind the medial epicondyle a branch anastomoses with the superior ulnar collateral and posterior ulnar recurrent arteries. The Radial artery appears, from its direction, to be the continuation of the brachial, but it is smaller in caliber than the ulnar. It commences at the bifurcation of the brachial, just below the bend of the elbow, and passes along the radial side of the forearm to the wrist. It then winds backward, around the lateral side of the carpus, beneath the tendons of the Abductor pollicis longus and Extensores pollicis longus and brevis to the upper end of the space between the metacarpal bones of the thumb and index finger. Finally it passes forward between the two heads of the first Interosseous dorsalis, into the palm of the hand, where it crosses the metacarpal bones and at the ulnar side of the hand unites with the deep palmar branch of the ulnar artery to form the deep palmar arch. Branches of radial artery are: •The radial recurrent artery (a. recurrens radialis) arises immediately below the elbow. It ascends between the branches of the radial nerve, lying on the Supinator and then between the Brachioradialis and Brachialis, supplying these muscles and the elbow-joint, and anastomosing with the terminal part of the profunda brachii. • The muscular branches (rami musculares) are distributed to the muscles on the radial side of the forearm. • The palmar carpal branch (ramus carpeus palmaris; anterior radial carpal artery) is a small vessel which arises near the lower border of the Pronator quadratus, and, running across the front of the carpus, anastomoses with the palmar carpal branch of the ulnar artery. This anastomosis is joined by a branch from the palmar interosseous above, and by recurrent branches from the deep palmar arch below, thus forming a palmar carpal net-work which supplies the articulations of the wrist and carpus. • The superficial palmar branch (ramus palmaris superficialis) arises from the radial artery, just where this vessel is about to wind around the lateral side of the wrist. Running forward, it passes through, occasionally over, the muscles of the ball of the thumb, which it supplies, and sometimes anastomoses with the terminal portion of the ulnar artery, completing the superficial palmar arch. • The dorsal carpal branch (ramus carpeus dorsalis; posterior radial carpal artery) is a small vessel which arises beneath the Extensor tendons of the thumb, it anastomoses with the dorsal carpal branch of the ulnar and with the palmar and dorsal interosseous arteries to form a dorsal carpal network. From this network are given off three slender dorsal metacarpal arteries, which run downward on the second, third, and fourth Interossei dorsales and bifurcate into the dorsal digital branches for the supply of the adjacent sides of the middle, ring, and little fingers respectively, communicating with the proper palmar digital branches of the superficial palmar arch. Near their origins they anastomose with the deep palmar arch by the superior perforating arteries, and near their points of bifurcation with the common palmar digital vessels of the superficial palmar arch by the inferior perforating arteries. •The first dorsal metacarpal arises just before the radial artery passes between the two heads of the first Interosseous dorsalis and divides almost immediately into two branches which supply the adjacent sides of the thumb and index finger; the radial side of the thumb receives a branch directly from the radial artery. • The arteria princeps pollicis arises from the radial just as it turns medialward to the deep part of the hand; it runs along the sides of the thumb, forming on the palmar surface of the last phalanx an arch, from which branches are distributed to the integument and subcutaneous tissue of the thumb. • The arteria palmaris indicis radialis (radialis indicis artery) arises close to the preceding, descends between the first Interosseus dorsalis and Adductor pollicis transversus, and runs along the radial side of the index finger to its extremity, where it anastomoses with the proper digital artery, supplying the ulnar side of the finger; with the princeps pollicis, and gives a communicating branch to the superficial palmar arch. The a. princeps pollicis and a. palmaris indicis radialis may spring from a common trunk termed the first palmar metacarpal artery. The deep palmar arch (arcus palmaris profundus; deep palmar arch) is formed by the anastomosis of the terminal part of the radial artery with the deep palmar branch of the ulnar. It lies upon the carpal extremities of the metacarpal bones and on the Interossei, being covered by the Adductor pollicis obliquus, the Flexor tendons of the fingers, and the Lumbricales. Alongside of it, but running in the opposite direction—that is to say, toward the radial side of the hand — is the deep branch of the ulnar nerve. The palmar metacarpal arteries (aa. metacarpeж palmares; palmar interosseous arteries), three or four in number, arise from the convexity of the deep palmar arch; they run distally upon the Interossei, and anastomose at the clefts of the fingers with the common digital branches of the superficial palmar arch. The perforating branches (rami perforantes), three in number, pass backward from the deep palmar arch, through the second, third, and fourth interosseous spaces and between the heads of the corresponding Interossei dorsalis, to anastomose with the dorsal metacarpal arteries. The recurrent branches arise from the concavity of the deep palmar arch. They ascend in front of the wrist, supply the intercarpal articulations, and end in the palmar carpal network. The Ulnar artery, the larger of the two terminal branches of the brachial, begins a little below the bend of the elbow, and, passing obliquely downward, reaches the ulnar side of the forearm at a point about midway between the elbow and the wrist. It then runs along the ulnar border to the wrist, crosses the transverse carpal ligament on the radial side of the pisiform bone, and immediately beyond this bone divides into two branches, which enter into the formation of the superficial and deep palmar arches. The branches of ulnar artery are: • The anterior ulnar recurrent artery (a. recurrentes ulnaris anterior) arises immediately below the elbow-joint, runs upward between the Brachialis and Pronator teres, supplies twigs to those muscles, and, in front of the medial epicondyle, anastomoses with the superior and inferior ulnar collateral arteries. • The posterior ulnar recurrent artery (a. recurrentes ulnaris posterior) is much larger, and arises somewhat lower than the preceding. It passes backward and medialward on the Flexor digitorum profundus, behind the Flexor digitorum sublimis, and ascends behind the medial epicondyle of the humerus. In the interval between this process and the olecranon, it lies beneath the Flexor carpi ulnaris, and ascending between the heads of that muscle, in relation with the ulnar nerve, it supplies the neighboring muscles and the elbow-joint, and anastomoses with the superior and inferior ulnar collateral and the interosseous recurrent arteries. • The common interosseous artery (a. interossea communis) about 1 cm. in length, arises immediately below the tuberosity of the radius, and, passing backward to the upper border of the interosseous membrane, divides into two branches, the anterior and posterior interosseous arteries (It gives off the interosseous recurrent artery, which ascends to elbow-joint). • The muscular branches (rami musculares) are distributed to the muscles along the ulnar side of the forearm. • The palmar carpal branch (ramus carpeus palmares; anterior ulnar carpal artery) is a small vessel which crosses the front of the carpus beneath the tendons of the Flexor digitorum profundus, and anastomoses with the corresponding branch of the radial artery. • The dorsal carpal branch (ramus carpeus dorsalis; posterior ulnar carpal artery) arises immediately above the pisiform bone, and winds backward beneath the tendon of the Flexor carpi ulnaris; it passes across the dorsal surface of the carpus beneath the Extensor tendons, to anastomose with a corresponding branch of the radial artery. Immediately after its origin, it gives off a small branch, which runs along the ulnar side of the fifth metacarpal bone, and supplies the ulnar side of the dorsal surface of the little finger. • The deep palmar branch (ramus palmaris profundus; profunda branch) passes between the Abductor digiti quinti and Flexor digiti quinti brevis and through the origin of the Opponens digiti quinti; it anastomoses with the radial artery, and completes the deep palmar arch. The superficial palmar arch (arcus palmaris superficialis; superficial palmar arch) is formed by the ulnar artery, and is usually completed by a branch from the a. palmaris indicis radialis, but sometimes by the superficial palmar or bya branch from the a. princeps pollicis of the radial artery. The arch passes across the palm, describing a curve, with its convexity downward. Three Common Palmar Digital Arteries (aa. digitales palmares communes; palmar digital arteries) arise from the convexity of the arch and proceed downward on the second, third, and fourth Lumbricales. Each receives the corresponding palmar metacarpal artery and then divides into a pair of proper palmar digital arteries (aa. digitales palmares propriж; collateral digital arteries) which run along the contiguous sides of the index, middle, ring, and little fingers, behind the corresponding digital nerves; they anastomose freely in the subcutaneous tissue of the finger tips and by smaller branches near the interphalangeal joints. Each gives off a couple of dorsal branches which anastomose with the dorsal digital arteries, and supply the soft parts on the back of the second and third phalanges, including the matrix of the finger-nail. The proper palmar digital artery for medial side of the little finger springs from the ulnar artery under cover of the Palmaris brevis. Materials for self-check: A. Tasks for self-check: specify topography of the brachial artery and its branches. Find ulnar and radial arteries, their branches on cadaver preparations, models, tables. Describe its branches and relation to the tissues. Explain articular branches of the big arteries, their anastomosises. B. Choose the correct answer. 1.Examining patients with cardovascular system pathology it is often necessary to compare the character of vessels pulsation in symmetrical points of both body parts. Pulsation of which artery is easy to feel on the anterior surface of the inferior third of forearm? A. A. ulnaris. B. A. radialis. C. A. interossea anterior. D. Ramus palmaris superficialis. E. A. interossea posterior. 2. A doctor examined a patient who got into a car accident. The patient has a fracture of the left clavicle and disorders of blood circulation in the extremity (radial artery pulsation is absent). What is the cause of blood circulation disorder? A. Compression of vertebral artery. B. Compression of axillary artery. C. Compression of subciavian vein. D. Compression of subciavian artery. E. Compression of axillary vein. 3. During an operative intervention on a mammary gland profuse bleeding appeared. Which artery was damaged? A. Internal thoracic. B. Lateral thoracic. C. Superior epigastric. D. Axillary. E. Superior thoracic. 4. After trauma, a 44-year-old patient had a rupture of left palm muscle tendons and of the surface of blood vessels. After operation and removal of the most part of the necrotically changed muscle tissue the bloodstream was normalized. What vessels have helped with restoration of bloodstream? A. Arcus palmaris profundus B. Arcus palmaris superficialis C. Aa. digitales palmares communes D. Aa. metacarpeae palmares E. Aa. Perforantes 5. While performing an operation in the area of axillary crease a surgeon has to define an arterial vessel surrounded by fascicles of brachial plexus. What artery is it? A. A. axillaris B. A. vertebralis C. A. transversa colli D. A. profunda brachii E. A. subscapularis 6. Specify parts of the aorta. A. The cerebral part B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 7. Specify parts of the descending aorta. A. The thoracic and abdominal parts B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 8. The narrowing of large vessel caused worsening of outflow of blood from the left ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein B. Pulmonary trunk C. Aorta D. Superior vena cava E. Inferior vena cava 9. Specify the border between the subclavian and axillary arteries: A. Sternal end of the clavicle B. Acromial end of the clavicle C. The outer edge of the first rib D. The outer edge of the second rib E. Anterior scalene muscle 10. Specify the location of origin of the right subclavian artery: A. Descending aorta B. Brachiocephalic trunk C. Right common carotid artery D. Aortic arch E. Ascending aorta References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/ Topic 9. Thoracic aorta. Parietal and paired visceral branches of abdominal aorta. 1. Relevance of the topic. Information about topography of the arteries of the abdominal and thoracic cavity is important for the surgeons which make operative interferences on pectoral and abdominal cavities. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the arterious vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Pars descendens aortae Descending part of the aorta Pars thoracica aortae Thoracic aorta Pars abdominalis aortae Abdominal aorta Aa. lumbales Lumbar arteries A. sacralis mediana The median sacral artery 4.2. Theoretical questions for the class: 1. Parietal branches of thoracic aorta. 2. Visceral branches of hthoracic aorta. 3. Parietal branches of abdominal aorta. 4. Paired branches of abdominal aorta. 4.3. Practical task pertaining to the topic and to be completed during the class: specify parietal and visceral branches of thoracic aorta; parietal, paired and unpaired visceral branches of abdominal aorta using the cadaver preparations, models, tables. Find anostomosises between different branches. Content of the topic. The descending aorta is divided into two portions, the thoracic and abdominal, in correspondence with the two great cavities of the trunk in which it is situated. The Thoracic Aorta (Aorta Thoracalis). The thoracic aorta is contained in the posterior mediastinal cavity. It begins at the lower border of the fourth thoracic vertebra where it is continuous with the aortic arch, and ends in front of the lower border of the twelfth at the aortic hiatus in the diaphragm. At its commencement, it is situated on the left of the vertebral column; it approaches the median line as it descends; and, at its termination, lies directly in front of the column. The vessel describes a curve which is concave forward, and as the branches given off from it are small, its diminution in size is inconsiderable. Branches of the Thoracic Aorta: Visceral Pericardial. Bronchial. Esophageal. Mediastinal. Parietal Intercostal. Subcostal. Superior Phrenic. The pericardial branches (rami pericardiaci) consist of a few small vessels which are distributed to the posterior surface of the pericardium. The bronchial arteries (aa. bronchiales) vary in number, size, and origin. There is as a rule only one right bronchial artery, which arises from the first aortic intercostal, or from the upper left bronchial artery. The left bronchial arteries are usually two in number, and arise from the thoracic aorta. The upper left bronchial arises opposite the fifth thoracic vertebra, the lower just below the level of the left bronchus. Each vessel runs on the back part of its bronchus, dividing and subdividing along the bronchial tubes, supplying them, the areolar tissue of the lungs, the bronchial lymph nodes, and the esophagus. The esophageal arteries (aa. esophageae) four or five in number, arise from the front of the aorta, and pass obliquely downward to the esophagus, forming a chain of anastomoses along that tube, anastomosing with the esophageal branches of the inferior thyroid arteries above, and with ascending branches from the left inferior phrenic and left gastric arteries below. The mediastinal branches (rami mediastinales) are numerous small vessels which supply the lymph nodes and loose areolar tissue in the posterior mediastinum. Intercostal Arteries (aa. intercostales).—There are usually nine pairs of aortic intercostal arteries. They arise from the back of the aorta, and a redistributed to the lower nine intercostal spaces, the first two spaces being supplied by the highest intercostal artery, a branch of the costocervical trunk of the subclavian. The subcostal arteries, so named because they lie below the last ribs, constitute the lowest pair of branches derived from the thoracic aorta, and are in series with the intercostal arteries. Each passes along the lower border of the twelfth rib behind the kidney and in front of the Quadratus lumborum muscle, and is accompanied by the twelfth thoracic nerve. The superior phrenic branches are small and arise from the lower part of the thoracic aorta; they are distributed to the posterior part of the upper surface of the diaphragm, and anastomose with the musculophrenic and pericardiacophrenic arteries. The Abdominal Aorta (Aorta Abdominalis). The abdominal aorta begins at the aortic hiatus of the diaphragm, in front of the lower border of the body of the last thoracic vertebra, and, descending in front of the vertebral column, ends on the body of the fourth lumbar vertebra, commonly a little to the left of the middle line, by dividing into the two common iliac arteries. It diminishes rapidly in size, in consequence of the many large branches which it gives off. As it lies upon the bodies of the vertebrae, the curve which it describes is convex forward, the summit of the convexity corresponding to the third lumbar vertebra. The branches of the abdominal aorta may be divided into two sets: visceral and parietal. 1.Visceral Branches: a. celiac trunk b. superior mesenteric c. inferior mesenteric d. middle suprarenals e. renals f. testicularis (in the male) g. ovarian (in the female) Parietal Branches: a. inferior phrenics b. lumbars c. middle sacral Of the visceral branches, the celiac artery and the superior and inferior mesenteric arteries are unpaired, while the suprarenals, renals, testiculars, and ovarian are paired. Of the parietal branches the inferior phrenics and lumbars are paired; the middle sacral is unpaired. The middle suprarenal arteries (aa. suprarenales media) are two small vessels which arise, one from either side of the aorta, opposite the superior mesenteric artery. They pass lateralward and slightly upward, over the crura of the diaphragm, to the suprarenal glands, where they anastomose with suprarenal branches of the inferior phrenic and renal arteries. The renal arteries (aa. renales), are two large trunks, which arise from the side of the aorta, immediately below the superior mesenteric artery. Before reaching the hilus of the kidney, each artery divides into four or five branches. Each vessel gives off some small inferior suprarenal branches to the suprarenal gland, the ureter, and the surrounding cellular tissue and muscles. The testicular arteries (aa. testicularis) are distributed to the testes. They are two slender vessels of considerable length, and arise from the front of the aorta a little below the renal arteries. Each passes obliquely downward to reach the abdominal inguinal ring, through which it passes, and accompanies the other constituents of the spermatic cord along the inguinal canal to the scrotum. The ovarian arteries (aa. ovaricae) are the corresponding arteries in the female to the testicular in the male. They supply the ovaries, are shorter than the testicular, and do not pass out of the abdominal cavity. At an early period of fetal life, when the testes or ovaries lie by the side of the vertebral column, below the kidneys, the testicular or ovarian arteries are short; but with the descent of these organs into the scrotum or lesser pelvis, the arteries are gradually lengthened. The inferior phrenic arteries (aa. phrenicae inferiores) are two small vessels, which supply the diaphragm. Each vessel gives off superior suprarenal branches to the suprarenal gland of its own side. The lumbar arteries (aa. lumbales) are in series with the intercostals. They are usually four in number on either side, and arise from the back of the aorta, opposite the bodies of the upper four lumbar vertebrae. They anastomose with the lower intercostal, the subcostal, the iliolumbar, the deep iliac circumflex, and the inferior epigastric arteries. The middle sacral artery (a. sacralis media) is a small vessel, which arises from the back of the aorta, a little above its bifurcation. It descends in the middle line in front of the fourth and fifth lumbar vertebrae, the sacrum and coccyx, and ends in the glomus coccygeum (coccygeal gland). Materials for self-check: A. Tasks for self-check: specify parietal and visceral branches of thoracic aorta; parietal, paired and unpaired visceral branches of abdominal aorta using the cadaver preparations, models, tables. Find anostomosises between different branches. B. Choose the correct answer. 1. The narrowing of large vessel caused worsening of outflow of blood from the left ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein B. Pulmonary trunk C. Aorta D. Superior vena cava E. Inferior vena cava 2. Specify parts of the aorta. A. The cerebral part B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 3. Specify parts of the descending aorta. A. The thoracic and abdominal parts B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 4. Specify the location of origin of the right subclavian artery: A. Descending aorta B. Brachiocephalic trunk C. Right common carotid artery D. Aortic arch E. Ascending aorta 5. Specify the location of origin of the left subclavian artery: A. Descending aorta B. Brachiocephalic trunk C. Right common carotid artery D. Aortic arch E. Ascending aorta 6. Contraction of a great vessel reduced blood derivation from the left ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein. B. Pulmonary trunk, C. Aorta. D. Superior vena cava. E. Inferior vena cava. 7. Blood pressure rise in aorta in¬creased the load of the cardiac muscle. The muscular wall of which region of the heart reacts to irritation? A. Left ventricle. B. Left atrium. C. Right ventricle. D. Right atrium. E. Venous sinus. 8. Specify the parietal branches of thoracic aorta. A. The esophageal branches B. The bronchial branches C. The posterior intercostal arteries, the superior phrenic arteries D. The pericardial branches E. The mediastinal branches 9. Specify what the superior phrenic arteries blood supply. A. The thyroid gland B. The pectoralis major C. The lumbar part of diaphragm D. The mammary gland E. The intercostal muscles 10. Specify what the posterior intercostal arteries blood supply. A. The spinal cord B. The pectoralis major C. The lumbar part of diaphragm D. The mammary gland E. The pericardium References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 10. Unpaired visceral branches of abdominal aorta. 1. Relevance of the topic. Information about topography of the arteries of the abdominal and thoracic cavity is important for the surgeons which make operative interferences on pectoral and abdominal cavities. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration)

The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the arterious vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Truncus coeliacus Coeliac trunk A. gastrica sinistra The left gastric artery A. hepatica communis Common hepatic artery A. gastroduodenalis Gastroduodenal artery A. pancreaticoduodenalis superior Pancreaticoduodenal superior posterior/anterior posterior/anterior artery Arteria mesenterica superior / inferior Mesenteric artery superior / inferior 4.2. Theoretical questions for the class: 1. Parietal branches of thoracic aorta. 2. Visceral branches of thoracic aorta. 3. Parietal branches of abdominal aorta. 4. Paired branches of abdominal aorta. 5. Ciliac trunk, its branches and topography. 6. Superior mesenteric artery. 7. Inferior mesenteric artery. 4.3. Practical task pertaining to the topic and to be completed during the class: specify parietal and visceral branches of thoracic aorta; parietal, paired and unpaired visceral branches of abdominal aorta using the cadaver preparations, models, tables. Find anostomosises between different branches. Content of the topic. The celiac trunk (truncus celiacus) is a short thick trunk, about 1.25 cm. in length, which arises from the front of the aorta, just below the aortic hiatus of the diaphragm, and, passing nearly horizontally forward, divides into three large branches, the left gastric, the common hepatic, and the splenic. 1) The left gastric artery (a. gastrica sinistra), the smallest of the three branches of the celiac artery, passes upward and to the left, posterior to the omental bursa, to the cardiac orifice of the stomach. Here it distributes branches to the esophagus, which anastomose with the aortic esophageal arteries; others supply the cardiac part of the stomach, anastomosing with branches of the lienal artery. It then runs from left to right, along the lesser curvature of the stomach to the pylorus, between the layers of the lesser omentum; it gives branches to both surfaces of the stomach and anastomoses with the right gastric artery. 2) The common hepatic artery (a. hepatica communis) is first directed forward and to the right, to the upper margin of the superior part of the duodenum, forming the lower boundary of the epiploic foramen (foramen of Winslow). It ascends between the layers of the lesser omentum, and in front of the epiploic foramen, to the porta hepatis, where it divides into two branches, right and left, which supply the corresponding lobes of the liver. Its branches are:  right gastric  gastroduodenal  cystic The right gastric artery (a. gastrica dextra) arises from the common hepatic, above the pylorus, descends to the pyloric end of the stomach, and passes from right to left along its lesser curvature, supplying it with branches, and anastomosing with the left gastric artery. The gastroduodenal artery (a. gastroduodenalis) is a short but large branch, which descends, near the pylorus, between the superior part of the duodenum and the neck of the pancreas, and divides at the lower border of the duodenum into two branches, the right gastroepiploic and the superior pancreaticoduodenal. Previous to its division it gives off two or three small branches to the pyloric end of the stomach and to the pancreas. The right gastroepiploic artery (a. gastroepiploica dextra) runs from right to left along the greater curvature of the stomach, between the layers of the greater omentum, anastomosing with the left gastroepiploic branch of the lienal artery. Except at the pylorus where it is in contact with the stomach, it lies about a finger's breadth from the greater curvature. This vessel gives off numerous branches, some of which ascend to supply both surfaces of the stomach, while others descend to supply the greater omentum and anastomose with branches of the middle colic. The superior pancreaticoduodenal artery (a. pancreaticoduodenalis superior) descends between the contiguous margins of the duodenum and pancreas. It supplies both these organs, and anastomoses with the inferior pancreaticoduodenal branch of the superior mesenteric artery, and with the pancreatic branches of the lienal artery. The cystic artery (a. cystica), usually a branch of the right hepatic, passes downward and forward along the neck of the gall-bladder, and divides into two branches, one of which ramifies on the free surface, the other on the attached surface of the gall-bladder. 3) The lienal or splenic artery (a. lienalis), the largest branch of the celiac trunk. It passes along the upper border of the pancreas; on arriving near the spleenit divides into branches, some of which enter the hilus of that organ to be distributed to the tissues of the spleen. Its branches are:  pancreatic  short gastric  left gastroepiploic The pancreatic branches (rami pancreatici) are numerous small vessels derived from the lienal as it runs behind the upper border of the pancreas, supplying its body and tail. These vessels anastomose with the pancreatic branches of the pancreaticoduodenal and superior mesenteric arteries. The short gastric arteries (aa. gastricae breves) consist of from five to seven small branches, which arise from the end of the lienal artery, and from its terminal divisions. They pass from left to right, between the layers of the gastrolienal ligament, and are distributed to the greater curvature of the stomach, anastomosing with branches of the left gastric and left gastroepiploic arteries. The left gastroepiploic artery (a. gastroepiploica sinistra) the largest branch of the lienal, runs from left to right about a finger’s breadth or more from the greater curvature of the stomach, between the layers of the greater omentum, and anastomoses with the right gastroepiploic. In its course it distributes several ascending branches to both surfaces of the stomach; others descend to supply the greater omentum and anastomose with branches of the middle colic. The superior mesenteric artery (a. mesenterica superior) is a large vessel which supplies the whole length of the small intestine, except the superior part of the duodenum; it also supplies the cecum and the ascending part of the colon and about one-half of the transverse part of the colon. It arises from the front of the aorta, about 1.25 cm. below the celiac artery. It descends between the layers of the mesentery to the right iliac fossa, where, considerably diminished in size, it anastomoses with one of its own branches, viz., the ileocolic. Its branches are:  inferior pancreaticoduodenal  intestinal  ileocolic  right colic  middle colic The inferior pancreaticoduodenal artery (a. pancreaticoduodenalis inferior) is given off from the superior mesenteric or from its first intestinal branch, opposite the upper border of the inferior part of the duodenum. It courses to the right between the head of the pancreas and duodenum, and then ascends to anastomose with the superior pancreaticoduodenal artery. It distributes branches to the head of the pancreas and to the descending and inferior parts of the duodenum. The intestinal arteries (aa. intestinales; vasa intestini tenuis) arise from the convex side of the superior mesenteric artery. They are usually from twelve to fifteen in number, and are distributed to the jejunum and ileum. They run nearly parallel with one another between the layers of the mesentery, each vessel dividing into two branches, which unite with adjacent branches, forming a series of arches, the convexities of which are directed toward the intestine. From this first set of arches branches arise, which unite with similar branches from above and below and thus a second series of arches is formed; from the lower branches of the artery, a third, a fourth, or even a fifth series of arches may be formed, diminilegg in size the nearer they approach the intestine. In the short, upper part of the mesentery only one set of arches exists, but as the depth of the mesentery increases, second, third, fourth, or even fifth groups are developed. From the terminal arches numerous small straight vessels arise which encircle the intestine, upon which they are distributed, ramifying between its coats. From the intestinal arteries small branches are given off to the lymph nodes and other structures between the layers of the mesentery. The ileocolic artery (a. ileocolica) is the lowest branch arising from the concavity of the superior mesenteric artery. It passes downward and to the right behind the peritoneum toward the right iliac fossa, where it divides into a superior and an inferior branch; the inferior anastomoses with the end of the superior mesenteric artery, the superior with the right colic artery. The inferior branch of the ileocolic runs toward the upper border of the ileocolic junction and supplies the following branches: (a) colic, which pass upward on the ascending colon; (b) anterior and posterior cecal, which are distributed to the front and back of the cecum; (c) an appendicular artery, which descends behind the termination of the ileum and enters the mesenteriole of the vermiform process; it runs near the free margin of this mesenteriole and ends in branches which supply the vermiform process; and (d) ileal, which run upward and to the left on the lower part of the ileum, and anastomose with the termination of the superior mesenteric. The right colic artery (a. colica dextra) arises from about the middle of the concavity of the superior mesenteric artery, or from a stem common to it and the ileocolic. It passes to the right behind the peritoneum, and in front of the right testicular or ovarian vessels, the right ureter and the Psoas major, toward the middle of the ascending colon. At the colon it divides into a descending branch, which anastomoses with the ileocolic, and an ascending branch, which anastomoses with the middle colic. These branches form arches, from the convexity of which vessels are distributed to the ascending colon. The middle colic artery (a. colica media) arises from the superior mesenteric just below the pancreas and, passing downward and forward between the layers of the transverse mesocolon, divides into two branches, right and left; the former anastomoses with the right colic; the latter with the left colic, a branch of the inferior mesenteric. The arches thus formed are placed about two fingers’ breadth from the transverse colon, to which they distribute branches. The inferior mesenteric artery (a. mesenterica inferior) supplies the left half of the transverse part of the colon, the whole of the descending and iliac parts of the colon, the sigmoid colon, and the greater part of the rectum. It is smaller than the superior mesenteric, and arises from the aorta, about 3 or 4 cm. above its division into the common iliacs and close to the lower border of the inferior part of the duodenum. It passes downward posterior to the peritoneum, and is continued into the lesser pelvis under the name of the superior rectal artery, which descends between the two layers of the sigmoid mesocolon and ends on the upper part of the rectum. Its branches are:  left colic  sigmoid  superior rectal The left colic artery (a. colica sinistra) runs to the left behind the peritoneumand in front of the Psoas major, and after a short, but variable, course divides into an ascending and a descending branch; the stem of the artery or its branches cross the left ureter and left testicular vessels. The ascending branch crosses in front of the left kidney and ends, between the two layers of the transverse mesocolon, by anastomosing with the middle colic artery; the descending branch anastomoses with the highest sigmoid artery. From the arches formed by these anastomoses branches are distributed to the descending colon and the left part of the transverse colon. The sigmoid arteries (aa. sigmoideae), two or three in number, run obliquely downward and to the left behind the peritoneum and in front of the Psoas major, ureter, and testicular vessels. Their branches supply the lower part of the descending colon, the iliac colon, and the sigmoid or pelvic colon; anastomosing above with the left colic, and below with the superior rectal artery. The superior rectal artery (a. rectalis superior) the continuation of the inferior mesenteric, descends into the pelvis between the layers of the mesentery of the sigmoid colon, crossing, in its course, the left common iliac vessels. It divides, opposite the third sacral vertebra, into two branches, which descend one on either side of the rectum, and about 10 or 12 cm. from the anus break up into several small branches. These pierce the muscular coat of the bowel and run downward, as straight vessels, placed at regular intervals from each other in the wall of the gut between its muscular and mucous coats, to the level of the Sphincter ani internus; here they form a series of loops around the lower end of the rectum, and communicate with the middle rectal branches of the internal iliac, and with the inferior rectal branches of the internal pudendal. Materials for self-check: A. Tasks for self-check: specify parietal and visceral branches of thoracic aorta; parietal, paired and unpaired visceral branches of abdominal aorta using the cadaver preparations, models, tables. Find anostomosises between different branches. B. Choose the correct answer. 1. A 40-year-old woman had appendectomy, during which an artery of the vermiform process was ligated. This artery separates from: A. Left colic artery. B. Jejunal artery C. Iliocolic artery. D. Right colic artery. E. Middle colic artery. 2. Examination of a patient has shown pancreas blood supply disorder. Which artery could be damaged? A. A. gastrica dextra. B. A. hepatica propria. C. A. gastrica sinistra. D. A. gastroepiploica dextra. E. A. lienalis. 3. A patient was admitted surgical department in grave condition with a stab wound in the right hypochondrium with signs of internal hemorrhage. After laparotomy, a doctor detected hepatic parenchyma injuries and blood in the abdominal cavity. For a temporary arrest of bleeding the doctor applied smooth tissue forceps hepatoduodenal ligament. Which vessels are bandaged in the region of this ligament? A. Right and left hepatic arteries. B. Hepatic veins and hepatic arteries. C. Proper hepatic artery and hepatic veins. D. Proper hepatic artery and porta. E. Coeliac trunk and superior mesenteric artery. 4. A patient with a stomach ulcer situated in the pyloric region on the lesser curvature of stomach has bleeding. What vessel should be ligated to stop the bleeding? A. Right gastric artery. B. Left gastric artery. C. Left gastroomental artery. D. Hepatic artery. E. Right gastroomental artery. 5. A surgeon makes operative intervention in the abdominal part of esophagus. Which vessel might be damaged? A. A. lienalis. B. A. gastrica dextra. C. A. gastrica sinistra. D. A. gastroomentalis sinistra. E. A. hepatica propria. 6. Examination of a patient with impaired blood coagulation revealed thrombosis of a branch of inferior mesenteric artery. What bowel segment is damaged? A. Colon sigmoideum B. Ileum C. Caecum D. Colon transversum E. Colon ascendens 7. Specify parts of the aorta. A. The cerebral part B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 8. Specify parts of the descending aorta. A. The thoracic and abdominal parts B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 9. The narrowing of large vessel caused worsening of outflow of blood from the left ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein B. Pulmonary trunk C. Aorta D. Superior vena cava E. Inferior vena cava 10. Contraction of a great vessel reduced blood derivation from the left ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein. B. Pulmonary trunk, C. Aorta. D. Superior vena cava. E. Inferior vena cava. References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 11. Iliac arteries. Arteries of the thigh. 1. Actuality of theme. Iliac arteries supply internal organs of pelvic cavity and locomotor part of the pelvic region – girdle of lower extremities. Information of the topography of iliac arteries is important for surgery of this region. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the arterious vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Arteria iliaca communis Common iliac artery Arteria iliaca interna The internal iliac artery Aa. sacrales laterales Sacral lateral artery A. obturatoria, R. pubicus Obturator artery, pubic branch Arteria profunda femoris Deep artery of thigh 4.2. Theoretical questions for the class: 1. Division of abdominal aorta. 2. Internal iliac artery. Parietal and visceral branches of internal iliac artery, regions of supplying.

3. External iliac artery. Anastomosises of system of iliac arteries. Topography, branches, regions of supplying. 4. Common iliac artery. Topography of common iliac artery, branches, division. 5. Anastomosises between branches of external and internal iliac arteries and systems of other arteries. 4.3. Practical task pertaining to the topic and to be completed during the class: specify interrelation between iliac arteries, its branches and walls and organs of pelvic cavity using the cadaver preparations. Content of the topic. The abdominal aorta diverges at sharp angle (60-70°) to give rise to the common iliac arteries. Each artery descends laterally to reach the respective sacroiliac joint. There, the arteries give rise to the external and internal iliac arteries. THE INTERNAL ILIAC ARTERY, ARTERIA ILIACA INTERNA Relations of the internal iliac artery The internal iliac artery arises from the common iliac artery and descends to the lesser pelvis. The artery is the principal nourishing vessel for this region. The artery gives off numerous branches, both parietal and visceral. The parietal branches: ■ the iliolumbar artery, arteria iliolumbalis ascends posteriorly to the related muscles, the ilium and the spinal cord (the spinal branches, rami spinales); ■ the lateral sacral arteries, arteriae sacrales laterales run to the sacrum and the spinal cord (the spinal branches); ■ the obturator artery, arteria obturatoria reaches the thigh region via the obturator canal. The artery supplies the adductors of thigh and the hip joint. The hip joint receives blood from the acetabular branch, ramus acetabularis, which passes within the ligament of head of femur. The obturator artery anastomoses with the inferior hypogastric artery via the pubic branch, ramus pubicus. In 25% of individuals, this anastomosis is quite well developed; in fact, the obturator artery in this case arises from the inferior hypogastric artery. This variant is of surgical concern because the artery passes next to the internal femoral ring and thus can be damaged during surgery (“corona mortis”); ■ the superior gluteal artery, arteria glutea superior, leaves the lesser pelvis cavity via the suprapiriform foramen. Within the gluteal region the artery gives off the branches to supply the gluteus medius and minimus; ■ the inferior gluteal artery, arteria glutea inferior, leaves the lesser pelvis cavity via the infrapiriform foramen. Within the gluteal region, the artery supplies the gluteus maximus and other related muscles. The visceral branches: ■ the umbilical artery, arteria umbilicalis appears as rather a large vessel during embryonic period. After birth it closes to form the medial umbilical ligament (the occluded part). The beginning of the artery remains open (the patent part), it gives off the superior vesical arteries, arteriae vesicales superiores; . the inferior vesical artery, arteria vesicalis inferior, descends to the fundus of bladder. In males, the artery gives branches to the seminal glands and prostate; in females — to the vagina; . the uterine artery, arteria uterine, descends on the lateral wall of the pelvis, anterior to the internal iliac artery, and enters the root of the broad ligament. Here it passes medially to reach the lateral margin of the uterus immediately superior to the lateral part of the fornix of the vagina. As it passes medially in the broad ligament, the uterine artery passes directly superior to the ureter near the lateral part of the fornix of the vagina. On reaching the side of the cervix, the uterine artery divides into a smaller descending vaginal branch, ramus vaginalis, which supplies the cer- vix and vagina, and a larger ascending branch, ramus ascendens, which runs along the lateral margin of the uterus, supplying the body and fundus of the uterus. The ascending branch bifurcates into ovarian and tubal branches, ramus ovaricus et tubarius, which continue within the broad ligament to supply the medial ends of the ovary and uterine tube and anastomose with the ovarian and tubal branches of the ovarian artery; . the middle rectal artery, arteria rectalis media, may arise independently from the internal iliac artery, or it may arise in common . with the inferior vesical artery or the internal pudendal artery. The middle rectal artery supplies the inferior part of the rectum, anastomosing with the superior and inferior rectal arteries, supplying the seminal glands and prostate (or the vagina); . the internal pudendal artery, arteria pudenda interna, passes infero- laterally, anterior to the piriformis muscle and sacral plexus. It leaves the pelvis between the piriformis and the coccygeus muscles by passing through the inferior part of the greater sciatic foramen. The internal pudendal artery then passes around the posterior aspect of the ischial spine or the sacrospinous ligament and enters the ischio-anal fossa through the lesser sciatic foramen. Within the ischio-anal fossa, the artery gives the branches as follows: . the inferior rectal artery, arteria rectalis inferior, passes to the anus; . the artery of bulb of penis, arteria bulbi penis, supplies the respective bulb of penis; . the dorsal artery of penis (clitoris), arteria dorsalis penis (clitoridis) passes below skin (to the penis or clitoris respectively); . the deep artery of penis (clitoris), arteria profunda penis (clitoridis) take the same route as the latter arteries yet deeper; . the perineal artery, arteria perinealis supplies the perineal muscles and skin; . the posterior labial branches, rami labiales posteriors, and the posterior scrotal branches, rami scrotales posteriores supply the respective external genitals. THE EXTERNAL ILIAC ARTERY, ARTERIA ILIACA EXTERNA Relations of the external iliac artery The external iliac artery descends on the medial aspect of the psoas major and quits the lesser pelvis via the vascular space. Within the femoral triangle, the artery becomes continuous with the femoral artery. The external iliac artery gives the branches as follows: . the inferior epigastric artery, arteria epigastrica inferior arises from the main trunk above the inguinal ligament and then ascends medially along the internal surface of the anterior abdominal wall occupying the lateral umbilical ligament. Then the artery enters the rectus sheath and ascends along its posterior surface to reach the umbilical ring. Here it anastomoses with the superior hypogastric artery. In the beginning, the artery gives off anastomotic branch (the pubic branch, ramus pubicus) to the obturator artery; . the deep circumflex iliac artery, arteria circumflexa ilium profunda . runs laterally along the inguinal ligament and the iliac crest. It supplies the iliacus and the muscles of abdominal w'all. THE FEMORAL ARTERY, ARTERIA FEMORALIS Relations of the femoral artery The femoral artery arises directly from the external iliac artery. The arteries are delimited by the inferior border of the inguinal ligament. On leaving the vascular space, the artery appears within the femoral triangle together with the femoral nerve (found laterally) and the femoral vein (found medially) (Fig. 103). Pulsation of the artery is palpable below' the inguinal ligament in the area related to the vascular space. Within the femoral triangle, the artery runs along the iliopectineal groove and then along the femoral groove. From the femoral groove, the artery proceeds to the adductor canal, which leads it to the popliteal fossa. Here it becomes continuous with the popliteal artery. The greatest branch of the femoral artery is the deep artery of thigh. The deep artery of thigh, arteria profunda femoris is nearly as wide as the femoral artery (5-7 mm). It arises 4-5 cm below the inguinal ligament and descends posteriorly running laterally from the femoral artery. It is the main artery, which supplies the thigh. Its shorter trunk splits into the following branches: . the medial circumflex femoral artery, arteria circumflexa femoris medialis passes in between the iliopsoas and the pectineus muscles to enter deep into the adductors of thigh. The artery gives off the deep, the ascending and the transverse branches, ramus profundus, ascendens et transversus. The branches supply the muscles of thigh and the hip joint and anastomose with the obturator and inferior gluteal arteries; . the lateral circumflex femoral artery, arteria cicumflexa femoris lateralis gives off the ascending and descending branches, ramus ascendens et descendens. The ascending branch anastomoses with the gluteal arteries; . the perforating arteries, arteriae perforantes rather wide, they penetrate the tendons of the adductors and proceed to the posterior femoral area. There they supply the related muscles and the femur. The arteries reach the knee joint and anastomose with the branches of the popliteal artery. The perforating arteries are important for collateral circulation. Clinical applications The deep artery of thigh is of great importance for collateral circulation. Intrinsic anastomoses and intersystem anastomoses (with the internal iliac and popliteal arteries) provide good conditions for collateral circulation, which is vital in occlusions of femoral artery. Other branches . Apart from the deep artery of thigh, the femoral artery gives some smaller arteries: . the superficial epigastric artery, arteria epigastrica superficialis arises below the inguinal ligament and ascends to the umbilical region. There it anastomoses with the superior epigastric artery; . the superficial circumflex iliac artery, arteria circumflexa ilium superficialis also arises below the inguinal ligament and passes laterally to reach the anterior superior iliac spine. The artery supplies the neighboring soft tissues; . the external pudendal arteries (superficial and deep), arteriae pudendae extemae (superficiales et profun- dae) are small branches that supply the scrotum (or the labia majores); . the descending genicular artery, arteria descendens genu arises within the adductor canal. Together with the saphenous nerve, the artery leaves the canal via the anterior opening and terminates at the knee joint (it forms the genicular anastomosis). Materials for self-check: A. Tasks for self-check: specify interrelation between iliac arteries, its branches and walls and organs of pelvic cavity using the cadaver preparations. B. Choose the correct answer. 1. A patient has the affection of the head of the femur of ischemic origin diagnosed. Which artery is damaged? A. Ramus acetabularis. B. A. femoralis. C. A. illiaca extcrna. D. A. profunda femoris. E. A. umbilicalis. 2. A 70-year-old female patient was diagnosed with fracture of left femoral neck accompanied by disruption of ligament of head of femur. The branch of the following artery is damaged: A. Obturator B. Femoral C. External iliac D. Inferior gluteal E. Internal pudendal 3. Specify parts of the aorta. A. The cerebral part B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 4. Specify parts of the descending aorta. A. The thoracic and abdominal parts B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 5. The narrowing of large vessel caused worsening of outflow of blood from the left ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein B. Pulmonary trunk C. Aorta D. Superior vena cava E. Inferior vena cava 6. A woman underwent an operation because of extrauterine (tubal) pregnancy. In course of the operation the surgeon should ligate the branches of the following arteries: A. Superior cystic and ovarian B. Uterine and ovarian C. Inferior cystic and ovarian D. Uterine and superior cystic E. Uterine and inferior cystic 7. Specify the terminal branches of the abdominal aorta. A. The right and left common iliac arteries B. The median sacral artery C. The left gastric artery D. The lateral sacral artery and lumbar arteries E. The coeliac trunk and superior mesenteric artery 8. Sick woman, 48 years old, needs in surgical intervention for ovarian neoplasms. Surgeon should remember that the ovary is blood supplied by anastomosing branches of large arterial vessels. What are they? A. Pars abdominalis aortae et a. iliaca interna. B. Pars abdominalis aortae et a. iliaca externa C A. iliaca interna et a. iliaca externa. D. A. mesenterica inferior et a. iliaca interna. E. A. mesenterica inferior et a. iliaca externa. 9. Sick woman, 57 years old, needs in surgical intervention for uterine neoplasms. Surgeon should remember that the uterus is blood supplied by branches of large arterial vessel. Specify its source. A. Pars abdominalis aortae B. A. iliaca externa C A. iliaca interna D. A. mesenterica inferior E. A. mesenterica superior 10. The patient was taken to hospital with a diagnosis - rupture of the femoral head. Which artery is violated in this case? A. Iliopsoas artery B. Superior gluteal artery C. Lateral sacral artery D. Acetabular artery E. Inferior gluteal artery References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 12. Arteries of lower extremity. 1. Relevance of the topic. The source of blood supplying of lower extremity is femoral artery – the continuation of external iliac artery. Topography of the arteries of lower extremity is important for surgery of this region. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the arterious vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Arteria tibialis anterior Anterior tibial artery A. recurrens tibialis anterior/posterior Tibial recurrent anterior / posterior artery Aа. malleolaris anterior Anterior malleolar arteries Arteria dorsalis pedis Dorsal artery of foot 4.2. Theoretical questions for the class: 1. Popliteal artery, its branches, blood supplying of knee-joint. 2. Tibial arteries, their branches, regions of supplying. 3. Name all sources of blood supply of the foot. 4. Name arterial anastomoses of the lower limb. 4.3. Practical task pertaining to the topic and to be completed during the class: specify arteries of the lower lumb using the cadaver preparations. Content of the topic. The POPLITEAL ARTERY is the continuation of the femoral, and courses through the popliteal fossa. It extends from the opening in the Adductor magnus, at the junction of the middle and lower thirds of the thigh, downward and lateralward to the intercondyloid fossa of the femur, and then vertically downward to the lower border of the Popliteus, where it divides into anterior and posterior tibial arteries. The branches of the popliteal artery are: 1.Medial superior genicular. 2. Lateral superior genicular. 3. Middle genicular. 4. Medial inferior genicular. 5. Lateral inferior genicular. The superior genicular arteries (aa. genu superiores; superior articular arteries), two in number, arise one on either side of the popliteal, and wind around the femur immediately above its condyles to the front of the knee-joint. The middle genicular artery (a. genu media; azygos articular artery) is a small branch, arising opposite the back of the knee-joint. It pierces the oblique popliteal ligament, and supplies the ligaments and synovial membrane in the interior of the articulation. The inferior genicular arteries (aa. genu inferiores; inferior articular arteries), two in number, arise from the popliteal beneath the Gastrocnemius. The Anastomosis Around the Knee-joint — Around and above the patella, and on the contiguous ends of the femur and tibia, is an intricate net-work of vessels forming a superficial and a deep plexus. The superficial plexus is situated between the fascia and skin around about the patella, and forms three well-defined arches: one, above the upper border of the patella, in the loose connective tissue over the Quadriceps femoris; the other two, below the level of the patella, are situated in the fat behind the ligamentum patellae. The deep plexus, which forms a close net-work of vessels, lies on the lower end of the femur and upper end of the tibia around their articular surfaces, and sends numerous offsets into the interior of the joint. The arteries which form this plexus are the two medial and the two lateral genicular branches of the popliteal, the highest genicular, the descending branch of the lateral femoral circumflex, and the anterior recurrent tibial. The ANTERIOR TIBIAL ARTERY commences at the bifurcation of the popliteal, at the lower border of the Popliteus, passes forward between the two heads of the Tibialis posterior, and through the aperture above the upper border of the interosseous membrane, to the deep part of the front of the leg: it here lies close to the medial side of the neck of the fibula. It then descends on the anterior surface of the interosseous membrane, gradually approaching the tibia; at the lower part of the leg it lies on this bone, and then on the front of the ankle-joint, where it is more superficial, and becomes the dorsalis pedis. The branches of the anterior tibial artery are: 1. Posterior tibial recurrent. 2. Anterior tibial recurrent. 3. Anterior medial malleolar. 4. Anterior lateral malleolar The posterior tibial recurrent artery (a. recurrens tibialis posterior) an inconstant branch, is given off from the anterior tibial before that vessel passes through the interosseous space. It ascends in front of the Popliteus, which it supplies, and anastomoses with the inferior genicular branches of the popliteal artery, giving an offset to the tibiofibular joint. The anterior tibial recurrent artery (a. recurrens tibialis anterior) arises from the anterior tibial, as soon as that vessel has passed through the interosseous space; it ascends in the Tibialis anterior, ramifies on the front and sides of the knee-joint, and assists in the formation of the patellar plexus by anastomosing with the genicular branches of the popliteal, and with the highest genicular artery. The anterior medial malleolar artery (a. malleolaris anterior medialis; internal malleolar artery) arises about 5 cm. above the ankle-joint and passes behind the tendons of the Extensor hallucis longus and Tibialis anterior, to the medial side of the ankle, upon which it ramifies, anastomosing with branches of the posterior tibial and medial plantar arteries and with the medial calcaneal from the posterior tibial. The anterior lateral malleolar artery (a. malleolaris anterior lateralis; external malleolar artery) passes beneath the tendons of the Extensor digitorum longus and Peronaeus tertius and supplies the lateral side of the ankle, anastomosing with the perforating branch of the peroneal artery, and with ascending twigs from the lateral tarsal artery. The arteries around the ankle-joint anastomose freely with one another and form net-works below the corresponding malleoli. The medial malleolar network is formed by the anterior medial malleolar branch of the anterior tibial, the medial tarsal branches of the dorsalis pedis, the posterior medial malleolar and medial calcaneal branches of the posterior tibial and branches from the medial plantar artery. The lateral malleolar net-work is formed by the anterior lateral malleolar branch of the anterior tibial, the lateral tarsal branch of the dorsalis pedis, the perforating and the lateral calcaneal branches of the peroneal, and twigs from the lateral plantar artery. The ARTERIA DORSALIS PEDIS, the continuation of the anterior tibial, passes forward from the ankle-joint along the tibial side of the dorsum of the foot to the proximal part of the first intermetatarsal space, where it divides into two branches, the first dorsal metatarsal and the deep plantar. The branches of the arteria dorsalis pedis are:

1. Lateral tarsal 2. Medial tarsal 3. Arcuate 4. First dorsal metatarsal 5. Deep plantar The lateral tarsal artery (a. tarsea lateralis; tarsal artery) arises from the dorsalis pedis, as that vessel crosses the navicular bone; it passes in an arched direction lateralward, lying upon the tarsal bones, and covered by the Extensor digitorum brevis; it supplies this muscle and the articulations of the tarsus, and anastomoses with branches of the arcuate, anterior lateral malleolar and lateral plantar arteries, and with the perforating branch of the peroneal artery. The medial tarsal arteries (aa. tarseae mediales) are two or three small branches which ramify on the medial border of the foot and join the medialmalleolar network. The arcuate artery (a. arcuata; metatarsal artery) arises a little anterior to the lateral tarsal artery; it passes lateralward, over the bases of the metatarsal bones, beneath the tendons of the Extensor digitorum brevis, its direction being influenced by its point of origin; and its anastomoses with the lateral tarsal and lateral plantar arteries. This vessel gives off the second, third, and fourth dorsal metatarsal arteries, which run forward upon the corresponding Interossei dorsales; in the clefts between the toes, each divides into two dorsal digital branches for the adjoining toes. At the proximal parts of the interosseous spaces these vessels receive the posterior perforating branches from the plantar arch, and at the distal parts of the spaces they are joined by the anterior perforating branches, from the plantar metatarsal arteries. The fourth dorsal metatarsal artery gives off a branch which supplies the lateral side of the fifth toe. The first dorsal metatarsal artery (a. dorsalis hallucis) runs forward on the first Interosseous dorsalis, and at the cleft between the first and second toes divides into two branches, one of which passes beneath the tendon of the Extensor hallucis longus, and is distributed to the medial border of the great toe; the other bifurcates to supply the adjoining sides of the great and second toes. The deep plantar artery (ramus plantaris profundus; communicating artery) descends into the sole of the foot, between the two heads of the first Interosseous dorsalis, and unites with the termination of the lateral plantar artery, to complete the plantar arch. It sends a branch along the medial side of the great toe, and is continued forward along the first interosseous space as the first plantar metatarsal artery, which bifurcates for the supply of the adjacent sides of the great and second toes. The POSTERIOR TIBIAL ARTERY begins at the lower border of the Popliteus, opposite the interval between the tibia and fibula; it extends obliquely downward, and, as it descends, it approaches the tibial side of the leg, lying behind the tibia, and in the lower part of its course is situated midway between the medial malleolus and the medial process of the calcaneal tuberosity. Here it divides beneath the origin of the Adductor hallucis into the medial and lateral plantar arteries. The branches of the posterior tibial artery are: 1. Peroneal 2. Posterior medial malleolar 3. Medial calcaneal The peroneal artery (a. peronea) is deeply seated on the back of the fibular side of the leg. It arises from the posterior tibial, about 2.5 cm. below the lower border of the Popliteus, passes obliquely toward the fibula, and then descends along the medial side of that bone, contained in a fibrous canal between the Tibialis posterior and the Flexor hallucis longus, or in the substance of the latter muscle. It then runs behind the tibiofibular syndesmosis and divides into lateral calcaneal branches which ramify on the lateral and posterior surfaces of the calcaneus. The posterior medial malleolar artery (a. malleolaris posterior medialis; internal malleolar artery) is a small branch which winds around the tibial malleolus and ends in the medial malleolar network. The medial calcaneal (rami calcanei mediales; internal calcaneal) are several large arteries which arise from the posterior tibial just before its division; they pierce the laciniate ligament and are distributed to the fat and integument behind the tendo calcaneus and about the heel, and to the muscles on the tibial side of the sole, anastomosing with the peroneal and medial malleolar and, on the back of the heel, with the lateral calcaneal arteries. The medial calcaneal (rami calcanei mediales; internal calcaneal) are several large arteries which arise from the posterior tibial just before its division; they pierce the laciniate ligament and are distributed to the fat and integument behind the tendo calcaneus and about the heel, and to the muscles on the tibial side of the sole, anastomosing with the peroneal and medial malleolar and, on the back of the heel, with the lateral calcaneal arteries. The medial plantar artery (a. plantaris medialis; internal plantar artery), much smaller than the lateral, passes forward along the medial side of the foot. Small superficial digital branches accompany the digital branches of the medial plantar nerve and join the plantar metatarsal arteries of the first three spaces. The lateral plantar artery (a. plantaris lateralis; external plantar artery), much larger than the medial, passes obliquely lateralward and forward to the base of the fifth metatarsal bone. It then turns medialward to the interval between the bases of the first and second metatarsal bones, where it unites with the deep plantar branch of the dorsalis pedis artery, thus completing the plantar arch. As this artery passes lateralward, it is first placed between the calcaneus and Abductor hallucis, and then between the Flexor digitorum brevis and Quadratus plantae as it runs forward to the base of the little toe it lies more superficially between the Flexor digitorum brevis and Abductor digiti quinti, covered by the plantar aponeurosis and integument. Materials for self-check: A. Tasks for self-check: specify arteries of the lower lumb using the cadaver preparations. B. Choose the correct answer. 1. A patient has the ischemia of tissues below the knee-joint accompanied by intermittent claudication. Which artery occlusion is meant? A. Popliteal. B. Femoral. C. Posterior tibial. D. Anterior tibial. E. Proximal part of femoral artery. 2. While examining a patient, a surgeon detects artery pulsation behind medial malleolus. Which artery is meant? A. Posterior tibial. B. Fibular. C. Anterior tibial. D. Posterior recurrent tibial. E. Anterior recurrent tibial. 3. A 45-year-old patient's skin of the right foot and leg is pale; there is pulsations of the dorsal artery of foot and posterior tibial artery. Pulsation of the femoral artery is preserved. Which artery is damaged? A. Descending genicular. B. External iliac. C. Fibular. D. Deep artery of thigh. E. Popliteal. 4. Examining blood supply a doctor detects pulsation of a large artery, which passes ahead of the talocrural joint between the tendons of the long extensor of the big toe and the long extensor of fingers in a separate fibrous canal. Which artery is this? A. A. tarsea lateralis. B. A. tibialis posterior. C. A. tarsea medialis. D. A. dorsalis pedis. E. A. fibularis. 5. Examining blood supply of a foot a doctor detects pulsation of a large artery behind the malleolus medialis in a separate fibrous canal. Which artery is this? A. A. dorsalis pedis. B. A. tibialis posterior. C. A. tibialis anterior. D. A. fibularis. E. A. malleolaris medialis. 6. After resection of the middle third of a femoral artery, obstructed by a clot, a lower extremity is supplied with blood due to collateral anastomoses. Which artery is the most important for bloodstream restoration? A. External pudendal artery. B. Superficial circumflex iliac artery. C. Descending artery of knee joint. D. Superficial epigastric artery. E. Deep artery of thigh. 7. After resection of the middle third of femoral artery, obliterated by a thromb the lower extremity is supplied with blood due to the surgical bypass. Name an artery that plays the main role in reestablishment of blood flow: A. Deep femoral artery B. Superficial circumflex artery of hip bone C. Descending genicular artery D. Superficial epigastric artery E. Deep external pudendal artery 8. Specify parts of the aorta. A. The cerebral part B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending parts 9. Specify parts of the descending aorta. A. The thoracic and abdominal parts B. The cervical, the petrous, the cavernous and cerebral parts C. The prevertebral, the cervical, the atlantic and intracranial parts D. The cervical, the atlantic and intracranial parts E. The ascending, the arch and the descending part 10. The narrowing of large vessel caused worsening of outflow of blood from the left ventricle. Which vessel has undergone pathological changes? A. Pulmonary vein B. Pulmonary trunk C. Aorta D. Superior vena cava E. Inferior vena cava References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 13. General characteristic of venous system. System of vena cava superior. Veins of head and neck. 1. Relevance of the topic. Veins are the vessels, which drain blood from the tissues and pass it to the heart. Information about structure, function and topography of the veins is very important for the physician. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the venous vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Vena cava superior Superior vena cava Vena brachiocephalica Brachiocephalic vein Vena jugularis interna The internal jugular vein Bulbus superior/inferior venae jugularis Upper / lower jugular bulb Vena jugularis externa External jugular vein 4.2. Theoretical questions for the class: 1. Topography veins of the head and neck. 2. Name the deep veins of the head and neck. 3. Name the superficial veins of the head and neck. 4. Brachiocephalic veins, their formation, topography. 6. The internal jugular vein, its topography. 7. Intracranial tributaries of internal jugular vein. 8. Name the dural venous sinuses. 9. Extracranial tributaries of internal jugular vein. 10. The external jugular vein, topography, anastomoses 11. The anterior jugular vein formation, tributaries 4.3. Practical task pertaining to the topic and to be completed during the class: specify venous drainage of the different regions of the head and neck: great veins and their tributaries, relation of the sinuses to the bones of the skull, connections between sinuses using cadaver preparations, skulls, models, tables. Content of the topic. The systemic circulatory route comprises three venous systems: 1) the superior vena cava (SVC) system; 2) the inferior vena cava system; 3) the coronary sinus system (the veins of heart). The SVC system features a spe-cific hepatic portal vein system that carries blood to the liver. Relations of the superior vena cava The superior vena cava arises from merging left and right brachiocephalic veins, venae brachiocephalicae posterior to the right first sternocostal joint. The brachiocephalic veins drain the head, the neck and the upper limbs. The SVC descends to enter the right atrium at the level of right third intercostal space; the vein is 5-6 cm long and 2.5 cm wide. On the left one can distinguish the ascending aorta and on the right — the mediastinal pleura and phrenic nerve. The right pulmonary vein resides posterior to the SVC and the thymus and right lung — anterior to it. The lower portion of the vein is enfolded into the serous pericardium. The VSC receives the azygos vein that rounds the root of right lung and passes from superior to inferior and from posterior to anterior. THE BRACHIOCEPHALIC VEIN, VENA BRACHIOCEPHALICA Relations of the brachiocephalic vein. Each brachiocephalic vein is formed of the internal jugular and the subclavian veins. The junction point is situated posterior to the respective sternoclavicular joint. The right vein is shorter than the right (2-3 cm); it runs vertically down. The left vein is about twice as longer (4-5 cm); it slants down and rightwards to join the right vein. The tributaries of brachiocephalic veins. The brachiocephalic veins receive the following tributaries: ■ the vertebral vein, vena vertebralis accompanies the vertebral artery (both run through the transverse foramina of the cervical vertebrae). The vein passes the foramen transversarium of the C7 and proceeds to the related collector. The vein drains the vertebral plexuses and the occipital region; ■ the inferior thyroid vein, vena thyroidea inferior drains the unpaired thyroid plexus. The plexus receives the thymic veins, the inferior laryngeal veins, the tracheal veins, the oesophageal veins etc; ■ the internal thoracic veins, venae thoracicae internae, paired, accompany each artery of the same name. They drain the abdominal walls (the superior epigastric veins, venae epigastricae superiores), the diaphragm (the musculophrenic veins, venae musculophrenicae) and the intercostal spaces (the anterior intercostal veins, venae intercostales anteriores). The superior epigastric veins anastomose with the inferior epigastric and the paraumbilical veins participating thus in formation of the cava-caval and portocaval anastomoses. Apart from the veins mentioned, the brachiocephalic veins drain the veins of thymus, pericardium, medi-astinum, bronchi, trachea and esophagus. THE INTERNAL JUGULAR VEIN, VENA JUGULARIS INTERNA Relations of the internal jugular vein. The internal jugular vein arises directly from the sigmoid sinus. The dilated segment situated within the jugular foramen is the superior bulb of jugular vein, bulbus superior venae jugularis. Within the cervical region, the vein initially runs posterior to the internal carotid artery and then laterally from the common carotid artery. The latter artery, the vagus nerve and the vein constitute the principal cervical neurovascular bundle. The inferior portion of the vein is also dilated — this is the inferior bulb of jugular vein, bulbus inferior venae jugularis. This area houses one or two valves. The tributaries of the internal jugular vein. The internal jugular vein drains the entire head and neck and thus features the intracranial and the extracranial tributaries. The intracranial tributaries of the internal jugular vein. The dural venous sinuses, sinus durae matris. Difference between the sinuses and veins. The dural venous sinuses are the venous canals formed of dura mater. Internal surface of the canals features endothelial investment. Unlike the veins, the sinuses are formed of dense fibrous tissue and lack muscular fibers. They are fixed to the cranial bones at the related grooves and have no valves. The lumen of a typical sinus is of triangular shape. The sinuses never collapse and always maintain the original shape (which is a surgical concern). The sinuses distinguished are like the following: ■ the transverse sinus, sinus trnsversus occupies the groove for transverse sinus of the occipital hone. It descends laterally to become continuous with the sigmoid sinus; parietal bones). The sinus reaches the jugular foramen and becomes continuous with the internal jugular vein; ■ the superior sagittal sinus, sinus sagittalis superior the unpaired sinus that occupies the grove for superior sagittal sinus. It runs from anterior to posterior along the upper border of the cerebral falx. Within the posterior cranial fossa, the sinus joins the transverse sinus on any side. The dilated junction area formed of three sinuses is the confluence of sinuses, confluens sinuum. At the frontal and parietal bones, the sinus has small extensions called the lateral lacunae, lacunae laterales; ■ the inferior sagittal sinus, sinus sagittalis inferior is an unpaired narrow canal that runs along the inferior border of the cerebral falx. The sinus opens into the straight sinus; ■ the straight sinus, sinus rectus runs along the junction of the cerebral falx and the tentorium cerebelli. It opens into the confluence of sinuses; ■ the occipital sinus, sinus occipitlis rises from the confluence and proceeds along the internal occipital crest. On reaching the foramen magnum, the sinus forks and then runs along the borders of foramen. The sinus is continuous with the sigmoid sinus; ■ the sphenoparietal sinus, sinus sphenoparietalis runs along the posterior border of the lesser wing of sphenoid. It opens into the anterior portion of the cavernous sinus; ■ the cavernous sinus, sinus caver-nosus resides on both lateral sides of the body of sphenoid. Its cavity contains numerous endotheliumlined cells separated by the septa. The sinuses communicate via the anterior and posterior intercavernous sinuses, sinus intercavernosus anterior et posterior. Posteriorly, the cavernous sinus opens into the superior and inferior petrosal sinuses. The cavity of the sinus passes the internal carotid artery and the abducent nerve, its lateral wall passes the ophthalmic, oculomotor and trochlear nerves; ■ the superior and inferior petrosal sinuses, sinus petrosus superior et inferior occupy the respective grooves of the temporal bone. They communicate the cavernous sinus with the sigmoid sinus; ■ the basilar plexus, plexus basilaris occupies the clivus. It communicates with the cavernous and cavernous sinuses and with the verte-bral venous plexuses. The cerebral veins, venae encephali The cerebral veins collect venous blood from the brain. They are subdivided into the superficial and deep veins. The superficial cerebral veins, venae cerebri superficiales form numerous anastomoses on all surfaces of brain. The following superficial veins are distinguishable: ■ the superior cerebral veins, venae superiores cerebri, numerous (10- 15 on each side), they drain the dorsal and medial surfaces of each hemisphere. These veins open into the superior sagittal sinus. The su-perior cerebral veins are represent-ed with the frontal, parietal and occipital veins; ■ the superficial middle cerebral vein, vena media superficial cerebri occupies the lateral sulcus. The vein opens into the cavernous sinus; ■ the inferior cerebral veins, venae inferiores cerebri drain the lateral and inferior surfaces of each hemisphere. They run posteriorly and open into the transverse sinus. The deep cerebral veins, venae profundae cerebri drain the internal compartments of brain. They merge into two internal cerebral veins, venae intemae cerebri that drain the basal nuclei, white matter, hippocampus, thalamus and the choroid plexuses. The internal veins reside within the roof of the third ventricle. They merge into one great cerebral vein, vena magna cerebri that opens into the straight sinus. The veins of brainstem open into the great cerebral vein. The superior veins of cerebellar hemisphere are continuous wit both great cerebral vein and the straight sinus. The inferior veins of cerebellar hemisphere open into the sinuses of cranial base. The ophthalmic veins, venae ophthalmicae. The ophthalmic veins drain the constituents of the orbit. The superior ophthalmic vein, vena ophthalmica superior runs above the eyeball. It drains the frontal area, the superior eyelid, the nasal cavity, the lacrimal gland, the related portion of the eyeball and neighboring muscles. At the medial angle of eye, the vein anastomoses with the angular vein (the beginning of the facial vein). The superior ophthalmic vein quits the orbit via the superior orbital fissure and opens into the cavernous sinus. The inferior ophthalmic vein, vena ophthalmica inferior runs along the inferior wall of the orbit. It drains the inferior eyelid, the inferior portion of the eyeball and neighboring muscles. Clinical application Anastomosis between the facial and orbital veins is of a certain clinical significance. The valveless angular vein may carry the pathogens or even the emboli to the superior ophthalmic vein from where they may appear within the cavernous sinus (i.e. within the cranial cavity). This may result in severe complications. The diploic veins, venae diploicae The diploic veins are the thinwalled veins embedded into the cancellous bone of calvaria. Depending on location, the following diploic veins are distinguished: ■ the frontal diploic vein, vena diploica frontalis; ■ the anterior and posterior temporal diploic veins, venae diploicae temporales (anterior et posterior); ■ the occipital diploic vein, vena diploica occipitalis; The diploic veins open into both dural venous sinuses and the extrinsic veins of head. The emissary veins, venae emissariae The emissary veins communicate the dural venous sinuses with the extrinsic veins of head. They pass within the respective cranial canals. The largest emissary veins are: ■ the parietal emissary vein, vena emissaria parietalis passes within the parietal foramen. It communicates the superior sagittal sinus with the superficial temporal vein; ■ the mastoid emissary vein, vena emissaria mastoidea passes within the mastoid foramen. It communicates the transverse sinus with the occipital vein; ■ the condylar emissary vein, vena emissaria condylaris passes within the condylar canal. It communicates the sigmoid sinus with the external vertebral plexus; ■ the occipital emissary vein, vena emissaria occipitalis; Small venous plexuses situated within the hypoglossal canal, the foramen ovale and the carotid canal also belong to the emissary veins. The extracranial tributaries of the internal jugular vein. The internal jugular vein has numerous tributaries within the cervical region. The greatest related vessels are the facial, retromandibular, superior thyroid and the pharyngeal veins. The facial vein, vena facialis branches off similarly to the facial artery. It arises at the medial angle of eye (as the angular vein, vena angularis) and descends to the cervical region. Within the cervical region, the artery declines posteriorly and joins the retromandibular vein. The veins merge into a single trunk, which opens into the internal jugular vein. Sometimes the veins join the jugular vein separately. The facial vein drains the frontal region, the nose, the eyelids, the lips, the soft palate, the parotid gland, the muscles of the oral diaphragm and the submandibular gland. The facial vein anastomoses with the ophthalmic arteries directly and with the pterygoid plexus via the deep facial vein. The retromandibular vein, vena retromandibularis is related to both superficial temporal and maxillary arteries. It arises anterior to the auricle within the parotid gland. It drains the superficial temporal and the maxillary veins. Upon reaching the cervical region, the vein joins the internal jugular vein. It features a permanent anastomosis with the external jugular vein. The retromandibular vein is formed of the following veins: ■ the superficial temporal veins, venae temporales superficiales, they drain several areas of head, face, the external ear, the parotid gland and the tympanic cavity; ■ the maxillary veins, venae maxillaries accompany the artery of the same name. They drain the pterygoid plexus, plexus pterygoideus situated deep around the pterygoid muscles. The plexus in turn drains the masticatory muscles, the dura mater, the upper and lower teeth and the oral and nasal mucosa. The pterygoid plexus anastomoses with the facial vein via the deep facial vein, vena profunda faciei. Other tributaries Apart from the retromandibular and facial veins, the internal jugular vein receives the following smaller veins: ■ the lingual vein, vena lingualis drains the tongue; ■ the superior thyroid vein, vena thy- roidea superior drains the thyroid gland, the larynx and the cervical muscles; ■ the pharyngeal veins, venae pha- ryngeae drain thephaiyngealplex-us, plexus pharyngeus. THE EXTERNAL JUGULAR VEIN, VENA JUGULARIS EXTERNA The external jugular vein is a subcutaneous vein that arises by the union of two tributaries — the anterior, which is the anastomosis with the ret-romandibular vein and the posterior formed of the occipital and posterior auricular veins. The vein crosses the sternocleidomastoid and enters the greater supraclavicular fossa. There it opens into the venous angle — the junction point of the subclavian and internal jugular veins. The external jugular vein receives the suprascapular and transverse cervical veins, and the anterior jugular vein. THE ANTERIOR JUGULAR VEIN, VENA JUGULARIS ANTERIOR The anterior jugular vein arises from small superficial veins of the sublingual area. The veins descend to the manubrium of sternum and merge to form the jugular venous arch, arcus venosus jugularis. The lateral ends of the arch open into the external jugular vein before it joins the venous angle. Materials for self-check: A. Tasks for self-check: specify venous drainage of the different regions of the head and neck: great veins and their tributaries, relation of the sinuses to the bones of the skull, connections between sinuses using cadaver preparations, skulls, models, tables. B. Choose the correct answer. 1. An injury of skin in the medial region of the sternocleidomastoid muscle caused air embolism. Which cervical vein was damaged? A. Posterior auricular. B. Anterior jugular. C. Internal jugular. D. External jugular. E. Transverse cervical. 2. A patient with a thymus tumor has cyanosis, extension of subcutaneous venous network, edema of soft tissues of the face, neck, upper half of the body, upper limbs. Which venous trunk is blocked? A. Superior vena cava. B. External jugular vein. C. Subclavian vein. D. Internal jugular vein. E. Anterior jugular vein. 3. A patient was admitted to an intensive therapy department with heavy poisoning. To provide infection it is necessary to catheterize the patient and inject medicines into subclavian vein. In what topographical place is it localized? A. Spatium interscalenum. B. Spatium retrosternocleidomastoideus. C. Spatium anterscalenum. D. Spatium interaponeuroticum suprasternale. E. Trigonum ornotrapezoideum. 4. A 70-y.o. man has cut an abscess off in the area of mastoid process during shaving. Two days later, he was admitted to the hospital with inflammation of arachnoid membranes. How did the infection penetrate into the cavity of skull? A. Vv. emissariaе mastoideaе B. Vv. labyrinthi C. Vv. tympanicae D. Vv. facialis E. Vv. auriculares 5. Surgical approach to the thyroid gland from the transverse (collar) approach involves opening of interaponeurotic suprasternal space. What anatomic structure localized in this space is dangerous to be damaged? A. Jugular venous arch B. External jugular vein C. Subclavicular vein D. Inferior thyroid artery E. Superior thyroid artery 6. Specify origins of the superior vena cava. A. Pulmonary veins B. Internal jugular veins C. Azygos vein and hemiazygos vein D. Brachiocephalic veins E. Subclavian veins 7. Specify chamber of the heart which the superior vena cava flows into. A. Left atrium B. Right atrium C. The right ventricle D. The left ventricle E. The left auricle 8. Specify chamber of the heart which the inferior vena cava flows into. A. Left atrium B. Right atrium C. The right ventricle D. The left ventricle E. The left auricle 9. Specify tributaries of the superior vena cava. A. Mediastinal veins B. Hemiazygos vein and azygos vein C. Subclavian veins D. Brachiocephalic veins. E. Internal jugular veins. 10. Specify tributaries of the brachiocephalic vein. A. Mediastinal veins B. Hemiazygos vein and azygos vein C. Subclavian veins and internal jugular veins D. Vertebral veins E. Internal thoracic veins. References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 14. System of vena cava superior. Veins of upper extremities and chest. 1. Relevance of the topic. Veins of the body are usually used like the ways of incoming of liquid medications. So, information about structure, relation to the organs, number and topography of tributaries is necessary for the future doctor. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the venous vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Vv. Bronchiales Bronchial veins Vv. tracheales Tracheal vein V. vertebralis Vertebral veins Vv. oesophageales Esophageal veins V. hemiazygos Hemiazygos vein Vv. pericardiacae Pericardial veins 4.2. Theoretical questions for the class: 1. Subclavian vein and its tributary. 2. Deep veins of the upper extremity. 3. Superficial veins of upper extremity. 4. Forming of superior vena cava; azygos, hemiazygos veins. 4.3. Practical task pertaining to the topic and to be completed during the class: specify interrelation between greater veins of the upper extremities and trunk and neighboring structures using cadaver preparations, models, bones of the upper limb, tables. Content of the topic. The subclavian vein is a direct continuation of the axillary vein. The veins are delimited by the external border of the first rib. The axillary vein is a great vessel that resides within the cervical region anterior to the scalenus anterior and posterior to the clavicle. The vein joins the internal jugular vein to form the brachiocephalic vein. The subclavian vein receives the pectoral veins, venae pectorales and the dorsal scapular vein, vena scapularis dorsalis. Clinical applications The axillary vein is fixed to periosteum of neighboring bones (i.e. the first rib and clavicle), to the tendon of the anterior scalene and to the cervical fascia. Fixed so, the vein is unable to collapse in case of severance. In this case, the air may appear within the vein lumen (because of negative pressure within the thoracic cavity and pumping action of heart) producing the venous air embolism. The state is extremely dangerous because the air may fill the entire right side of heart and stop blood flow through it. THE AXILLARY VEIN, VENA AXILLARIS The axillary vein is a direct continuation of the brachial vein. The vein ascends anteromedially from the axillary artery and reaches the first rib to become continuous with the subclavian vein. The tributaries of the axillary vein correspond to the branches of the axillary artery (the lateral thoracic and subscapular veins, the anterior and posterior circumflex humeral veins etc.). It also receives the thoraco- epigastric veins, venae thoraco-epigastricae that drain the thoracic and abdominal walls. The thoracoepigastric veins anastomose with the superficial epigastric veins related to the femoral vein. These veins form the cava-caval anastomosis. THE VEINS OF UPPER LIMBS The paired veins of the upper limbs are divided into the superficial and deep, deep veins accompany the respective The superficial veins are embedded arteries (the venae comitantes). The superficial veins arise at the dorsal surface of hand with the dorsal venous network of hand, rete venosum dorsal manus that drains the fingers. The venous network gives rise to the principal superficial veins of upper limb — the cephalic and basilic veins: ■ the cephalic vein, vena cephalica arises at the dorsal aspect of thumb. The vein runs along the radial aspect of forearm (here it is called the cephalic vein of forearm, vena cephalica antebrachii), passes the lateral bicipital and deltoideopectoral grooves and reaches the clavipectoral triangle. There it penetrates the clavipectoral fascia and joins the axillary vein; ■ the basilic vein, vena basilica arises from the ulnar portion of the venous network and ascends along the anterior surface of the forearm on the same side (the basilic vein of forearm, vena basilica antebrachii). Then the vein crosses the cubital fossa and enters the medial bicipital groove. At the upper third of the arm, the vein pierces the brachial fascia and joins one of the brachial veins. Very often, the basilic vein appears to be larger than the brachial vein because it is continuous with the axillary vein; ■ the median cubital vein, vena mediana cubiti is a short but important anastomosis between the cephalic and basilic veins that crosses the cubital fossa. The vein maintains communication with the deep veins of the cubital fossa. Shape and position of the vein vary from individual to individual. This vein is of clinical significance because it is used for injections. The deep veins, usually paired, accompany the respective arteries. The upper limb thus features double superficial and deep palmar arches, double ulnar veins, venae ulnares, double radial veins, venae radiales etc. Two brachial veins, venae brachiales merge into a single vein in the upper third of the arm. The latter vein joins the basilic vein, which becomes continuous with the axillary veins. The deep veins anastomose with each other and with the superficial veins. Both superficial and deep veins have numerous valves. THE AZYGOS VEIN, VENA AZYGOS The azygos vein arises within the abdominal cavity as the longitudinal anastomosis that associates the right lumbar veins — the right ascending lumbar vein, vena lumbalis ascendens dextra. The latter vein reaches the thoracic cavity via the opening in the diaphragm. Within the thoracic cavity, the vein resides on the right side of the vertebral column, posterior to the esophagus, and to the right of the thoracic duct and aorta. At the level of the Th4, the vein rounds the right main bronchus (this is the arch of azygos vein, arcus venae azygos) and joins the SVC outside its pericardial enfolding. The vein accepts the visceral and the parietal tributaries. The parietal tributaries The parietal tributaries of the azygos vein are like the following: ■ the posterior intercostal veins, ve-nae intercostales posteriores (nine right lower veins) accompany the respective arteries within the costal grooves. They drain the vertebral plexuses and the thoracic walls; ■ the right superior intercostal vein, vena intercostalis superior dextra is the common trunk formed of three upper right posterior intercostal veins; ■ the superior phrenic veins, vena phrenicae superiores drain the diaphragm. The visceral tributaries are the oesophageal veins, venae oesophageales, the bronchial veins, venae bronchiales, the pericardial veins, venae pericardiacae and the medias-tinal veins, venae médiastinales. The oesophageal veins anastomose with the gastric veins that carry blood to the hepatic portal vein. THE HEMIAZYGOS VEIN, VENA HEMIAZYGOS The hemiazygos vein arises similarly to the azygos vein i.e. with the left ascending lumbar vein, vena lumbalis ascendens sinistra. Within the thoracic cavity, the vein runs along the left side of the vertebral column, posterior to the aorta. The vein receives 4-5 left lower posterior intercostal veins, venae intercostales posteriores. At the level of Th7 or Th8, the hemiazygos vein declines rightwards, crosses the vertebral col-umn and joins the azygos vein. The left upper posterior intercostal veins merge to form the accessory hemiazygos vein, vena hemiazygos accessoria, which joins the hemiazygos vein. Anastomoses related to the azygos and hemiazygos veins. Both veins arise from the lumbar veins, which are the tributaries of the inferior vena cava. As far as they open into the superior vena cava, they form a large cava- caval anastomosis. The veins of vertebral column. The veins of vertebral column form the plexuses situated all along the vertebral column. Depending on location, the external and internal venous vertebral plexuses are distinguishable: ■ the anterior and posterior internal vertebral plexuses, plexus venosus vertebralis internus (anterior et posterior) reside within the epi-dural space of the vertebral canal. They arise from the vertebral veins, the spinal veins and the meningeal veins; ■ the anterior and posterior external vertebral plexuses, plexus venosus vertebralis externus (anterior et posterior) reside outside the vertebral canal. The plexuses commu-nicate via the basivertebral veins, venae basivertebrales embedded into the cancellous bone of the vertebrae. The vertebral plexuses drain blood to the intervertebral veins, venae intervertebrales and further to the vertebral veins (in the cervical region), posterior intercostal veins (in the thoracic region), lumbar veins (in the lumbar region) and the sacral veins (the sacral region). The plexuses associate the systems of the superior and inferior venae cavae forming thus a large cava-caval anastomosis. Materials for self-check: A. Tasks for self-check: specify interrelation between greater veins of the upper extremities and trunk and neighboring structures using cadaver preparations, models, bones of the upper limb, tables. B. Choose the correct answer. 1. Specify origins of the superior vena cava. A. Pulmonary veins B. Internal jugular veins C. Azygos vein and hemiazygos vein D. Brachiocephalic veins E. Subclavian veins 2. Specify chamber of the heart which the superior vena cava flows into. A. Left atrium B. Right atrium C. The right ventricle D. The left ventricle E. The left auricle 3. Specify chamber of the heart which the inferior vena cava flows into. A. Left atrium B. Right atrium C. The right ventricle D. The left ventricle E. The left auricle 4. Specify tributaries of the superior vena cava. A. Mediastinal veins B. Hemiazygos vein and azygos vein C. Subclavian veins D. Brachiocephalic veins. E. Internal jugular veins. 5. Specify tributaries of the brachiocephalic vein. A. Mediastinal veins B. Hemiazygos vein and azygos vein C. Subclavian veins and internal jugular veins D. Vertebral veins E. Internal thoracic veins. 6. Which triangle of the neck is situated internal jugular vein? A. Omotrapezoid B. Omoclavicular C. Submental D. Submandibular E. Carotid 7. What are the boundaries of the carotid triangle? A. Anterior belly of digastric, superior belly of omohyoid, sternocleidomastoid B. Posterior belly of digastric, inferior belly of omohyoid, sternocleidomastoid C. Posterior belly of digastric, sternocleidomastoid D. Posterior belly of digastric, superior belly of omohyoid, sternocleidomastoid E. Anterior belly of digastric, thyrohyoid, sternocleidomastoid 8. Specify the length of the superior vena cava. A. 3-4 cm B. 5-6 cm C. 9- 12 cm D. 13-16 cm B. 17-20 cm 9. Specify the width of the superior vena cava. A. 3-4 cm B. 5-6 cm C. 9- 12 cm D. 2-3 cm B. 17-20 cm 10. Specify anatomical structure that reside on the left of the superior vena cava: A. The ascending aorta B. The thymus C. The mediastinal pleura D. The root of the right lung E. Phrenic nerve References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 15. System of vena cava inferior. Veins of lower extremities, pelvis and abdominal cavity. 1. Actuality of theme. Inferior vena cava with their tributaries drains blood from the lower half of the body, excepting unpaired organs of digestive system. Disruptions of venous drainage can cause different diseases of different systems of organs. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the venous vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Vena cava inferior Inferior vena cava Vv. phrenicae inferiores Inferior diaphragmatic veins Vv. lumbales Lumbar veins Vena iliaca communis The common iliac vein V. femoralis Femoral vein V. profunda femoris Deep femoral vein 4.2. Theoretical questions for the class: 1. Review of the inferior vena cava. 2. The common iliac vein. 3. Topography of the common iliac vein. 4. Features of the visceral veins of the pelvic cavity 5. Venous plexus, their value. 6. The internal iliac vein, topography, tributaries. 7. The deep veins of the lower limbs, their tributaries, topography. 8. The superficial veins of the lower limbs, their tributaries, topography. 9. Anastomoses veins of the lower limbs, their clinical significance 4.3. Practical task pertaining to the topic and to be completed during the class: specify deep and superficial veins of the lower limb, regions of blood drainage, tributaries using cadaver preparations, models, tables. Find parietal and visceral veins, venous plexuses using cadaver preparations, models, tables. Show forming of inferior vena cava, its tributaries using cadaver preparations, models, tables. Content of the topic. The inferior vena cava is the greatest systemic vein (2.5-3 cm wide). It arises at L5 by the union of the com-mon iliac veins. The junction point resides below and to the right of the aortic bifurcation, and posterior to the right common iliac artery. The IVC ascends on the right sides of the bodies of the L3-L5 vertebrae and on the right psoas major to the right of the aorta. The upper portion of IVC occupies the groove for vena cava on the visceral surface of liver. The IVC leaves the abdominal cavity via the caval opening in the central tendon of the diaphragm and enters the thoracic cavity at the level of Th8. Upon reaching the heart, the IVC traverses the pericardium and enters the right atrium. The IVC is 17-20 cm long; the thoracic portion is 2-3 cm long. The vein receives parietal and visceral tributaries. The visceral tributaries The greatest visceral tributaries of the IVC are the hepatic and the renal veins. T he IVC also receives the veins from the gonads and suprarenal glands. ■ the hepatic veins, venae hepaticae drain the entire liver. They open into the IVC segment related to the groove for vena cava. The hepatic veins distinguishable are three larger veins (the superior, intermediate and inferior) and some smaller ones. All veins are fully incorporated into the liver parenchyme and one can see their openings after dissecting the posterior wall of the vein; ■ the renal vein, vena renalis, paired, it becomes evident within the hilum of kidney. Both veins run medially to join the IVC. The left renal vein is longer than the right one; it crosses the aorta. The left renal vein receives the left testicular (or ovarian) and the left suprarenal veins; ■ the right testicular (ovarian) vein, vena testicularis (ovarica) dextra opens right into the IVC (while the left veins open into the left renal vein). The long veins run along the respective arteries. In males, the testicular vein arises from the pampiniform plexus, plexus pampiniformis situated within the spermatic cord; ■ the right suprarenal vein, vena suprarenalis dextra opens right into the IVC; the left opens into the left renal artery. The parietal tributaries The parietal tributaries of the IVC include the lumbar and inferior phrenic veins: ■ the lumbar veins, venae lumbales, four on each side, they run along the arteries of the same name. The lumbar veins drain the vertebral plexuses and the abdominal walls. The lumbar veins on each side anastomose by means of the ascending lumbar veins, venae lumbales ascendens, which give rise to the azygos and hemiazygos veins; ■ the inferior phrenic veins, venae phrenicae accompany the respective arteries. THE COMMON ILIAC VEIN, VENA ILIACA COMMUNIS The common iliac vein arises from the union of the external and internal iliac veins at the sacroiliac joint. The right vein resides posterior to the artery of the same name, the left — posterior and medially from the respective artery. Both veins run medially and merge to form the IVC. The left common iliac vein receives the middle sacral vein. THE INTERNAL ILIAC VEIN, VENA ILIACA INTERNA The internal iliac vein is the principal venous collector of the lesser pelvis. It drains the walls of lesser pelvis and all retaining viscera. Its short thick trunk ascends posterior to the artery of the same name and reaches the sacroiliac joint. There the vein joins the external iliac vein to give rise to the common iliac vein. The internal iliac vein receives the parietal and visceral tributaries. The visceral tributaries form the venous plexuses around the pelvic viscera. The double parietal tributaries accompany the respective arteries. They are the iliolumbar veins, venae iliolumbales, the superior gluteal veins, venae gluteae superiores, the inferior gluteal veins, venae gluteae inferiores, the obturator veins, venae obturatoriae and the lateral sacral veins, venae sacrales laterals. THE VENOUS PLEXUSES AND VISCERAL TRIBUTARIES OF THE LESSER PELVIS The lesser pelvis contains the venous plexuses as follows: 1. The rectal venous plexus, plexus venosus rectalis surrounds the rectum. It is drained by the following veins: ■ the superior rectal veins, venae rectales superiores join the inferior mesenteric vein (which belongs to the portal venous system); ■ the middle rectal veins, venae rectales medii join the internal iliac vein; ■ the inferior rectal veins, venae rectales inferiores join the internal pudendal vein (the tributary of the internal iliac vein). The rectal venous plexus associates the IVC system with the portal venous system and thus constitutes the portocaval (the portal systemic) anastomosis. 2. The vesical venous plexus, plexus venosus vesicalis occupies the fundus and the lateral aspects of the urinary bladder. The plexus is drained by the vesical veins, venae vesicales that open into the internal iliac vein; 3. The prostatic venous plexus S, plexus venosus prostaticus surrounds the prostate. It drains the seminal glands, prostate and penis. The plexus is drained by the by the vesical and middle rectal veins. 4. The vaginal venous plexus, plexus venosus vaginalis surrounds the vagina. The plexus is drained by the vesical, uterine and middle rectal veins; 5. The uterine venous plexus, plexus venosus uterinus resides laterally from the uterus, in between the layers of the broad ligament of uterus. The plexus is drained by the uterine veins, venae uterinae (which open into the internal iliac vein) and the ovarian veins (they open into the IVC). The perineum and external genitalia are drained by the interned pudendal vein, vena pudenda interna that opens into the internal iliac vein. Its tributaries correspond to the branches of the pudendal artery. THE EXTERNAL ILIAC VEIN, VENA ILIACA EXTERNA Relations of the external iliac vein The external iliac vein is a direct continuation of the femoral vein. On passing the vascular space, the vein resides posterior and medial to the femoral artery. The external iliac vein joins the internal iliac vein to give rise to the common iliac vein. The tributaries of the external iliac vein are like the following: ■ the inferior epigastric vein, vena epigastrica inferior arises within the umbilical region (there it anas-tomoses with the superior epigastrie and paraumbilical veins). These interconnections give rise to the portocaval and cava-caval anastomoses. Descending as a single trunk along the inferior epigastric artery, the vein drains the anterior abdominal wall. Inferiorly, it anastomoses with the obturator vein; the deep circumflex iliac vein, vena circumflexa ilium profunda ac-companies the artery of the same name and drains the respective area. Materials for self-check: A. Tasks for self-check: specify deep and superficial veins of the lower limb, regions of blood drainage, tributaries using cadaver preparations, models, tables. Find parietal and visceral veins, venous plexuses using cadaver preparations, models, tables. Show forming of inferior vena cava, its tributaries using cadaver preparations, models, tables. B. Choose the correct answer. 1. A patient has varicose veins and thrombophlebitis on the posterolateral surface of the leg. Which vein is damaged? A. V. saphena magna. B. V. saphena parva. C. V. tibialis posterior. D. V. peronea. E. V. tibialis anterior. 2. A patient complains of pain and spasms along the posteromedial surface of the shin. Which vein is damaged? A. V. femoralis. B. V. saphena magna. C. V. epigastrica supert'icialis. D.V. poplitea. E. V. saphena parva. 3. Examination of a patient has shown ail edema on the medial surface of the femur, enlargement of veins, and nodulation. Which vein has pathology? A. V. poplitea. B. V. saphena parva. C. V. femoralis. D. V. saphena magna. E. V. iliaca externa. 4. A patient has vessel dilation on the anteromedial surface of the shin. Which vessel dilation caused this process? A. V. saphena parva. B. A. tibialis anterior. C. V. saphena magna. D.A. tibialis posterior. E. V. poplitea. 5. A patient complains of pain and edema of her lower extremities. Examination has shown edema of tissues, noticeable varicose veins, and nodulation on the medial surface of the thigh. Which vein damage might have caused such changes? A. V. saphena magna. B. V. saphena parva. C. V. femoralis. D. V. profunda femoris. E. Vv. tibiales. 6. A woman appealed to a doctor with complaints of pain and edema of the lower extremity, veins swelling, and varicose nodes formation on the medial surface of the thigh. Which vein is damaged? A. Popliteal. B. Small saphenous. C. Femoral. D. Large saphenous. E. Posterior tibial. 7. A patient complains about edemata of legs, skin cyanosis, small ulcers on one side of the lateral condyle. Examination revealed a swelling, enlarged veins, formation of nodes. The pathological process has started in the following vein: A. V. saphena parva B. V. saphena magna C. V. femoralis D. V. profunda femoris E. V. iliaca externa 8. A patient has left-side varicocele. Blood outflow disorder has taken place in: A. V. testicularis dextra. B. V. testicularis sinistra. C. V. renalis sinistra. D.V. renalis dextra. E. V. ovarica. 9. During operation on kidneys, a surgeon must select the renal stalk. What goes out from a kidney gate? A. Renal artery, ureter B. Renal artery, nerves C. Renal vessels and nerves D. Renal artery and vein E. Renal vein, ureter and lymphatic vessels 10. The patient was delivered in the hospital with abdominal injuries. At the same time lateral umbilical fold was corrupted. Determine its contents. A. A. et V. epigastrica inferior B. A. umbilicalis C. A. et V. epigastrica superior D Urarchus E A. et V. epigastrica superficialis References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 16. System of portal vein. Fetal circulation. 1. Relevance of the topic. Portal vein drains blood from the organs of abdominal cavity which placed on the border with external envirinment. System of the portal vein connected with the systems of cave veins. Those anastomosises work due deseases of the liver. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the venous vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Vena portae hepatic Portal vein of liver Vv. paraumbilicales Paraumbilical veins V. rectalis superior The upper rectal vein Lig. teres hepatis Round ligament of liver 4.2. Theoretical questions for the class: 1. Topography of the portal vein. 2. What are the porto-caval anastomoses. 3. The superior mesenteric vein, its tributaries. 4. Splenic vein and its tributaries. 5. The inferior mesenteric vein, its tributaries. 6. Gastric veins and their tributaries. 7. What are the cavo-caval anastomoses. 8. What are the porto-cavo-caval anastomoses. 4.3. Practical task pertaining to the topic and to be completed during the class: specify blood outflow from unpaired organs of abdominal cavity; forming of portal vein by their tributaries using the cadaver preparations, tables, models. Find connections between tributaries of the portal vein and tributaries of the superior and inferior cave veins using the cadaver preparations, tables, models. Show differences in blood circulation in fetal life. Content of the topic. The hepatic portal vein (HPV) is a great venous vessel (1.5-2 cm wide) that drains the unpaired abdominal viscera and carries the blood collected to the liver. The blood drained from the intestines, stomach, pancreas and spleen passes through the hepatic capillaries before proceeding to the systemic circulation. This venous system serves the liver with its various important functions. The liver is responsible for synthesis and depositing of glycogen; it also plays a key role in metabolism of the proteins, lipids and vitamins. Detoxification belongs to one of the most important functions of liver because it neutralizes the toxic agents absorbed by the intestines together with the nutrients and water. Direct anastomosis between the IVC and HPV is fatal. Relations of the HPV The HPV resides within the hepa-toduodenal ligament posterior to the common hepatic duct and hepatic artery. Its main trunk (4-5 cm long) arises posterior to the head of pancreas by the union of the superior and in-ferior mesenteric veins and the splenic vein. The superior mesenteric vein, vena mesenterica superior resides within the mesentery of the small intestine next to the mesenteric artery. Its tributaries correspond to the branches of neighboring artery. These branches are the intestinal veins, venae intestinales, the right gastro-epiploic vein, vena gastroepiploica dextra, the pancreaticoduodenal veins, venae pancreaticoduodenales, the ileocolic vein, vena ileocolica (with featured appendicular vein, vena appendicularis), the light colic vein, vena colica dextra and the middle colic vein, vena colica media. The superior mesenteric vein thus drains the entire small intestine, the caecum and vermiform appendix, the ascending and transverse colon, and partially the stomach, duodenum and pancreas. The inferior mesenteric vein, vena mesenterica inferior also neighbors the artery of the same name and its tributaries run next to the arterial branches. The tributaries are the superior rectal vein, vena rectalis superior, the sigmoid veins, venae sigmoideae, and the left colic vein, vena colica sinistra. The splenic vein, vena lienalis becomes evident within the splenic hilum and proceeds right wards, posterior to the pancreas. On reaching the head of pancreas, the vein joins the superior mesenteric vein. The splenic vein has the following tributaries: the pancreatic veins, venae pancreaticae, the short gastric veins, venae gastricae breves and the left gastro-epiploic vein, vena gastroepiploica sinistra. The splenic vein thus drains the spleen, pancreas and the stomach. The tributaries of the main trunk The main trunk of the HPV receives the tributaries as follows: the tight gastric vein, vena gastrica dextra, the left gastric vein, vena gastrica sinistra, the cystic vein, vena cystic, the prepyloric vein, vena prepylorica and the paraumbilical veins, venae paraumbilicales. The paraumbilical veins are the small vessels that occupy the round ligament of liver. In the umbilical region, the veins anastomose with the superior and inferior epigastric veins and with some subcutaneous veins (the thoraco-epigastric veins and the superficial epigastric veins). In portal obstruction, the paraumbilical veins become distended because they provide collateral circulation for blocked portal system. The blood thus drains to the veins of the anterior abdominal wall and further to the SVC and IVC. THE INTRINSIC VASCULATURE OF LIVER The liver receives the hepatic portal vein and the hepatic artery proper. The HPV is the functional blood vessel while the artery supplies the liver with oxygenated blood. Within the liver, the HPV forks into the right and left branches that in turn split into the segmental branches. The segmental branches eventually become continuous with the interlobular branches and they give off radiating capillaries to the center of hepatic lobe. The capillaries merge into the central veins (they reside in the center of each lobule) that quit the lobule and join to form the hepatic veins, venae hepaticae. The hepatic veins constitute the efferent venous system of liver; they leave the liver within the groove for vena cava and open into the IVC. Branches of the hepatic artery generally correspond to the branches of the HPV. The arterial precapillaries join the common lobular capillary network. THE VEINS OF LOWER LIMB The veins of the lower limb are subdivided into the superficial and deep. The superficial veins run below the skin and outside the proper fascia. The double deep veins accompany the arteries. The superficial veins give rise to the great and small saphenous veins. They arise from the dorsal and plantar venous netu'orks of foot: ■ the great saphenous vein, vena sa-phena magna arises from the medial portion of the dorsal venous network of foot and ascend along the medial aspect of the leg and thigh. In the upper third of thigh, the vein runs along its ante-rior surface to reach the saphenous opening. On passing the saphenous opening, the vein joins the femoral vein. On the way to destination point, the vein receives numerous tributaries that anastomose with each other and with the tributaries of small saphenous vein and deep veins of lower limb. At the saphenous opening, the vein receives the external pudendal veins, venae pu- dendae externae, the superficial circumflex iliac vein, vena circumflexa ilium superficialis and the superficial epigastric vein, vena epigastrica superficialis. These veins may join the femoral vein as well; ■ the small saphenous vein, vena sa-phena parva arises at the lateral aspect of foot. The vein rounds the lateral malleolus and ascends along the posterior surface of leg in between the heads of the gastrocne-mius muscle. At the popliteal fossa, the muscle pierces the fascia and joins the popliteal vein. The small saphenous vein receives numerous tributaries that anastomose with the tributaries of the great saphenous vein and with the deep veins of thigh. The deep veins accompany the pertaining arteries (two veins accompany one artery). Therefore, two anterior tihial veins, venae tibiales anteriores accompany the anterior tibial artery, two posterior tibial veins, venae tibiales posteriores accompany the posterior tibial artery, etc. In the upper portion of leg, the anterior and posterior tibial veins merge to form a single popliteal vein, vena poplitea. The latter vein ascends to the adductor canal and becomes continuous with the femoral vein. The femoral vein, vena femoralis resides within the femoral triangle medially from the femoral artery. Upon passing through the vascular space, it becomes continuous with the external iliac vein. The greatest tributary of the femoral vein is the deep vein of thigh, vena profunda femoris. The deep veins anastomose with each other and with the superficial veins. Both superficial and deep veins have numerous valves. Clinical applications. The varicose veins are distended, lengthened and tortuous veins. The state is caused by loose fascia, low resilience of vein wall and valve incompetence. The most commonly affected vein is the great saphenous vein yet other superficial veins are also susceptible. Treatment includes medication and surgical intervention (removal of the affected veins). THE CAVA-CAVAL ANASTOMOSES The cava-caval anastomoses as-sociate the systems of the SVC and I VC. The most significant anastomoses reside by anterior and posterior abdominal walls. The vertebral venous plexuses, plexus venosus vertebralis interni et externi are represented with wide anastomoses that reside all along the vertebral column. The sacral and lumbar veins (they are related to the IVC system) drain the plexuses in the sacral and lumbar regions. The vertebral, azygos and hemiazygos veins (they belong to the SVC system) drain the plexuses in the cervical and thoracic regions. The azygos and hemiazygos veins carry blood to the SVC. They represent another significant anastomosis because beginning of each vein (the ascending lumbar veins) is connected to the lumbar veins that join the IVC. The anterior abdominal wall houses anastomosis between the superior and inferior epigastric veins. The superior vein carries blood to the internal thoracic vein (and thus to the SVC system) and the inferior one descends to join the external iliac vein (which belongs to I VC system). The subcutaneous veins also anastomose by the anterior abdominal wall and the thoraco-epigastric vein joins the axillary vein while the superficial epigastric vein joins the femoral vein. THE PORTOCAVAL ANASTOMOSES The portocaval anastomoses as-sociate the HPV with either SVC or IVC. The most significant anastomoses are like the following: The esophagus and stomach house anastomosis between the oesophageal and left gastric veins. The oesophageal veins carry blood to the azygos and hemiazygos veins; the left gastric vein opens into the HPV. The rectum houses anastomosis between the superior, middle and in-ferior rectal veins. The superior rectal vein joins the inferior mesenteric vein (which belongs to the HPV system) and the middle and inferior rectal veins join the internal iliac artery (and it belongs to the IVC system). The paraumbilical veins that run along the round ligament of liver join the HPV. Within the umbilical region, the paraumbilical veins anastomose with the veins of anterior abdominal wall. The latter veins join the SVC and IVC systems. Fetal circulation The chief peculiarities of the fetal heart are the direct communication between the atria through the foramen ovale, and the large size of the valve of the inferior vena cava. Among other peculiarities the following may be noted. (1) In early fetal life the heart lies immediately below the mandibular arch and is relatively large in size. As development proceeds it is gradually drawn within the thorax, but at first it lies in the middle line; toward the end of pregnancy it gradually becomes oblique in direction. (2) For a time the atrial portion exceeds the ventricular in size, and the walls of the ventricles are of equal thickness: toward the end of fetal life the ventricular portion becomes the larger and the wall of the left ventricle exceeds that of the right in thickness. (3) Its size is large as compared with that of the rest of the body, the proportion at the second month being 1 to 50, and at birth, 1 to 120, while in the adult the average is about 1 to 160. The foramen ovale, situated at the lower part of the atrial septum, forms a free communication between the atria until the end of fetal life. A septum (septum secundum) grows down from the upper wall of the atrium to the right of the primary septum in which the foramen ovale is situated; shortly after birth it fuses with the primary septum and the foramen ovale is obliterated. The valve of the inferior vena cava serves to direct the blood from that vessel through the foramen ovale into the left atrium. The peculiarities in the arterial system of the fetus are the communication between the pulmonary artery and the aorta by means of the ductus arteriosus, and the continuation of the inferior epigastric arteries as the umbilical arteries to the placenta. The ductus arteriosus is a short tube, about 1.25 cm. in length at birth, and of the diameter of a goose-quill. In the early condition it forms the continuation of the pulmonary artery, and opens into the aorta, just beyond the origin of the left subclavian artery; and so conducts the greater amount of the blood from the right ventricle into the aorta. When the branches of the pulmonary artery have become larger relatively to the ductus arteriosus, the latter is chiefly connected to the left pulmonary artery. The inferior epigastric arteries run along the sides of the bladder and thence upward on the back of the anterior abdominal wall to the umbilicus; here they pass out of the abdomen and are continued as the umbilical arteries in the umbilical cord to the placenta. They convey the fetal blood to the placenta. The peculiarities in the venous system of the fetus are the communications established between the placenta and the liver and portal vein, through the umbilical vein; and between the umbilical vein and the inferior vena cava through the ductus venosus. Fetal Circulation — The fetal blood is returned from the placenta to the fetus by the umbilical vein. This vein enters the abdomen at the umbilicus, and passes upward along the free margin of the falciform ligament of the liver to the under surface of that organ, where it gives off two or three branches, one of large size to the left lobe, and others to the lobus quadratus and lobus caudatus. At the porta hepatis (transverse fissure of the liver) it divides into two branches: of these, the larger is joined by the portal vein, and enters the right lobe; the smaller is continued upward, under the name of the ductus venosus, and joins the inferior vena cava. The blood, therefore, which traverses the umbilical vein, passes to the inferior vena cava in three different ways. A considerable quantity circulates through the liver with the portal venous blood, before entering the inferior vena cava by the hepatic veins; some enters the liver directly, and is carried to the inferior cava by the hepatic veins; the remainder passes directly into the inferior vena cava through the ductus venosus. In the inferior vena cava, the blood carried by the ductus venosus and hepatic veins becomes mixed with that returning from the lower extremities and abdominal wall. It enters the right atrium, and, guided by the valve of the inferior vena cava, passes through the formen ovale into the left atrium, where it mixes with a small quantity of blood returned from the lungs by the pulmonary veins. From the left atrium it passes into the left ventricle; and from the left ventricle into the aorta, by means of which it is distributed almost entirely to the head and upper extremities, a small quantity being probably carried into the descending aorta. From the head and upper extremities the blood is returned by the superior vena cava to the right atrium, where it mixes with a small portion of the blood from the inferior vena cava. From the right atrium it descends into the right ventricle, and thence passes into the pulmonary artery. The lungs of the fetus being inactive, only a small quantity of the blood of the pulmonary artery is distributed to them by the right and left pulmonary arteries, and returned by the pulmonary veins to the left atrium: the greater part passes through the ductus arteriosus into the aorta, where it mixes with a small quantity of the blood transmitted by the left ventricle into the aorta. Through this vessel it descends, and is in part distributed to the lower extremities and the viscera of the abdomen and pelvis, but the greater amount is conveyed by the umbilical arteries to the placenta. From the preceding account of the circulation of the blood in the fetus the following facts will be evident: (1) The placenta serves the purposes of nutrition and excretion, receiving the impure blood from the fetus, and returning it purified and charged with additional nutritive material. (2) Nearly the whole of the blood of the umbilical vein traverses the liver before entering the inferior vena cava; hence the large size of the liver, especially at an early period of fetal life. (3) The right atrium is the point of meeting of a double current, the blood in the inferior vena cava being guided by the valve of this vessel into the left atrium, while that in the superior vena cava descends into the right ventricle. At an early period of fetal life it is highly probable that the two streams are quite distinct; for the inferior vena cava opens almost directly into the left atrium, and the valve of the inferior vena cava would exclude the current from the right ventricle. At a later period, as the separation between the two atria becomes more distinct, it seems probable that some mixture of the two streams must take place. (4) The pure blood carried from the placenta to the fetus by the umbilical vein, mixed with the blood from the portal vein and inferior vena cava, passes almost directly to the arch of the aorta, and is distributed by the branches of that vessel to the head and upper extremities. (5) The blood contained in the descending aorta, chiefly derived from that which has already circulated through the head and limbs, together with a small quantity from the left ventricle, is distributed to the abdomen and lower extremities. Changes in the Vascular System at Birth.—At birth, when respiration is established, an increased amount of blood from the pulmonary artery passes through the lungs, and the placental circulation is cut off. The foramen ovale is closed by about the tenth day after birth: the valvular fold above mentioned adheres to the margin of the foramen for the greater part of its circumference, but a slit-like opening is left between the two atria above, and this sometimes persists. The ductus arteriosus begins to contract immediately after respiration is established, and is completely closed from the fourth to the tenth day; it ultimately degenerates into an impervious cord, the ligamentum arteriosum, which connects the left pulmonary artery to the arch of the aorta. Of the inferior epigastric arteries, the parts extending from the sides of the bladder to the umbilicus become obliterated between the second and fifth days after birth, and project as fibrous cords, the lateral umbilical ligaments, toward the abdominal cavity, carrying on them folds of peritoneum. The umbilical vein and ductus venosus are completely obliterated between the second and fifth days after birth; the former becomes the ligamentum teres, the latter the ligamentum venosum, of the liver. Materials for self-check: A. Tasks for self-check: specify blood outflow from unpaired organs of abdominal cavity; forming of portal vein by their tributaries using the cadaver preparations, tables, models. Find connections between tributaries of the portal vein and tributaries of the superior and inferior cave veins using the cadaver preparations, tables, models. Show differences in blood circulation in fetal life. B. Choose the correct answer. 1.A patient suffers from liver cirrhosis. The varicose veins of which portacaval shunt are observed? A. V. subcostalis. B. V. femoral is. C. V. epigastrica superficialis. D. V. circumflexa ilium profunda. E. Vv. intercostales posteriores. 2. A patient with complaints of pain in the right hypochondrium and bloody vomit was admitted to a hospital. Examination has shown that the patient had enlarged liver, subcutaneous veins of the anterior abdominal wall dilation. In which vessel is blood out flow hindered? A. In the hepatic vein. B. In the abdominal aorta. C. In the porta. D. In the inferior vena cava. E. In the superior vena cava. 3. Examination of a patient has shown a tumor of the head of pancreas and disorder of venous outflow from some organs of the abdominal cavity. Which venous vessel was pressed by the tumor? A. Porta. B. Renal vein. C. Left gastric vein. D. Inferior vena cava. E. Right gastric vein. 4. A 60-year-old patient has distended, lengthened and tortuous subcutaneous veins of the interior abdominal wall. Circulation of which vein was violated? A. Vena cava superior. B. Vena azygos. C. Vena portae. D. Vena mesenterica superior. E. Vena cava inferior. 5. A patient was admitted surgical department in grave condition with a stab wound in the right hypochondrium with signs of internal hemorrhage. After laparotomy, a doctor detected hepatic parenchyma injuries and blood in the abdominal cavity. For a temporary arrest of bleeding the doctor applied smooth tissue forceps hepatoduodenal ligament. Which vessels are bandaged in the region of this ligament? A. Right and left hepatic arteries. B. Hepatic veins and hepatic arteries. C. Proper hepatic artery and hepatic veins. D. Proper hepatic artery and porta. E. Coeliac trunk and superior mesenteric artery. 6. Examining a 48-year-old patient a doctor detected ascites (peritoneal dropsy), in the site of the umbilicus - dilated plethoric veins (Medusa head symptom). In past history there is alcohol abuse. What organ of the abdominal cavity is affected, and by what venous anastomoses does venous blood outflow? A. Liver. Portacavocaval anastomosis through paraumbilical veins. B. Pancreas. Cavocaval anastomosis through a mesenteric vein. C. Spleen. Portacaval anastomosis through the system of gastric veins. D. Liver. Portacaval anastomosis through the system of inferior and superior mesenteric and lumbar veins. E. Stomach. Portacaval anastomosis through the system of gastric veins, inferior and superior mesenteric veins. 7. A patient was admitted hospital with subcutaneous veins dilation in the area of umbilicus (cirrhosis). The vascular permeability which great venous vessel is damaged? A. V. renalis. B. V. mesenterica superior. C. V. mesenterica inferior. D.V. iliaca interna. E. V. portae hepatis. 8. A 30-year-old patient has a tumor of the ascending colon, which squeezes v. colica dextra interfering venous outflow into the portal system. By which veins is blood derivation into the system of the inferior vena cava possible? A. Vv. gastricae. B. V. renalis dextra. C. V. colica sinistra. D. V. colica media. E. Vv. lumbales. 9. An ambulance delivered a patient with bloody vomit to an admission room. In past history there is liver cirrhosis. Which vein might be damaged in this case? A. Porta. B. Superior mesenteric. C. Hepatic. D. Esophageal. E. Splenic. 10. A 54-year-old man was admitted to the hospital with complaints of pain in the right subcostal region, vomiting with blood. Objectively: enlarged liver, varicose veins in the stomach and esophagus. Disfunction of what vessel is likely to be? A. Vena porta B. Aorta abdominalis C. Vena hepatica D. Vena cava superior E. Vena cava inferior References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 17. Immune system. Organs of haemopoesis. Central part of the immune system. The red bone marrow. The thymus. 1. Relevance of the topic. Immune system protects internal environment of the human organism from foreign exo- and endogenic substances. Greater part of deseases caused by disfunction of immune system. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology Location of the immune organs Histology Structure of the immune organs Hematology, Describe the structure related to primary and secondary immunology immune jrgans. 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Lien, splen Spleen Medulla ossеum rubra Red bone marrow Nodulus lymphaticus Lymph node 4.2. Theoretical questions for the class: 1. Features of the immune organs. 2. Structure of the bone marrow. 3. Thymus. Topography, structure. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the organs of haemopoesis and immune system, their structure using tables, models. Content of the topic. The immune (lymphois) organs possess certain developmental and structural features: 1. Parenchyme of all lymphoid organs is made up of lymphoid tissue, which comprises T- and B-lymphocytes and macrophages. 2. All primordia of the lymphoid organs appear at early stages of development (e.g. the red bone marrow and thymus appear at the 4th or 5th week, the spleen appears at the 5th or 6th week, the lymph nodes — at the 7th or 8th week, the palatine and pharyngeal tonsils — between the 9th and 14th weeks, the intestinal aggregated lymphoid nodules and appendicular lymphoid nodules — between the 14th and 16th weeks, the mucosal solitary lymphoid nodules — at the 16th week, the lingual tonsil — at the 24th week and the tubal tonsils — at the 28th week). 3. All lymphoid organs in newborns are fully developed and ready to perform the protective function. However, newborn’s immune system is not capable of normal immune response and requires maternal support provided by breastfeeding. 4. All lymphoid organs reach maximum development (i.e. size, weight and number) in childhood and teen years. 5. All lymphoid organs undergo early age-related involution, which starts in teen years. The lymphoid tissue becomes substituted with fat and connective tissue (thymus is the best example of such involution). 6. The primary lymphoid organs occupy well-protected areas (red bone marrow resides within the bones, the thymus occupies the superior medi-astinum). The lymphoid tissue has a specific microenvironment — myeloid tissue for the red bone marrow and epithelioreticulocytes for the thymus. 7. The secondary lymphoid organs occupy the areas of possible pathogens invasion or guard possible expansion routes. For instance, the pharyngeal lymphoid ring encircles the pharyngeal inlet next to openings of the nasal and oral cavities. Mucosa of the alimentary and respiratory systems and the urine voiding passages contains numerous solitary and aggregated lymphoid nodules. The lymph nodes interrupt lymph flow from the organs and tissues. The spleen that passes blood from arteries to veins is the only blood control organ. 8. At early developmental stages, lymphoid tissue exhibits continuous differentiation of diffuse lymphoid cells into lymphoid nodules. The nodules feature germinative centers responsible for antigen dependent proliferation and differentiation of T- and B-lymphocytes. Antigen influence leads to proliferation of lymphoid nodules. THE PRIMARY (IMMUNE) LYMPHOID ORGANS The red bone marrow The bone marrow, medulla ossium is the hemopoietic and lymphoid organ (analogue bursa of Fabricius in birds) responsible for antigen independent proliferation and differentiation of B-lymphocytes produced by the stem cells. The bone marrow is subdivided into the red bone marrow, medulla ossium rubra situated within the cancellous bone cells of flat, short and long bones (in the long bones, the red bone marrow occupies the epiphyses) and the yellow bone marrow, medulla ossium flava situated within the diaphyses of long bones. In adult individual, the bone marrow weighs about 2.5-3 kilograms; half of this weight comes at the red bone marrow. Stroma of the red bone marrow is formed of reticular cells and fibers; the stem cells as the progenitors of all blood cells are also present there. The red bone marrow appears as long strands that enfold the arterioles. Great discontinuous capillaries called the sinusoids separate the strands. Hemopoiesis in embryo starts at the 19th day of development within the hemopoietic islets of yolk sac. Hemopoiesis here lasts up to the 4th month of development and then passes to the liver. In liver, hemopoiesis becomes evident at the 6th week and in the spleen — at the 3rd month (here it lasts until birth). The red bone marrow originates by the end of the 2nd month of development; the pertaining vessels (and sinusoids) appear at the 12 th week of embryo’s life. The reticular tissue enfolds the vessels and the hemopoietic islets appear and begin functioning. Since this time, the red bone marrow acquires full functionality. Beginning from the 20,h week of development, the red bone marrow exhibits intensive growth and enters the epiphyses and diaphysial cavities. In newborns, all bones are filled with red bone marrow. First fat cells appear in 1-6 month after birth. Be-ginning from 4-5 years of life, one can see active replacement of red bone marrow with the yellow bone marrow (rounded cells with cytoplasmic fat deposits). In adults, diaphyseal cavities contain only yellow' bone marrow. The thymus The thymus is the primary lymphoid organ responsible for antigen independent proliferation and differentiation of T-lymphocytes. From thymus, the T- lymphocytes carried by blood low reach the secondary lymphoid organs where they occupy thymus dependent zones (T-zones). Apart from this, the thymus is an endocrine gland. The thymus is covered with a thin connective tissue capsule, which gives numerous thin septa into parenchyme. The septa separate lobules that range from 1 to 10 mm in size. The peripheral portion of each lobule is called the cortex and the central portion — the medulla. The cortex contains compacted small and middle surrounded by the macrophages. The cortex receives progenitors of the T-lymphocytes borne in red bone marrow. Here they proliferate under effect of thymosin. The subcapsular area contains numer-ous large (12-13 pm) T-lymphocytes. The lymphoblasts divide and migrate to the medulla where they end dif-ferentiation and appear ever since as small cells (6-7pm). The medulla of thymic lobule is formed of small, middle and large T- lvmphocytes. Another specific feature of the medulla constitutes presence of special concentric layers of epithelial cells called the thymic bodies (the Hassal’s bodies). Their function is still unknowm. The microcirculatory network of thymus features hematothymic barrier that protects the thymic parenchyme against circulating antigens. The thymus originates at the 4th week of development from the epithelial cells of the III and IV branchial arches on each side. The primordia grow in caudal direction and join the mesenchyme. The epithelial cells give rise to the epithelioreticulocytes. At the 2nd month of development, the thymus receives the blood capillaries that bring the stem cells — the lymphocytes progenitors. These cells occupy the peripheral area of the pri- mordium; they divide, differentiate into small lymphocytes and migrate deeper into the parenchyme. Divisions of thymus (lobules, cortex and medulla) become evident at the 3rd month of development. Maximum development of thymus comes at 10-15 years of life. At that period, the thymus weighs about 375 grams and sizes about 7.5-16 cm in length. With aging, the thymus undergoes involution and in elderly individuals, it weighs about 13-15 grams. Ninety per cent of thymus weight comes at fat and connective tissue. Persistent thymus causes severe disease called the status lymphaticus. The pathology is manifested mainly as low resistance to infections and intoxication; the organism also becomes susceptible to malignancies. Stress, traumas, intoxications, infections etc cause so-called accidental involution of thymus. In this case, majority of lymphocytes die and the rest migrate to the secondary lymphoid organs; the epithelioreticulocytes undergo intensive proliferation, which makes cortex and medulla indistinguishable. These changes result from protective reaction of the organism. Materials for self-check: A. Tasks for self-check: specify division of the organs of haemopoesis and immune system, their structure using tables, models. B. Choose the correct answer. 1. A patient with a thymus tumor has cyanosis, extension of subcutaneous venous network, edema of soft tissues of the face, neck, upper half of the body, upper limbs. Which venous trunk is blocked? A. Superior vena cava. B. External jugular vein. C. Subclavian vein. D. Internal jugular vein. E. Anterior jugular vein. 2. According to the results of diagnostic tests, a doctor decided to do lymphography of thoracic cavity organs of a 40-year-old patient. The doctor detected that the swelling affected the organ, from lymphoid vessels of which the lymph gets directly into the thoracic duct. Which organ is damaged? A. Esophagus. B. Trachea. C. Left principal bronchus. D. Heart. E. Pericardium. 3. Where should the catheter for evacuation of the lymph from the thoracic lymph duct be inserted? A. To the left venous corner B. To the right venous corner C. To the superior vena cava D. To the inferior vena cava E. To the left inguinal vein 4. An 18-year-old youth was admitted to a hospital with the signs of internal bleeding. While playing football he was hit in the left hypochondrium region. Damage of which of the organs, projected into this region, may cause profuse bleeding? A. Left flexure of colon. B. Tail of pancreas. C. Fundus of stomach. D. Left kidney. E. Spleen. 5. Children frequently have nasal breathing affection caused by the overgrowth of the pharyngeal mucous mem¬brane lymphoid tissue. Which tonsils excrescence may cause this? A. Palatine. B. Pharyngeal. C. Lingual. D. Tubal. E. All mentioned. 6. A 10-year-old child complains of nasal breathing affection. Examination has shown that the cause of this is lymphoid tissue hypertrophy. Which tonsil is increased? A. Left tubal tonsil. B. Palatine. C. Pharyngeal. D. Lingual. E. Right tubal tonsil. 7. Some children have mouth breath prevailing because of lymphoid tissue overgrowth. Which structures overgrowth causes this? A. Lingual tonsil. B. Palatine tonsil. C. Pharyngeal tonsil. D. Tubal tonsil. E. Lymph nodes. 8. Mouth breath prevailing of a 7 year-old child is observed. A doctor diagnoses lymphoid tissue overgrowth. Which structures overgrowth causes this? A. Palatine and pharyngeal tonsils. B. Lingual and pharyngeal tonsils. C. Lymph nodes. D. Lingual and palatine tonsils. E. Pharyngeal and tubal tonsils 9. The examination of the patient revealed hypertrophy and inflammation of the lymphoid tissue, swelling of the mucous membrane of the soft palate between the arches (acute tonsillitis). Which of the tonsils is contained in the norm in this place? A. Tonsilla tubaria B. Tonsilla pharyngealis C. Tonsilla lingualis D. Tonsilla palatina E. All answers are correct 10. Where is located palatine tonsil? A. Between the musculus uvulae and palatopharyngeal arches B. Between the tensor veli palatini and the levator veli palatine C. Between the palatoglossal and the tensor veli palatini D. Between the palatoglossal and the levator veli palatini E. In the tonsillar sinus References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 18. Peripheral part of the immune system. The lymph nodes. The spleen. The tonsils. The lymphoid nodules. 1. Relevance of the topic. Immune system protects internal environment of the human organism from foreign exo- and endogenic substances. Greater part of deseases caused by disfunction of immune system. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology Location of the immune organs Histology Structure of the immune organs Hematology, Describe the structure related to primary and secondary immunology immune jrgans. 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Lien, splen Spleen Medulla ossеum rubra Red bone marrow Nodulus lymphaticus Lymph node Tonsillae Tonsils 4.2. Theoretical questions for the class: 1. Features of the immune organs. 2. Structure of the bone marrow. 3. Thymus. Topography, structure. 4. Structure and topography of the limphoepithelial ring. 5. Structure and function of lymph nodes. 6. Structure, topography and functions of the spleen. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the organs of haemopoesis and immune system, their structure using tables, models. Content of the topic. THE SECONDARY LYMPHOID ORGANS The lymph node, nodus lymphoideus (nodus lymphaticus, lymphonodus). The lymph nodes are the secondary lymphoid organs that interrupt lymph flow on the way from the organs to the trunks and ducts. The lymph nodes are the biological filters that inactivate antigens and generate targeting immune response. The lymph nodes feature variety of shapes but most commonly they appear as bean-shaped bodies, which range in size from 0.5 to 50 mm and even more. The lymph nodes are embedded into loose connective tissue; they may be single or clustered (a cluster may comprise up to several dozens of nodes). The nodes related to a certain body area are called the regional lymph nodes. The regional nodes are subdivided into the parietal, visceral and mixed nodes. The parietal nodes receive the afferent vessels from skin, subcutaneous fat and all components of locomotor apparatus; the visceral nodes drain the respective viscera and the mixed nodes drain both body and viscera. The lymph node is covered with connective tissue capsule, capsula, which gives trabeculae into the node parenchyme. The trabeculae are subdivided into the cortical and medullary. The trabeculae form a kind of framework; they also pass the blood vessels and nerves. Spaces between the trabeculae are filled with stroma represented with reticular cells and fibers. This three- dimensional network holds the lymphoid parenchyme, which consists of lymphoid cells, macrophages and other cells. The convex portion of the node receives 4-8 or even more afferent lymph vessels, vasa afferentia, which open into the marginal (subcapsular) sinus, sinus marginalis. On the opposite side, one can see a small excavation — the hilum, which passes blood vessels, nerves and the efferent lymph vessels, vasa efferentia. The efferent vessels pass to next node or join the collector. The parenchyme of the node consists of the cortex, which is the peripheral portion adherent to capsule and the medulla, which is its central portion situated closer to the hilum. The parenchyme comprises the structural components related to T- and B-dependent zones. The parenchyme of the node also has numerous narrow canals called the intermediate lymphoid sinuses, sinus intermedius lymphonodi, which lead lymph from the marginal sinus to the hilar sinus. All sinuses are invested with endothelium- like littoral cells. The cortex passes the cortical intermediate sinuses, sinus intermedius corticales, which neighbor the cortical trabecula on one side and the parenchyme on another. The medulla contains the medullary intermediate sinuses, sinus intermedius medullares. The medullary sinuses feature variety of shapes; some sinuses reside between the medullary strands while other sinuses enfold the medullary trabeculae and the medullary strands stay outside. The peripheral portion of the cortex contains numerous lymphoid nodules, noduli lymphoidei sized 0.5- 1 mm. These nodules are aggregated lymphocytes mainly of B-lineage. These structures therefore are called the B-dependent zones. The nodules are subdivided into the primary lymphoid nodules, which have no light center (they are scarce) and the secondary lymphoid nodules with featured light (germinative) center. The peripheral area of the lymphoid nodule is called the crown or mantle. The lymphoid cells, macrophages and other cells continuously migrate through the crown. Number of secondary nodules increases after antigen influence. The portion of cortex situated between the lymphoid nodules and marginal sinus is called the subcapsular or marginal zone. Here one can distinguish small and middle lymphocytes. Deeper layer of cortex that neighbor medulla is called the paracortical zone. This zone is T-dependent because it contains small T-lymphocytes. The paracortical zone features numerous postcapillary venules invested with high endothelium. These venules are responsible for recirculation of lymphocytes. The medullary parenchyme is represented with various medullary strands, chordae medullares. The strands contain mostly B-lymphocytes. In part, one can distinguish mature plasmatic cells (B-effectors) that produce antigens and macrophages (they are obligatory cells in this zone). The medullary strands thus belong to B-dependent zone. The lymphoid cells continuously migrate, proliferate and differentiate within the structural components of the lymphatic node. A considerable share of lymphocytes proceeds to other lymph nodes or to the lymphatic trunks and ducts, which open into the veins. Further, the lymphocytes return to the secondary lymphoid organs and tissues. The lymph nodes originate at the 5th week of development from the mesenchyme that enfolds newly formed blood and lymph vessels. The mesenchyme enters the vessel lumen and its cells differentiate into node parenchyme. The lumen of captured segment transforms into the marginal sinus and its branches give rise to the marginal sinuses. Beginning from the 19th week of development, the demar- cation line between the cortex and medulla becomes apparent. The lym-phoid nodules appear somewhat later. Germinative centers appear shortly before birth. Formation of lymphoid nodules continues throughout the entire prenatal developmental period and even after birth. The main forma¬tion processes commonly end by 10- 12 years of life. Involution of the lym-phoid organs begins becomes apparent after puberty. With aging, number of lymph nodes decreases. The spleen, splen or lien is a secondary lymphoid organ that provides immune control on blood running from aorta to the HPV system. The spleen destroys waste RBC and other blood cells, and inactivates the antigens. Apart from this, the spleen is responsible for antigen dependent proliferation and differentiation of T- and B-lymphocytes. The spleen resides within the upper portion of the abdominopelvic cavity (with the respect to the left hypochondriac re-gion) at the level of the ribs 9 through 11. With the respect to peritoneal cavity, the spleen occupies the splenic recess related to the superior level. In adults, the spleen weighs about 150-200 grams; it appears as concave- convex body 10-14 cm long, 6-10 cm wide and 3-4 cm thick. The spleen has the diaphragmatic and visceral surfaces, facies diaphragmatica et visceralis, the superior and inferior borders, margo superior et inferior and the anterior and posterior extremities, extremitas anterior et posterior. The visceral surface contains the renal, gastric and colic impressions, which are in contact with the respective organs. On the visceral surface, one can distinguish an elongated excavation called the splenic hilum, hilum splenicum (hilum lienale), which passes the vessels and nerves. The spleen is covered with peritoneum almost from all sides except for the hilum. The peritoneum forms the ligaments that suspend the organ. The ligaments are the gastrosplenic ligament, ligamentum gastrosplenicum (gastrolienale), which runs from the hilum to the greater curvature of stomach, the phrenicosplenic ligament, ligamentum phrenicosplenicum the splenocolic ligament, ligamentum splenocolicum and the splenorenal ligament, ligamentum splenorenale. The peritoneum adheres to the fibrous capsule, capsula (tunica fibrosa). The capsule gives the splenic trabeculae, trabeculae splenicae into splenic parenchyme. Apart from the trabeculae, the fibrous framework of spleen forms stroma, which consists of the reticular cells and fibers. The stroma supports the splenic parenchyme — the splenic pulp, pulpa splenica. The pulp is subdivided into the red pulp, pulpa rubra and the white pulp, pulpa alba. The red pulp is dominating portion of splenic parenchyme (its share is about 75-80% of the entire spleen weight). It is represented with formed blood elements that occupy the stroma or splenic sinuses. The portions of red pulp situated between the venous sinuses are called the splenic cords, chordae lienis. In the cords, B- lymphocytes and monocytes transform into plasmatic cells and macrophages respectively. The splenic macrophages destroy old or damaged RBC and platelets. The white pulp constitutes 20- 25% of spleen mass. It appears as islets disseminated around the red pulp. The white pulp is the lymphoid tissue formed of lymphocytes, dendrite cells and interdigitating cells. The white pulp functions as the secondary lymphoid organ. The white pulp consists of the lymphoid nodules and periarterial lymphoid sheaths. The splenic lymphoid nodules, noduli lymphoidei splenici (0.3-0.5 mm in diameter) comprise four zones — the periarterial, mantle and marginal zones and the light (germinative) center. The nodules are responsible for proliferation and differentiation of lymphocytes. The periarterial zone comprises aggregated T- lymphocytes and macrophages that enfold the central artery (it pierces the nodule eccentrically). This area is analogue paracortical zone of lymph nodes. Darker mantle zone that surrounds the light center comprises small B-lymphocytes, small number of lymphocytes, plasmatic cells and mac-rophages. The marginal zone neighbors the red pulp; it is surrounded by sinu-soid capillaries. This zone contains the lymphocytes and macrophages. Upon maturation, the lymphocytes migrate from the light center to the mantle and marginal zones from where they pass to the blood flow. The lymphoid periarterial sheaths, vaginae periarteriales lymphoidei are elongated aggregations of lymphocytes that enfold the arteries of white pulp; they are continuous with the lymphoid nodules. The central portion of the sheath comprises B-lymphocytes and the peripheral — T-lymphocytes. The spleen features a special cir-culatory network that ensures proper functioning of the organ. The splenic artery gives off several branches yet outside the hilum. These branches enter the splenic hilum and give off the segmental arteries, which in turn give the trabecular arteries. The trabecular arteries pass the splenic trabeculae and eventually enter splenic parenchyme. The trabecular arteries feature well-developed muscular layer especially the spiral layer. The arteries related to pulp are the pulpar arteries (0.2 mm in diameter). They run within the periarterial lymphoid sheaths. These arteries pass the lymphoid nodules where they are called the central arteries. The central arteries lack the internal elastic membrane; their endothelial invest-ment is thin. On leaving the nodule, the central artery gives 2-6 penicilli to the red pulp. The penicilli are enfolded into ellipsoid muffs — the aggregations of macrophages, lymphocytes and reticular cells. Because of contents and shape these muffs are also called the macrophageal-lymphoid or ellipsoid muffs. The pertaining arterioles are also called the ellipsoid arterioles. The reticular cells and fibers of these structures work as sphincters. Wall of such arteriole is similar to that of a typical capillary. The penicilli are continuous with the capillaries, which open into the splenic sinuses, sinus splenicus. Some capillaries open directly to the red pulp forming thus the open blood flow system. The venous sinuses also perform depot function. The sinuses are continuous with the veins of red pulp. The junction points contain venous sphincters formed of smooth muscular cells. The sphincters regu-late blood flow within the spleen. The veins of red pulp are continuous with the trabecular veins that merge into splenic vein. The splenic vein carries blood to the HPV. The spleen originates at the 5th or 6th week of development from mesenchymal aggregation situated within the dorsal mesentery. Later, within this aggregation one can distinguish several fissures — future splenic vessels with neighboring pulp cells. The venous sinuses and other vasculature segments develop between the 2nd and 4th months of development. At this time, the capsule gives the projections, which form the trabeculae. Next to the venous sinuses, one can distinguish hemopoietic islets. At the 3rd month of development, all components of white pulp, in part the germinative centers become apparent. The red pulp becomes evident at the 6th month. Beginning from the 6th month, the myeloid hemopoiesis slows down and almost ceases before birth. Intensity of lymphocytes production on the contrary increases. In newborn, the spleen weighs about 9.5 grams; white pulp share constitutes 5-10% of total weight. Red pulp share remains relatively stable throughout the life and ranges between 82 and 85%. White pulp share decreases with aging. After 50 years of life, its share does not exceed 6.5% of total weight. The lymphoid structures of the alimentary, respiratory and genitourinary systems The tonsils, tonsillae are the secondary lymphoid organs that reside in the fauces, root of tongue and nasopharynx. They form the pharyngeal lymphoid ring, anulus lymphoideus pharyngis, which encircles the pharyngeal inlet. The structural functional unit of the tonsil is the lymphoid nodule, nodulus lymphoideus, which is similar to nodule of the lymph node. The lingual tonsil, tonsilla lingualis occupies the lamina propria of the mucosa of the root of tongue. It consists of numerous (80-90) lymphoid nodules 1-4 mm of diameter. The tonsil is of ovoid shape; it reaches maximum length (up to 25 mm) in mid-teen age (in about 14). The mucosa above the tonsil features the excavations called crypts. The crypts are invested with the squamous epithelium infiltrated with the lymphocytes. The lingual tonsil originates at the 6th month of development and the nodules become apparent at the 8th month. The germinative centers arise only after birth and develop throughout the first month of life. Initially, number of lymphoid nodules con¬tinuously increases: in neonates — up to 66, in early childhood — up to 85 and in teenagers — up to 90 nodules. Diameter of the nodules in this period reaches 2-4 mm. After puberty, number of lymphoid nodules gradually decreases. The palatine tonsil, tonsilla palatina is a paired elongated body that occupies the tonsillar fossa (it is delimited by the palatoglossal and palatopharyngeal arches). The lateral aspect of the tonsil adheres to the fibrous plate of pharynx. The plate gives thin septa that separate the lobules of tonsil. The medial surface is covered with the squamous epithelium; in that area, one can distinguish the tonsillar pits, fossulae tonsillares. Somewhat deeper one can see the tonsillar crypts, cryptae tonsillares that open into the pits. The parenchyme of the tonsil comprises numerous lymphoid nodules; the largest ones have well distinguishable germinative centers. The lymphoid tissue resides between the nodules. The palatine tonsils originate at the 12th week of development from the mesenchymal aggregation situated below the second pharyngeal cleft. At the 5th month, the lymphoid tissue receives the epithelial cords that further give rise to the crypts. Number of lymphoid nodules continuously increases; the solitary nodes appear shortly before birth yet the germinative centers appear only after birth. During the first year of life, the palatine tonsil doubles in size — in that period, it is 15 mm long and 12 mm wide. Maximum size is observed in 8-13 year old children; then it is 28 mm long and 22 mm wide. Beginning from 22-30years of life, the lymphoid tissue undergoes age-related involution. The pharyngeal (adenoid) tonsil, tonsilla pharyngea (adenoidea) resides under the mucosa of the nasopharynx in the area where the vault and posterior wall of pharynx meet. Here, the mucosa covered with simple ciliary epithelium forms 4 to 6 transverse and oblique folds. The parenchyme of the tonsil comprises the lymphoid tissue and lymphoid nodules. In children, the tonsils sometimes enlarge and the folds may even cover the choanae, which results in labored nasal breathing. The pharyngeal tonsil arises at the 3rd month of development within developing pharyngeal mucosa. In newborns, the tonsil is well distinguishable; it is 5-7 mm long and 5-6 mm wide. During the first year of life, the tonsil exhibits rapid growth; the lymphoid nodules appear in the same period. By the end of the first year of life, the tonsil is 12 mm long and 6-10 mm wide. The greatest size of the tonsil is observed in the period from8 to 20 years of life — it is 13-21 mm long and 10-15 mm wide. Further, the tonsil undergoes age-related involution. The tubal tonsil, tonsilla tubaria, also paired, it resides within the pharyngeal mucosa next to the pharyngeal opening of auditory tube. Here, the mucosa is invested with the simple ciliary epithelium and features the tonsillar crypts, cryptae tosillares. The tubal tonsil arises at the 7th month of development within the mucosa of the respective area. The lymphoid tissue appears during prenatal development while the lymphoid nodules and germinative centers appear during the first year of life. In newborns, the tonsil sizes about 7.5 mm; maximum size is observed in 4-7 year old children. The lymphoid nodules, noduli lymphoidei The mucosa and submucosa of the alimentary system (the pharynx, esophagus, stomach, small and large intestines and gallbladder), respiratory system (the larynx, trachea and large bronchi) and voiding passages (ureters, urinary bladder and urethra) contains numerous (up to 45 nodules per 1 sq. cm of mucosa) lymphoid nodules that ‘monitor’ antigen status of the respective passages. Apart from the nodules, these organs also contain the lymphoid tissue. The lymphoid nodules are subdivided into the solitary lymphoid nodules, noduli lymphoidei solitarii and the aggregated lymphoid nodules, noduli lymphoidei aggregati. The solitary lymphoid nodules, noduli lymphoidei solitarii are the rounded or oblong bodies sized about 1.5-2 mm. Stroma of the nodules comprises the reticular cells and fibers that hold T- and B-lymphocytes. In childhood and adolescent years, majority of nodules feature germinative centers with numerous lymphoblasts (i.e. the progenitors of lymphocytes), macrophages and plasmatic cells, which points at intensive lymphopoiesis. The germinative center is surrounded by darker mantle, which comprises compacted small lymphocytes. Blood capillaries form network around each nodule. Some capacitated cells migrate to blood flow via the walls of postcapillarv venules; other cells pass to the related organ. The aggregated lymph nodules, noduli lymphoidei aggregati comprise 5-150 packed solitary lymph nodules and diffuse lymphoid tissue. The small intestine and especially ileum feature numerous aggregated lymphoid nodules called the lymphoid or Peyer’s patches. A typical patch is 2-15 cm long and 0.2-1.5 cm wide. The mucosa above the patch is elevated and the patch is well visible. The patches usually reside opposite to the mesenteric aspect of the intestine. The lymphoid nodules and patches originate within the respective organs at the 4th month of development. The primordia appear as colonies of myeloid cells; by the 6th month, the nodules and patches£re fully developed. In newborns, the patches are flat and only 2 cm long however the nodules already have the active germinative centers. In 10-15 year old children, number of both solitary and aggregated nodules increases twofold as compared to newborns. Beginning from adolescent years, number of nodules gradually decreases and in 50-60 year old individuals, the nodules lack germinative centers. In elderly individuals, only diffuse lymphoid tissue persists. The appendicular aggregated lymphoid nodules, noduli lymphoidei aggregati appendicis vermiformis reside within mucosa and submucosa of the vermiform appendix. In children and teenagers, number of these nodules reaches maximum value — up to 550; their diameter ranges between 0.2 and 1.2 mm. Most of the nodules in this period contain germinative centers with lymphoblasts, macrophages and plasmatic cells. The appendicular lymph nodules become apparent at the 4 th month of development, first within the mucosa and then within the submucosa. The germinative centers appear either shortly before or right after birth. Diameter of nodules in this period already reaches mature 0.2-1.5 mm; number of nodules is about 150-200. Beginning from adolescence, number of nodules gradually decreases. Only few nodules remain in individuals above 60. Materials for self-check: A. Tasks for self-check: specify division of the organs of haemopoesis and immune system, their structure using tables, models. B. Choose the correct answer. 1. An 18-year-old youth was admitted to a hospital with the signs of internal bleeding. While playing football he was hit in the left hypochondrium region. Damage of which of the organs, projected into this region, may cause profuse bleeding? A. Left flexure of colon. B. Tail of pancreas. C. Fundus of stomach. D. Left kidney. E. Spleen. 2. Children frequently have nasal breathing affection caused by the overgrowth of the pharyngeal mucous membrane lymphoid tissue. Which tonsils excrescence may cause this? A. Palatine. B. Pharyngeal. C. Lingual. D. Tubal. E. All mentioned. 3. A 10-year-old child complains of nasal breathing affection. Examination has shown that the cause of this is lymphoid tissue hypertrophy. Which tonsil is increased? A. Left tubal tonsil. B. Palatine. C. Pharyngeal. D. Lingual. E. Right tubal tonsil. 4. Some children have mouth breath prevailing because of lymphoid tissue overgrowth. Which structures overgrowth causes this? A. Lingual tonsil. B. Palatine tonsil. C. Pharyngeal tonsil. D. Tubal tonsil. E. Lymph nodes. 5. Mouth breath prevailing of a 7 year-old child is observed. A doctor diagnoses lymphoid tissue overgrowth. Which structures overgrowth causes this? A. Palatine and pharyngeal tonsils. B. Lingual and pharyngeal tonsils. C. Lymph nodes. D. Lingual and palatine tonsils. E. Pharyngeal and tubal tonsils 6. The examination of the patient revealed hypertrophy and inflammation of the lymphoid tissue, swelling of the mucous membrane of the soft palate between the arches (acute tonsillitis). Which of the tonsils is contained in the norm in this place? A. Tonsilla tubaria B. Tonsilla pharyngealis C. Tonsilla lingualis D. Tonsilla palatina E. All answers are correct 7. Where is located palatine tonsil? A. Between the musculus uvulae and palatopharyngeal arches B. Between the tensor veli palatini and the levator veli palatine C. Between the palatoglossal and the tensor veli palatini D. Between the palatoglossal and the levator veli palatini E. In the tonsillar sinus 8. Where is located the lingual tonsil? A. In the root of tongue B. In the apex of tongue C. In the inferior surface of tongue D. In the dorsum of tongue E. In the tonsil sinus 9. What structures form the pharyngeal lymphoid ring? A. The palatal and the tubal tonsils B. The palatal tonsils C. The tubal and the pharyngeal tonsils D. The palatal, the tubal, pharyngeal and lingual tonsils E. The pharyngeal and lingual tonsils 10. A 10-year-old child complains of nasal breathing affection. Examination has shown that the cause of this is lymphoid tissue hypertrophy. Which tonsil is increased? A. Left tubal tonsil. B. Palatine. C. Lingual. D. Pharyngeal. E. Right tubal tonsil. References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 19. Lymphatic vessels and nodes of the lower limb, pelvis and abdomen. 1. Actuality of theme. Information about topography of the lymphatic vessels and nodes is important for understanding of localization of pathological processes of adequate regions. In many diseases, pathogens and malignant cells disseminate via the lymphatic vessels. Studying of lymph circulation and location of regional lymph nodes thus is of great importance for diagnostics, treatment and prognosis of inflammatory diseases and malignancies. Clinical specialists employ lymphatic injections, optic fibers for laser microsurgery and lymph absorption. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the lymphatic vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream and lymph through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Organa lymphoidea Lymphatic organs Nodi lymphoidei Lymph nodes Nodi lymphoidei viscerales Visceral lymph nodes

4.2. Theoretical questions for the class: 1. What structural features allow differentiation of blood and lymphatic capillaries? 2. Name the groups of parietal abdominal lymph nodes. 3. Name the groups of visceral abdominal lymph nodes. Name the viscera drained by these nodes. 4. What lymph nodes receive lymph from the lesser pelvis? 5. What groups of lymph vessels are distinguishable in the lower limb? Name the destination point of these vessels. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the lymphoid organs, their structure using tables, models, preparations. Content of the topic The lymphoid system, systema lymphoideum is tightly associated with the cardiovascular system and thus constitutes a part of a joint cardiovascular and immune systems. Terminology: the term originates from Latin word ‘lympha' — ‘spring water’ and Greek word nympha’ — ‘bride’ or ‘goddess of springs, forests and mountains’. Functions of the lymphoid system. The lymphatic capillaries absorb the interstitial fluid that contains the products of cellular metabolism, lymphocytes, sometimes red blood cells and several foreign substances in part fragments of dead cells, mutant cells, microorganisms, viruses etc. The lymph nodes are responsible for withdrawal of these products. The macrophages absorb and process the antigens to pass antigen data to plasmatic cells. The antigens trigger this mechanism of antigen dependent proliferation and differentiation of T- and B-lymphocytes and generation of immune response. The lymphoid system thus features protective function. Lymph, lympha is made up of interstitial fluid absorbed by lymphatic capillaries. It is a clear colorless fluid similar to blood plasma yet low in protein. The principal cellular elements of lymph are the lymphocytes (96-98 %). Normally, lymphatic system of an adult individual contains about 2 liters of lymph. After a meal (especially reach in fats), lymph drained from small intestine has milky appearance (milky juice, chylus). Greek word ‘chylus’ stands for ‘artificial juice’. This term was coined for lymph of intestinal lymphatic capillaries. THE LYMPHATIC SYSTEM consists (1) of complex capillary networks which collect the lymph in the various organs and tissues; (2) of an elaborate system of collecting vessels which conduct the lymph from the capillaries to the large veins of the neck at the junction of the internal jugular and subclavian veins, where the lymph is poured into the blood stream; and (3) lymph nodes or nodes which are interspaced in the pathways of the collecting vessels filtering the lymph as it passes through them and contributing lymphocytes to it. The lymphatic capillaries and collecting vessels are lined throughout by a continuous layer of endothelial cells, forming thus a closed system. The lymphatic vessels of the small intestine receive the special designation of lacteals vessels; they differ in no respect from the lymphatic vessels generally excepting that during the process of digestion they contain a milk-white fluid, the chyle. Lymphatic Capillaries. The complex capillary plexuses which consist of a single layer of thin flat endothelial cells lie in the connective-tissue spaces in the various regions of the body to which they are distributed and are bathed by the intercellular tissue fluids. Two views are at present held as to the mode in which the lymph is formed: one being by the physical processes of filtration, diffusion, and osmosis, and the other, that in addition to these physical processes the endothelial cells have an active secretory function. The colorless liquid lymph has about the same composition as the blood plasma. It contains many lymphocytes and frequently red blood corpuscles. Granules and bacteria are also taken up by the lymph from the connective-tissue spaces, partly by the action of lymphocytes which pass into the lymph between the endothelial cells and partly by the direct passage of the granules through the endothelial cells. The lymphatic capillary plexuses vary greatly in form; the anastomoses are usually numerous; blind ends or culde-sacs are especially common in the intestinal villi, the dermal papillж and the filiform papillж of the tongue. The plexuses are often in two layers: a superficial and a deep, the superficial being of smaller caliber than the deep. The caliber, however, varies greatly in a given plexus from a few micromillimeters to one millimeter. The capillaries are without valves. Lymphatic Vessels. The lymphatic vessels are exceedingly delicate, and their coats are so transparent that the fluid they contain is readily seen through them. They are interrupted at intervals by constrictions, which give them a knotted or beaded appearance; these constrictions correspond to the situations of valves in their interior. Lymphatic vessels have been found in nearly every texture and organ of the body which contains bloodvessels. Such nonvascular structures as cartilage, the nails, cuticle, and hair have none, but with these exceptions it is probable that eventually all parts will be found to be permeated by these vessels. Lymph Nodes. The lymph nodes are small oval or bean-shaped bodies, situated in the course of lymphatic and lacteal vessels so that the lymph and chyle pass through them on their way to the blood. Each generally presents on one side a slight depression—the hilus—through which the bloodvessels enter and leave the interior. The efferent lymphatic vessel also emerges from the gland to this spot, while the afferent vessels enter the organ at different parts of the periphery. On section a lymph gland displays two different structures: an external, of lighter color —the cortical; and an internal, darker — the medullary. The cortical structure does not form a complete investment, but is deficient at the hilus, where the medullary portion reaches the surface of the gland; so that the efferent vessel is derived directly from the medullary structures, while the afferent vessels empty themselves into the cortical substance. The thoracic duct (ductus thoracicus) conveys the greater part of the lymph and chyle into the blood. It is the common trunk of all the lymphatic vessels of the body, excepting those on the right side of the head, neck, and thorax, and right upper extremity, the right lung, right side of the heart, and the convex surface of the liver. It extends from the second lumbar vertebra to the root of the neck. It begins in the abdomen by a triangular dilatation, the cisterna chyli. It enters the thorax through the aortic hiatus of the diaphragm, and it ends by opening into the angle of junction of the left subclavian vein with the left internal jugular vein. The cisterna chyli (receptaculum chyli) receives the two lumbar lymphatic trunks, right and left, and the intestinal lymphatic trunk. The lumbar trunks are formed by the union of the efferent vessels from the lateral aortic lymph nodes. They receive the lymph from the lower limbs, from the walls and viscera of the pelvis, from the kidneys and suprarenal nodes and the deep lymphatics of the greater part of the abdominal wall. The intestinal trunk receives the lymph from the stomach and intestine, from the pancreas and spleen, and from the lower and front part of the liver. Opening into the commencement of the thoracic duct, on either side, is a descending trunk from the posterior intercostal lymph nodes of the lower six or seven intercostal spaces. In the thorax the duct is joined, on either side, by a trunk which drains the upper lumbar lymph nodes and pierces the crus of the diaphragm. It also receives the efferents from the posterior mediastinal lymph nodes and from the posterior intercostal lymph nodes of the upper six left spaces. In the neck it is joined by the left jugular and left subclavian trunks, and sometimes by the left bronchomediastinal trunk; the last-named, however, usually opens independently into the junction of the left subclavian and internal jugular veins. The right lymphatic duct (ductus lymphaticus dexter), about 1.25 cm. in length, courses along the medial border of the Scalenus anterior at the root of the neck and ends in the right subclavian vein, at its angle of junction with the right internal jugular vein. The right lymphatic duct receives the lymph from the right side of the head and neck through the right jugular trunk; from the right upper extremity through the right subclavian trunk; from the right side of the thorax, right lung, right side of the heart, and part of the convex surface of the liver, through the right bronchomediastinal trunk. These three collecting trunks frequently open separately in the angle of union of the two veins. The Lymph Nodes of the Lower Extremity. The lymph nodes of the lower extremity consist of the anterior tibial gland and the popliteal and inguinal nodes. The popliteal nodes, small in size and some six or seven in number, are imbedded in the fat contained in the popliteal fossa. One lies immediately beneath the popliteal fascia, near the terminal part of the small saphenous vein, and drains the region from which this vein derives its tributaries. Another is placed between the popliteal artery and the posterior surface of the knee-joint; it receives the lymphatic vessels from the knee-joint together with those which accompany the genicular arteries. The others lie at the sides of the popliteal vessels, and receive as efferents the trunks which accompany the anterior and posterior tibial vessels. The efferents of the popliteal nodes pass almost entirely alongside the femoral vessels to the deep inguinal nodes, but a few may accompany the great saphenous vein, and end in the nodes of the superficial subinguinal group. The inguinal nodes, from twelve to twenty in number, are situated at the upper part of the femoral triangle. They may be divided into two groups by a horizontal line at the level of the termination of the great saphenous vein; those lying above this line are termed the superficial inguinal nodes, and those below it the subinguinal nodes, the latter group consisting of a superficial and a deep set. The Superficial Inguinal Nodes form a chain immediately below the inguinal ligament. They receive as afferents lymphatic vessels from the integument of the penis, scrotum, perineum, buttock, and abdominal wall below the level of the umbilicus. The Superficial Subinguinal Nodes are placed on either side of the upper part of the great saphenous vein; their efferents consist chiefly of the superficial lymphatic vessels of the lower extremity; but they also receive some of the vessels which drain the integument of the penis, scrotum, perineum, and buttock. The Deep Subinguinal Nodes vary from one to three in number, and are placed under the fascia lata, on the medial side of the femoral vein. When three are present, the lowest is situated just below the junction of the great saphenous and femoral veins, the middle in the femoral canal, and the highest in the lateral part of the femoral ring. They receive as afferents the deep lymphatic trunks which accompany the femoral vessels, the lymphatics from the glans penis vel clitoridis, and also some of the efferents from the superficial subinguinal nodes. The Lymph Nodes of the Abdomen and Pelvis. The lymph nodes of the abdomen and pelvis may be divided, from their situations, into (a) parietal, lying behind the peritoneum and in close association with the larger bloodvessels; and (b) visceral, which are found in relation to the visceral arteries. The parietal nodes include the following groups: External Iliac. Lumbar Lateral Aortic. Common Iliac. Internal iliac. Preaortic. Epigastric. Sacral. Retroaortic. The External Iliac Nodes, from eight to ten in number, lie along the external iliac vessels. Their principal afferents are derived from the inguinal and subinguinal nodes, the deep lymphatics of the abdominal wall below the umbilicus and of the adductor region of the thigh, and the lymphatics from the glans penis, clitoridis, the membranous urethra, the prostate, the fundus of the bladder, the cervix uteri, and upper part of the vagina. The Common Iliac Nodes, four to six in number, are grouped behind and on the sides of the common iliac artery, one or two being placed below the bifurcation of the aorta, in front of the fifth lumbar vertebra. They drain chiefly the internal iliac and external iliac nodes, and their efferents pass to the lateral aortic nodes. The Epigastric Nodes, three or four in number, are placed alongside the lower portion of the inferior epigastric vessels. The Internal iliac Nodes surround the internal iliac vessels, and receive the lymphatics corresponding to the distribution of the branches of the internal iliac artery, i. e., they receive lymphatics from all the pelvic viscera, from the deeper parts of the perineum, including the membranous and cavernous portions of the urethra, and from the buttock and back of the thigh. The Sacral Nodes are placed in the concavity of the sacrum, in relation to the middle and lateral sacral arteries; they receive lymphatics from the rectum and posterior wall of the pelvis. The efferents of the internal iliac group end in the common iliac nodes. The Lumbar Nodes are very numerous, and consist of right and left lateral aortic, preaortic, and retroaortic groups. The visceral nodes are associated with the branches of the celiac, superior and inferior mesenteric arteries. Those related to the branches of the celiac artery form three sets, gastric, hepatic, and pancreaticolienal. The Hepatic Nodes, consist of the following groups: (a) hepatic, on the stem of the hepatic artery, and extending upward along the common bile duct, between the two layers of the lesser omentum, as far as the porta hepatis; the cystic gland, a member of this group, is placed near the neck of the gallbladder; (b) subpyloric, four or five in number, in close relation to the bifurcation of the gastroduodenal artery, in the angle between the superior and descending parts of the duodenum; an outlying member of this group is sometimes found above the duodenum on the right gastric (pyloric) artery. The nodes of the hepatic chain receive afferents from the stomach, duodenum, liver, gallbladder, and pancreas; their efferents join the celiac group of preaortic nodes. The Pancreaticolienal Nodes accompany the lienal (splenic) artery, and are situated in relation to the posterior surface and upper border of the pancreas; one or two members of this group are found in the gastrolienal ligament. Their afferents are derived from the stomach, spleen, and pancreas, their efferents join the celiac group of preaortic nodes. The superior mesenteric nodes may be divided into three principal groups: mesenteric (lie between the layers of the mesentery), ileocolic (form a chain around the ileocolic artery), and mesocolic (lie between the layers of the transverse mesocolon). Materials for self-check: A. Tasks for self-check: specify division of the lymphoid organs, their structure using tables, models, preparations. B. Choose the correct answer. 1. An 18-year-old youth was admitted to a hospital with the signs of internal bleeding. While playing football he was hit in the left hypochondrium region. Damage of which of the organs, projected into this region, may cause profuse bleeding? A. Left flexure of colon. B. Tail of pancreas. C. Fundus of stomach. D. Left kidney. E. Spleen. 2. A patient has a malignant swelling in the abdominal part of the esophagus. Which group of lymph nodes is regional for this part of esophagus? A. Anulus lymphaticus cardiacae. B. Nodi paratracheales. C. Nodi prevertebrales. D. Nodi perecardiales laterales. E. Nodi mediastinales posteriores. 3. According to the results of diagnostic tests, a doctor decided to do lymphography of thoracic cavity organs of a 40-year-old patient. The doctor detected that the swelling affected the organ, from lymphoid vessels of which the lymph gets directly into the thoracic duct. Which organ is damaged? A. Esophagus. B. Trachea. C. Left principal bronchus. D. Heart. E. Pericardium. 4. Where should the catheter for evacuation of the lymph from the thoracic lymph duct be inserted? A. To the left venous corner B. To the right venous corner C. To the superior vena cava D. To the inferior vena cava E. To the left inguinal vein 5. Preventive examination of a patient revealed an enlarged lymph node of metastatic origin on the medial wall of the left axillary crease. Specify the most likely localization of the primary tumour: A. Mammary gland B. Submandibular salivary gland C. Lung D. Stomach E. Thyroid gland 6. While palpating mammary gland of a patient a doctor revealed an induration in form of a node in the inferior medial quadrant. Metastases may extend to the following lymph nodes: A. Parasternal B. Posterior mediastinal C. Profound lateral cervical D. Bronchopulmonary E. Superior diaphragmal 7. During operation on kidneys, a surgeon must select the renal stalk. What goes out from a kidney gate? A. Renal artery, ureter B. Renal artery, nerves C. Renal vessels and nerves D. Renal artery and vein E. Renal vein, ureter and lymphatic vessels 8. Specify the roots of the right lymphatic duct. A. Right bronchomediastinal, jugular and subclavian trunks B. Lumbar trunks, intestinal trunks C. Right bronchomediastinal trunks D. Subclavian trunks E. Jugular trunks 9. Where does the right lymphatic duct open? A. Right venous angle B. Left venous angle C. External jugular vein D. Anterior jugular vein E. Axillary vein 10. Specify the roots of the thoracic duct. A. Right bronchomediastinal, jugular and subclavian trunks B. Lumbar trunks, intestinal trunks C. Right bronchomediastinal trunks D. Subclavian trunks E. Jugular trunks References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/ Topic 20. Lymphatic vessels and nodes of the head and neck. 1. Information about topography of the lymphatic vessels and nodes is important for understanding of localization of pathological processes of adequate regions. In many diseases, pathogens and malignant cells disseminate via the lymphatic vessels. Studying of lymph circulation and location of regional lymph nodes thus is of great importance for diagnostics, treatment and prognosis of inflammatory diseases and malignancies. Clinical specialists employ lymphatic injections, optic fibers for laser microsurgery and lymph absorption. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main vessels of the systemic and pulmonary circulations Histology Structure of the wall of the lymphatic vessels Cardiology Describe the relevant areas of blood supply of the vessels Physics Describe the mechanism of movement of bloodstream and lymph through the vessels 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Organa lymphoidea Lymphatic organs Nodi lymphoidei Lymph nodes Nodi lymphoidei viscerales Visceral lymph nodes Truncus jugularis Jugular trunk Truncus subclavius Subclavian trunk 4.2. Theoretical questions for the class: 1. What structural features allow differentiation of blood and lymphatic capillaries? 2. Name the groups of cervical lymph nodes. 3. Name the groups of head lymph nodes. 4. What lymph nodes receive lymph from the chest? 5. What groups of lymph vessels are distinguishable in the upper limb? Name the destination point of these vessels. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the lymphoid organs, their structure using tables, models, preparations, examine lymph vessels and nodes of the upper limbs, head, neck, chest cavity. Content of the topic. The Lymph Nodes of the Head. The lymph nodes of the head are arranged in the following groups: 1.Occipital. 2.Facial. 3.Posterior Auricular. 4.Deep Facial. 5.Anterior Auricular. 6.Lingual. 7.Parotid. 8.Retropharyngeal. The occipital nodes, one to three in number, are placed on the back of the head close to the margin of the Trapezius and resting on the insertion of the Semispinalis capitis. Their afferent vessels drain the occipital region of the scalp, while their efferents pass to the superior deep cervical nodes. The posterior auricular nodes, usually two in number, are situated on the mastoid insertion of the Sternocleidomastoideus, beneath the Auricularis posterior. Their afferent vessels drain the posterior part of the temporoparietal region, the upper part of the cranial surface of the auricula or pinna, and the back of the external acoustic meatus; their efferents pass to the superior deep cervical nodes. The anterior auricular nodes, from one to three in number, lie immediately in front of the tragus. Their afferents drain the lateral surface of the auricula and the skin of the adjacent part of the temporal region; their efferents pass to the superior deep cervical nodes. The parotid nodes, form two groups in relation with the parotid salivary gland, viz., a group imbedded in the substance of the gland, and a group of subparotid nodes lying on the lateral wall of the pharynx. Occasionally small nodes are found in the subcutaneous tissue over the parotid gland. Their afferent vessels drain the root of the nose, the eyelids, the frontotemporal region, the external acoustic meatus and the tympanic cavity, possibly also the posterior parts of the palate and the floor of the nasal cavity. The efferents of these nodes pass to the superior deep cervical nodes. The afferents of the subparotid nodes drain the nasal part of the pharynx and the posterior parts of the nasal cavities; their efferents pass to the superior deep cervical nodes. The facial nodes comprise three groups: (a) infraorbital or maxillary, scattered over the infraorbital region from the groove between the nose and cheek to the zygomatic arch; (b) buccinator, one or more placed on the Buccinator opposite the angle of the mouth; (c) supramandibular, on the outer surface of the mandible, in front of the Masseter and in contact with the external maxillary artery and anterior facial vein. Their efferent vessels drain the eyelids, the conjunctiva, and the skin and mucous membrane of the nose and cheek; their efferents pass to the submandibular nodes. The deep facial nodes are placed beneath the ramus of the mandible, on the outer surface of the Pterygoideus externus, in relation to the internal maxillary artery. Their afferent vessels drain the temporal and infratemporal fossж and the nasal part of the pharynx their efferents pass to the superior deep cervical nodes. The lingual nodes are two or three small nodules lying on the Hyoglossus and under the Genioglossus. They form merely glandular substations in the course of the lymphatic vessels of the tongue. The retropharyngeal nodes, from one to three in number, lie in the buccopharyngeal fascia, behind the upper part of the pharynx and in front of the arch of the atlas, being separated, however, from the latter by the Longus capitis. Their afferents drain the nasal cavities, the nasal part of the pharynx, and the auditory tubes; their efferents pass to the superior deep cervical nodes. Lymphatic Vessels of the Mouth. – The vessels of the gums pass to the submandibular nodes; those of the hard palate are continuous in front with those of the upper gum, but pass backward to pierce the Constrictor pharyngis superior and end in the superior deep cervical and subparotid nodes; those of the soft palate pass backward and lateralward and end partly in the retropharyngeal and subparotid, and partly in the superior deep cervical nodes. The vessels of the anterior part of the floor of the mouth pass either directly to the inferior nodes of the superior deep cervical group, or indirectly through the submental nodes; from the rest of the floor of the mouth the vessels pass to the submandibular and superior deep cervical nodes. The Lymph Nodes of the Neck – The lymph nodes of the neck include the following groups: Submandibular. Superficial Cervical. Submental. Anterior Cervical. Deep Cervical. The submandibular nodes, three to six in number, are placed beneath the body of the mandible in the submandibular triangle, and rest on the superficial surface of the submandibular salivary gland. The afferents of the submandibular nodes drain the medial palpebral commissure, the cheek, the side of the nose, the upper lip, the lateral part of the lower lip, the gums, and the anterior part of the margin of the tongue; efferent vessels from the facial and submental nodes also enter the submandibular nodes. Their efferent vessels pass to the superior deep cervical nodes. The submental or suprahyoid nodes are situated between the anterior bellies of the Digastrici. Their afferents drain the central portions of the lower lip and floor of the mouth and the apex of the tongue; their efferents pass partly to the submandibular nodes and partly to a gland of the deep cervical group situated on the internal jugular vein at the level of the cricoid cartilage. The superficial cervical nodes lie in close relationship with the external jugular vein as it emerges from the parotid gland, and, therefore, superficial to the Sternocleidomastoideus. Their afferents drain the lower parts of the auricula and parotid region, while their efferents pass around the anterior margin of the Sternocleidomastoideus to join the superior deep cervical nodes. The anterior cervical nodes form an irregular and inconstant group on the front of the larynx and trachea. They may be divided into (a) a superficial set, placed on the anterior jugular vein; (b) a deeper set, which is further subdivided into prelaryngeal, and pretracheal. This deeper set drains the lower part of the larynx, the thyroid gland, and the upper part of the trachea; its efferents pass to the lowest of the superior deep cervical nodes. The deep cervical nodes are numerous and of large size: they form a chain along the carotid sheath, lying by the side of the pharynx, esophagus, and trachea, and extending from the base of the skull to the root of the neck. They are usually described in two groups: (1) the superior deep cervical nodes lying under the Sternocleidomastoideus in close relation with the accessory nerve and the internal jugular vein, some of the nodes lying in front of and others behind the vessel; (2) the inferior deep cervical nodes extending beyond the posterior margin of the Sternocleidomastoideus into the supraclavicular triangle, where they are closely related to the brachial plexus and subclavian vein. The superior deep cervical nodes drain the occipital portion of the scalp, the auricula, the back of the neck, a considerable part of the tongue, the larynx, thyroid gland, trachea, nasal part of the pharynx, nasal cavities, palate, and esophagus. They receive also the efferent vessels from all the other nodes of the head and neck, except those from the inferior deep cervical nodes. The inferior deep cervical nodes drain the back of the scalp and neck, the superficial pectoral region, part of the arm, they receive vessels from the superior deep cervical nodes. The efferents of the superior deep cervical nodes pass partly to the inferior deep cervical nodes and partly to a trunk which unites with the efferent vessel of the inferior deep cervical nodes and forms the jugular trunk. On the right side, this trunk ends in the junction of the internal jugular and subclavian veins; on the left side it joins the thoracic duct. The Lymph Nodes of the Upper Extremity. – The lymph nodes of the upper extremity are divided into two sets, superficial and deep. The superficial lymph nodes are few and of small size. One or two supratrochlear nodes are placed above the medial epicondyle of the humerus, medial to the basilic vein. Their afferents drain the middle, ring, and little fingers, the medial portion of the hand, and the superficial area over the ulnar side of the forearm; these vessels are, however, in free communication with the other lymphatic vessels of the forearm. Their efferents accompany the basilic vein and join the deeper vessels. One or two deltoideopectoral nodes are found beside the cephalic vein, between the Pectoralis major and Deltoideus, immediately below the clavicle. They are situated in the course of the external collecting trunks of the arm. The deep lymph nodes are chiefly grouped in the axilla, although a few may be found in the forearm, in the course of the radial, ulnar, and interosseous vessels, and in the arm along the medial side of the brachial artery. The Axillary Nodes are of large size, vary from twenty to thirty in number, and may be arranged in the following groups: 1. A lateral group of from four to six nodes lies in relation to the medial and posterior aspects of the axillary vein; the afferents of these nodes drain the whole arm with the exception of that portion whose vessels accompany the cephalic vein. The efferent vessels pass partly to the central and subclavicular groups of axillary nodes and partly to the inferior deep cervical nodes. 2. An anterior or pectoral group consists of four or five nodes along the lower border of the Pectoralis minor, in relation with the lateral thoracic artery. Their afferents drain the skin and muscles of the anterior and lateral thoracic walls, and the central and lateral parts of the mamma; their efferents pass partly to the central and partly to the subclavicular groups of axillary nodes. 3. A posterior or subscapular group of six or seven nodes is placed along the lower margin of the posterior wall of the axilla in the course of the subscapular artery. The afferents of this group drain the skin and muscles of the lower part of the back of the neck and of the posterior thoracic wall; their efferents pass to the central group of axillary nodes. 4. A central or intermediate group of three or four large nodes is imbedded in the adipose tissue near the base of the axilla. Its afferents are the efferent vessels of all the preceding groups of axillary nodes; its efferents pass to the subclavicular group. 5. A medial or subclavicular group of six to twelve nodes is situated partly posterior to the upper portion of the Pectoralis minor and partly above the upper border of this muscle. Its only direct territorial afferents are those which accompany the cephalic vein and one which drains the upper peripheral part of the mamma, but it receives the efferents of all the other axillary nodes. The efferent vessels of the subclavicular group unite to form the subclavian trunk, which opens either directly into the junction of the internal jugular and subclavian veins or into the jugular lymphatic trunk; on the left side it may end in the thoracic duct. The lymph nodes of the thorax may be divided into parietal and visceral— the former being situated in the thoracic wall, the latter in relation to the viscera. The parietal lymph nodes include the sternal, intercostal, and diaphragmatic nodes. 1. The Sternal Nodes are placed at the anterior ends of the intercostal spaces, by the side of the internal mammary artery. They derive afferents from the mamma, from the deeper structures of the anterior abdominal wall above the level of the umbilicus, from the upper surface of the liver through a small group of nodes which lie behind the xiphoid process, and from the deeper parts of the anterior portion of the thoracic wall. Their efferents usually unite to form a single trunk on either side; this may open directly into the junction of the internal jugular and subclavian veins, or that of the right side may join the right subclavian trunk, and that of the left the thoracic duct. 2. The Intercostal Nodes occupy the posterior parts of the intercostal spaces, in relation to the intercostal vessels. They receive the deep lymphatics from the postero lateral aspect of the chest; some of these vessels are interrupted by small lateral intercostal nodes. The efferents of the nodes in the lower four or five spaces unite to form a trunk, which descends and opens either into the cisterna chyli or into the commencement of the thoracic duct. The efferents of the nodes in the upper spaces of the left side end in the thoracic duct; those of the corresponding right spaces, in the right lymphatic duct. 3. The Diaphragmatic Nodes lie on the thoracic aspect of the diaphragm, and consist of three sets, anterior (behind the base of the xiphoid process), middle, and posterior (situated on the back of the crura of the diaphragm). The visceral lymph nodes consist of three groups, viz.: anterior mediastinal, posterior mediastinal, and tracheobronchial. The Anterior Mediastinal Nodes (are placed in the anterior part of the superior mediastinal cavity, in front of the aortic arch and in relation to the innominate veins and the large arterial trunks which arise from the aortic arch. They receive afferents from the thymus and pericardium, and from the sternal nodes; their efferents unite with those of the tracheobronchial nodes, to form the right and left bronchomediastinal trunks. The Posterior Mediastinal Nodes lie behind the pericardium in relation to the esophagus and descending thoracic aorta. Their afferents are derived from the esophagus, the posterior part of the pericardium, the diaphragm, and the convex surface of the liver. Their efferents mostly end in the thoracic duct, but some join the tracheobronchial nodes. The Tracheobronchial Nodes form four main groups: (a) tracheal, on either side of the trachea; (b) bronchial, in the angles between the lower part of the trachea and bronchi and in the angle between the two bronchi; (c) bronchopulmonary, in the hilus of each lung; and (d) pulmonary, in the lung substance, on the larger branches of the bronchi. The afferents of the tracheobronchial nodes drain the lungs and bronchi, the thoracic part of the trachea and the heart; some of the efferents of the posterior mediastinal nodes also end in this group. Their efferent vessels ascend upon the trachea and unite with efferents of the internal mammary and anterior mediastinal nodes to form the right and left bronchomediastinal trunks. The right bronchomediastinal trunk may join the right lymphatic duct, and the left the thoracic duct, but more frequently they open independently of these ducts into the junction of the internal jugular and subclavian veins of their own side. Materials for self-check: A. Tasks for self-check: specify division of the lymphoid organs, their structure using tables, models, preparations, examine lymph vessels and nodes of the upper limbs, head, neck, chest cavity. B. Choose the correct answer. 1. Where should the catheter for evacuation of the lymph from the thoracic lymph duct be inserted? A. To the left venous corner B. To the right venous corner C. To the superior vena cava D. To the inferior vena cava E. To the left inguinal vein 2. While palpating mammary gland of a patient a doctor revealed an induration in form of a node in the inferior medial quadrant. Metastases may extend to the following lymph nodes: A. Parasternal B. Posterior mediastinal C. Profound lateral cervical D. Bronchopulmonary E. Superior diaphragmal 3. Specify the roots of the right lymphatic duct. A. Right bronchomediastinal, jugular and subclavian trunks B. Lumbar trunks, intestinal trunks C. Right bronchomediastinal trunks D. Subclavian trunks E. Jugular trunks 4. Where does the right lymphatic duct open? A. Right venous angle B. Left venous angle C. External jugular vein D. Anterior jugular vein E. Axillary vein 5. Specify the roots of the thoracic duct. A. Right bronchomediastinal, jugular and subclavian trunks B. Lumbar trunks, intestinal trunks C. Right bronchomediastinal trunks D. Subclavian trunks E. Jugular trunks 6. Where does the thoracic duct open? A. Right venous angle B. Left venous angle C. External jugular vein D. Anterior jugular vein E. Axillary vein 7. Specify veins that form venous angle. A. Internal jugular and subclavian veins B. Internal thoracic and vertebral veins C. External jugular vein and subclavian veins D. Anterior jugular vein and subclavian veins E. Axillary vein and subclavian veins 8. Specify the length of the right lymphatic duct. A. 4-5 cm B. 7-8 cm C. 10-15 cm D. 1-2 cm B. 30-40 cm 9. Specify the length of the thoracic duct. A. 4-5 cm B. 7-8 cm C. 10-15 cm D. 1-2 cm B. 30-40 cm 10. According to the results of dia¬gnostic tests, a doctor decided to do lymphography of thoracic cavity organs of a 40-year-old patient. The doctor detected that the swelling affected the organ, from lymphoid vessels of which the lymph gets directly into the thoracic duct. Which organ is damaged? A. Esophagus. B. Trachea. C. Left principal bronchus. D. Heart. E. Pericardium. References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 21. Submodule on Cardiovascular system and immune system. Situation problems. Control questions: 1. Name the principal parts of heart. 2. Name the surfaces of heart. 3. What cardiac chambers feature the auricles? 4. Name the borders of the heart. 5. Name the layers of cardiac wall. 6. How many muscular layers are distinguishable in the atrial myocardium? 7. How many muscular layers are distinguishable in the ventricular myocardium? 8. Name the insertion point of all myocardial fibers. 9. Name the cardiac chambers that comprise the papillary muscles and the musculi pectinati. 10. What cardiac chamber contains the fossa ovalis, the opening of coronary sinus and the valve of inferior vena cava? 11. Name the cardiac opening that features the tricuspid valve. 12. Name the cardiac opening that features the mitral valve. 13. Name the cusps of the right atrio-ventricular valve. 14. Name the cusps of the left atrio-ventricular valve. 15. Where do the semilunar cusps reside? 16. What valves have their cusps attached to the chordae tendineae? 17. What area contains the opening of right coronary artery? 18. What area contains the opening of left coronary artery? 19. Name the areas supplied by the left coronary artery. 20. Name the main branch given by the right coronary artery. 21. Name the areas supplied by the right coronary artery. 22. Name the cardiac veins that open into the right atrium directly. Name the cardiac veins drained by the coronary sinus. 23. Where does the sinu-atrial node reside? 24. Where does the atrioventricular node reside? 25. Where does the atrioventricular bundle reside? 26. Name the layers of pericardium. Name the limits of pericardial cavity. Name the pericardial sinuses. What is the average heart weight in males and females? 27. Describe surface relations of the left boundary of heart. 28. Describe surface relations of the right boundary of heart. 29. Describe surface relations of the superior boundary of heart. Describe surface relations of the inferior boundary of heart. Describe surface relations of the apex of heart. 30. Name the auscultatory point for the left atrioventricular valve. Name the auscultatory point for the right atrioventricular valve. Name the auscultatory point for the aortic valve. Name the auscultatory point for the pulmonary valve. 31. Describe surface relations of the aortic and pulmonary valves. 32. Describe surface relations of the mitral and tricuspid valves. 33. Name three main positions of heart with respect to constitutional type of body. 34. Name the organs that receive the most oxygenated blood during embryo’s development. 35. What vessels are connected by the ductus arteriosus in fetus? 36. Name the area, where the umbilical vein enters the fetus’ body. 37. Describe the pulmonary trunk and its topography. 38. Describe topography of pulmonary arteries 39. Describe intrinsic divisions of the pulmonary arteries. 40. Describe formation and topography of the pulmonary veins. 41. Give general description of the aorta. Describe the aortic arch and name its branches. 42. Describe the common carotid artery (both left and right). 43. Describe the external carotid artery. 44. Describe the anterior branches of the external carotid artery. 45. Describe the facial artery. 46. Describe the posterior branches of the external carotid artery. 47. Describe the medial branches of the external carotid artery. 48. Describe the superficial temporal artery. 49. Describe the maxillary artery. 50. Describe the internal carotid artery. 51. Describe the subclavian artery. 52. Describe the basilar artery. 53. Describe the cerebral arterial circle. 54. Describe the axillary artery. 55. Describe the brachial artery. 56. Describe the radial artery. 57. Describe ulnar artery. 58. Describe the cubital anastomosis. 59. Describe the superficial palmar arch 60. Describe the deep palmar arch. 61. Describe the dorsal carpal arch. 62. Describe the palmar carpal arch. 63. Describe the palmar arterial anastomoses. 64. Describe the thoracic aorta. 65. Give general description of the abdominal aorta. 66. Describe the parietal branches of the abdominal aorta. 67. Describe the paired and unpaired visceral branches of the abdominal aorta. 68. Describe the intersystem and in-trinsic anastomoses of the branches of abdominal aorta. 69. Describe the common iliac artery. 70. Describe the parietal branches of the internal iliac artery. 71. Describe the visceral branches of the internal iliac artery. 72. Describe the external iliac artery. 73. Describe the femoral artery. 74. Describe the deep artery of thigh. 75. Describe the popliteal artery. 76. Describe the anterior tibial artery. 77. Describe the posterior tibial artery. 78. Describe the genicular anastomosis. 79. Describe the medial plantar artery. 80. Describe the lateral plantar artery. 81. Describe the dorsal artery of foot. 82. Describe the arterial anastomoses of foot. 83. Discuss arrangement regularities of the veins. Give definition of the root veins and tributary veins. 84. Describe the superior vena cava. 85. Describe the internal jugular vein. 86. Describe the intracranial tributaries of the internal jugular vein. 87. Describe the extracranial tributaries of the internal jugular vein. 88. Describe anastomoses between the intracranial and extracranial tributaries of the internal jugular vein. 89. Describe the venous angle. 90. Describe the external jugular vein. 91. Describe the anterior jugular vein and the jugular venous arch. 92. Describe the brachiocephalic vein. 93. Give general description and classification of the veins of upper limb. Describe the superficial veins. 94. Describe the deep veins of upper limb. Discuss their features. 95. Describe the axillary vein. 96. Describe the azygos vein. 97. Describe the hemiazygos vein. 98. Describe the accessory hemiazygos vein. 99. Describe the intercostal veins. 100. Describe the veins of vertebral column. 101. Describe the inferior vena cava. 102. Describe the visceral tributaries of the inferior vena cava. 103. Describe the parietal branches of the inferior vena cava. 104. Describe the hepatic portal vein. 105. Describe the internal iliac vein. 106. Describe the parietal tributaries of the internal iliac vein. 107. Describe the external iliac vein. 108. Give general description of the veins of lower limb. Describe the superficial veins of the lower limbs. 109. Describe the great saphenous vein. 110. Describe the deep veins of lower limb. 111. Describe the femoral vein. 112. Describe the venous plexuses of lesser pelvis. 113. Give definition of intrinsic and intersystem venous anastomoses. 114. Describe the porto-caval anastomoses at the esophagus. 115. Describe porto-caval anastomoses at the rectum. 116. Describe the portocaval anastomoses by the posterior abdominal wall. 117. Describe the cava-caval anastomoses by the anterior abdominal wall. 118. Describe the porto-cava-caval anastomosis by the anterior abdominal wall. 119. Describe the cava-caval anasto-mosis by the posterior abdominal wall. 120. Describe the cava-caval anastomosis along the vertebral column. 121. What structural features allow differentiation of blood and lymphatic capillaries? 122. What parts are distinguishable in the thoracic duct? 123. Describe formation of the right lymphatic duct. 124. Name the lymphatic ducts. 125. Where do the lymphatic trunks and ducts open? Name the body regions drained by each trunk and duct. 126. Name the groups of lymph nodes situated on the border of head and neck. 127. What groups of lymph nodes reside within the cervical region? 128. Name the groups of parietal tho-racic lymph nodes. Name the regions drained by these nodes. 129. Name the groups of visceral thoracic lymph nodes. Name the viscera drained by these nodes. 130. Name the groups of parietal abdominal lymph nodes. 131. Name the groups of visceral abdominal lymph nodes. Name the viscera drained by these nodes. 132. What lymph nodes receive lymph from the lesser pelvis viscera in part from the rectum? 133. What groups of lymph vessels are distinguishable in the upper limb? Name the destination point of these vessels. 134. What groups of lymph vessels are distinguishable in the lower limb? Name the destination point of these vessels. 135. What lymph nodes receive lymph from the breast? 136. Name the structures related to the primary and secondary organs. Explain your choice. 137. What populations of lymphocytes form the lymphoid tissue? 138. Discuss developmental and structural regularities of the lymphoid system. 139. Name the common morphological features of all secondary lymphoid organs. 140. What organs contain the lymphoid nodules? 141. Discuss structural features of the tonsils that from the pharyngeal lymphoid ring. 2. Situational tasks from database "Step - 1". 1. A 58-year-old patient is admitted to a cardiological clinic with acute persistent pain in substernal area, which does not reduce after the second taking of nitroglycerine. Electrocardiogram shows that he has big necrosis of the posterior surface of the heart. The diagnosis is transmural myocardial infarction of the posterior wall of the heart. Acute occlusion of which vessel led to this disease? A. Right coronary artery. B. Coronary sinus. C. Right pulmonary artery. D. Left coronary artery. E. Left common carotid artery. 2. A patient has an infarction the anterior wall of the left ventricle. Blood circulation of which vessel is damaged? A. Anterior interventricular branch the left coronary artery. B. Atrioventricular branches of the right coronary artery. C. Circumflex branch of the left coronary artery. D. Posterior interventricular branch of the right coronary artery. E. Left marginal branch of the left coronary artery. 3. Examining a patient ischemic disease a doctor detected deterioration of venous blood flow in the one of a cardiac vein, which passes through the anterior interventricular sulcus. Which vein is this? A. V. cordis parva. B. V. cordis media. C. V. cordis magna. D. V. posterior ventriculi sinistri. E. V. obliqua atrii sinistri. 4. During the period of prenatal development in the vascular system of a fetus an arterial duct functions, which turns into lig. arteriosum after birth. What vessels does it join? A. Pulmonary trunk and aorta. B. Right and left atrium. C. Aorta and inferior vena cava. D. Pulmonary trunk and superior vena cava. E. Aorta and superior vena cava. 5. A 56-year-old patient has worked for 28 years at a chemical plant in a workshop with harmful productions conditions. He often has hemorrhages of the nasal cavity mucosa. Which arteries involved? A. Anterior and posterior ethmoidal B. Supraorbital. C. Ciliary. D. Anterior cerebral. E. Ophthalmic. 6. An 18-year-old man was admitted to a hospital after a car accident. In the traumathology center numerous traumas of soft tissues of the face in the region of the medial angle of eye accompanied by profuse bleeding were detected. What arterial anastomosis is formed in this region? A. A. carotis externa et a. carotis interna. B. A. carotis externa et a. subclavia. C. A. carotis interna et a. subclavia. D. A. subclavia et a. ophthalmica. E. A. carotis interna et a. ophthalmica. 7. A 80 year-old patient had hemorrhage of the brain and was taken to the hospital. The place of hemorrhage was revealed on the lateral hemispheres surfaces during the medical examination. What artery was injured? A. The middle cerebral artery B. The anterior cerebral artery C. The posterior cerebral artery D. The anterior communicating artery E. The posterior communicating artery 8. After the injury of temporal region, a patient got epidural hematoma. Which artery is damaged? A. Deep temporal. B. Middle meningeal. C. Deep auriculary. D. Superior tympanic. E. Inferior tympanic. 9. A patient was admitted to a hospital with an open fracture of the ramus mandible and profuse bleeding in the fracture site. Which artery is damaged? A. A. palatina ascendens. B. A. temporalis media. C. A. facialis. D. A. lingualis. E. A. alveolaris inferior. 10. A surgeon, accessing the organs of the thoracic cavity, made an incision on the anterior chest wall along one of the intercostal spaces. He carefully dissected the tissues of the anterior medial region of the intercostal space in order not to damage the artery situated in parallel to the edge of the breastbone, by 1-1.5 cm more lateral from it. Which artery is meant? A. Inferior phrenic. B. Anterior intercostal. C. Superior phrenic. D. Costocervical trunk. E. Internal thoracic. 11. A doctor examined a patient who got into a car accident. The patient has a fracture of the left clavicle and disorders of blood circulation in the extremity (radial artery pulsation is absent). What is the cause of blood circulation disorder? A. Compression of vertebral artery. B. Compression of axillary artery. C. Compression of subciavian vein. D. Compression of subciavian artery. E. Compression of axillary vein. 12. During an operative interven¬tion on a mammary gland profuse bleed¬ing appeared. Which artery was da¬maged? A. Internal thoracic. B. Lateral thoracic. C. Superior epigastric. D. Axillary. E. Superior thoracic. 13. After trauma, a 44-year-old patient had a rupture of left palm muscle tendons and of the surface of blood vessels. After operation and removal of the most part of the necrotically changed muscle tissue the bloodstream was normalized. What vessels have helped with restoration of bloodstream? A. Arcus palmaris profundus B. Arcus palmaris superficialis C. Aa. digitales palmares communes D. Aa. metacarpeae palmares E. Aa. Perforantes 14. While performing an operation in the area of axillary crease a surgeon has to define an arterial vessel surrounded by fascicles of brachial plexus. What artery is it? A. A. axillaris B. A. vertebralis C. A. transversa colli D. A. profunda brachii E. A. subscapularis 15. A woman underwent an operation because of extrauterine (tubal) pregnancy. In course of the operation the surgeon should ligate the branches of the following arteries: A. Superior cystic and ovarian B. Uterine and ovarian C. Inferior cystic and ovarian D. Uterine and superior cystic E. Uterine and inferior cystic 16. A 29-year-old woman was admitted to a gynecology department with complaints of pain in the abdominal region. An ovary tumor was clinically detected and prescribed to be removed. During the operation, a ligament containing the ovarian vessels and nerves must be dissected. Which ligament is it? A. Lig. suspensorium ovarii. B. Lig. latum uteri. C. Lig. cardinale. D.Lig. umbilicalis lateralis. E. Lig. ovarii proprium. 17. A 40-year-old woman had appendectomy, during which an artery of the vermiform process was ligated. This artery separates from: A. Left colic artery. B. Jejunal artery C. Iliocolic artery. D. Right colic artery. E. Middle colic artery. 18. Examination of a patient has shown pancreas blood supply disorder. Which artery could be damaged? A. A. gastrica dextra. B. A. hepatica propria. C. A. gastrica sinistra. D. A. gastroepiploica dextra. E. A. lienalis. 19. A patient was admitted surgical department in grave condition with a stab wound in the right hypochondrium with signs of internal hemorrhage. After laparotomy, a doctor detected hepatic parenchyma injuries and blood in the abdominal cavity. For a temporary arrest of bleeding the doctor applied smooth tissue forceps hepatoduodenal ligament. Which vessels are bandaged in the region of this ligament? A. Right and left hepatic arteries. B. Hepatic veins and hepatic arteries. C. Proper hepatic artery and hepatic veins. D. Proper hepatic artery and porta. E. Coeliac trunk and superior mesenteric artery. 20. A patient with a stomach ulcer situated in the pyloric region on the lesser curvature of stomach has bleeding. What vessel should be ligated to stop the bleeding? A. Right gastric artery. B. Left gastric artery. C. Left gastroomental artery. D. Hepatic artery. E. Right gastroomental artery. 21. A 45-year-old patient's skin of the right foot and leg is pale; there is pulsations of the dorsal artery of foot and posterior tibial artery. Pulsation of the femoral artery is preserved. Which artery is damaged? A. Descending genicular. B. External iliac. C. Fibular. D. Deep artery of thigh. E. Popliteal. 22. Examining blood supply a doctor detects pulsation of a large artery, which passes ahead of the talocrural joint between the tendons of the long extensor of the big toe and the long extensor of fingers in a separate fibrous canal. Which artery is this? A. A. tarsea lateralis. B. A. tibialis posterior. C. A. tarsea medialis. D. A. dorsalis pedis. E. A. fibularis. 23. Young man 27 years old was delivered to hospital with an open fracture of the occipital bone and heavy bleeding from the wound. What could be causing severe bleeding in this case? A. Damage of inferior petrosal sinus B. Damage of cavernous sinus. C. Damage of superior petrosal sinus. D. Damage of transverse venous sinus. E. Damage of sphenoid sinus. 24. A patient was admitted surgical department in grave condition with a stab wound in the right hypochondrium with signs of internal hemorrhage. After laparotomy, a doctor detected hepatic parenchyma injuries and blood in the abdominal cavity. For a temporary arrest of bleeding the doctor applied smooth tissue forceps hepatoduodenal ligament. Which vessels are bandaged in the region of this ligament? A. Right and left hepatic arteries. B. Hepatic veins and hepatic arteries. C. Proper hepatic artery and hepatic veins. D. Proper hepatic artery and porta. E. Coeliac trunk and superior mesenteric artery. 25. Examining a 48-year-old patient a doctor detected ascites (peritoneal dropsy), in the site of the umbilicus - dilated plethoric veins (Medusa head symptom). In past history there is alcohol abuse. What organ of the abdominal cavity is affected, and by what venous anastomoses does venous blood outflow? A. Liver. Portacavocaval anastomosis through paraumbilical veins. B. Pancreas. Cavocaval anastomosis through a mesenteric vein. C. Spleen. Portacaval anastomosis through the system of gastric veins. D. Liver. Portacaval anastomosis through the system of inferior and superior mesenteric and lumbar veins. E. Stomach. Portacaval anastomosis through the system of gastric veins, inferior and superior mesenteric veins. 26. According to the results of diagnostic tests, a doctor decided to do lymphography of thoracic cavity organs of a 40-year-old patient. The doctor detected that the swelling affected the organ, from lymphoid vessels of which the lymph gets directly into the thoracic duct. Which organ is damaged? A. Esophagus. B. Trachea. C. Left principal bronchus. D. Heart. E. Pericardium. 27. An 18-year-old youth was admitted to a hospital with the signs of internal bleeding. While playing football he was hit in the left hypochondrium region. Damage of which of the organs, projected into this region, may cause profuse bleeding? A. Left flexure of colon. B. Tail of pancreas. C. Fundus of stomach. D. Left kidney. E. Spleen. 28. Mouth breath prevailing of a 7 year-old child is observed. A doctor diagnoses lymphoid tissue overgrowth. Which structures overgrowth causes this? A. Palatine and pharyngeal tonsils. B. Lingual and pharyngeal tonsils. C. Lymph nodes. D. Lingual and palatine tonsils. E. Pharyngeal and tubal tonsils 29. The examination of the patient revealed hypertrophy and inflammation of the lymphoid tissue, swelling of the mucous membrane of the soft palate between the arches (acute tonsillitis). Which of the tonsils is contained in the norm in this place? A. Tonsilla tubaria B. Tonsilla pharyngealis C. Tonsilla lingualis D. Tonsilla palatina E. All answers are correct 30. A 70-year-old female patient was diagnosed with fracture of left femoral neck accompanied by disruption of ligament of head of femur. The branch of the following artery is damaged: A. Obturator B. Femoral C. External iliac D. Inferior gluteal E. Internal pudendal 31. Which of the following statements is correct about middle colic artery? A. It takes origin from the celiac trunk B. It supplies the cecum C. It anastomoses with the inferior pancreatico-duodenal artery *D. It is a branch of the superior mesenteric artery E. It primarily supplies the left colic flexure 32. Which of the following is supplied by branches of the superior mesenteric artery? *A. Duodenojejunal junction B. Rectum C. Descending colon D. Stomach E. Spleen 33. Which of the following structures represents the obliterated remains of the umbilical vein? *A. Ligamentum teres hepatis B. Ligamentum venosum C. Ductus arteriosus D. Falciform ligament E. Porta hepatis 34. The cystic artery usually arises from the following arteries? A. Splenic B. Gastroduodenal C. Right gastroepiploic *D. Right hepatic E. Celiac trunk 35. The superior mesenteric and splenic veins unite to form the portal vein behind A. First part of the duodenum B. Transverse colon C. Spleen *D. Neck of the pancreas E. Duodenojejunal junction References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 22. General characteristics of the peripheral nervous system. The spinal nerves. The posterior rami of the spinal nerves. The anterior rami of the spinal nerves. The cervical plexus. 1. Relevance of the topic. The peripheral nervous system consists of the cranial and spinal nerves and their associated ganglia. There are 31 pairs of spinal nerves that leave the spinal cord and pass through intervertebral foramina in the vertebral column. Inflammatory processes, toxic lesions and injury sequelae are known under common term ‘neuritis’. The state manifests itself as painful sensation in the affected area (mostly in the lumbar and the sacral regions). 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Histology Structure of nerve fibers. Neurology Topography of the nervous branches. Physics Describe the mechanism of nerve impulse. Anatomy Structure of the spinal cord, internal and external structures. 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi spinаles Spinal nerves Plexus cervicalis Cervical plexus Ansa cervicalis Cervical loop 4.2. Theoretical questions for the class: 1. Formation of the cervical plexus. 2. Topography of the cervical plexus. 3. Classification of branches of the cervical plexus. 4. Skin branches of the cervical plexus, their topography and innervation zone. 5. Muscle branches of the cervical plexus, their topography and innervation zone. 6. Mixed branch of the cervical plexus: phrenic nerve, its topography and the innervation zone. 4.3. Practical task pertaining to the topic and to be completed during the class: specify the forming of the spinal nerve, its division, branches of cervical plexus using models, tables, preparations. Content of the topic. The spinal cord gives rise to 31 pair of the spinal nerves. These nerves are like the following: 8 pairs of the cervical nerves, nervi cervicales (Cl — C8); 12 pairs of the thoracic nerves, ner¬vi thoracici (Thl — Th 12); 5 pairs of the lumbar nerves, nervi lumbales (LI — L5); 5 pairs of the sacral nerves, nervi sacrales (SI — S5); 1 coccygeal newes, nervus coccygeus (Col). Formation of the spinal nerve Each spinal nerve arises in the area of the intervertebral foramen as the result of merging of the anterior and the posterior roots of the spinal cord: ■ the anterior (ventral) root, radix anterior (ventralis) comprises the motor fibers that arise from the motor nuclei of the anterior grey columns. The roots of the segments C8 through L2 also comprise the autonomic (sympathetic) fibers that arise from the sympathetic nuclei of the lateral grey columns; ■ the posterior (dorsal) root, radix posterior (dorsalis) comprises the sensory fibers represented with the central processes of the sensory pseudounipolar cells of the spinal ganglia, ganglia spinales. The fibers run to respective relay centers of the spinal cord and the medulla oblongata. The peripheral processes of the cells join the spinal nerves and run to the respective receptors. (Note: the posterior roots actually take but little part in formation of the spinal nerve. It would be more correct to say that the spinal nerve comprises the fibers of the anterior roots and the peripheral processes of the sensory pseudounipolar neurons of the spinal ganglia. The posterior roots were included for convenience reason.) Typical divisions of the spinal nerve The principal trunk of spinal nerve, truncus nervi spinalis (approx. 1 cm long) escapes from the intervertebral foramen and gives rise to four branches — the anterior ramus, the posterior ramus, the meningeal branch and so called ramus communicans. The latter is present in the nerves C8 through L2: ■ the anterior (ventral) rami, rami anteriores (ventrales) are the mixed branches that supply the ventral areas of the neck, the trunk and the limbs. All anterior branch- es except for those of the thoracic nerves form the plexuses; ■ the posterior (dorsal) rami, rami posteriores (dorsales) also mixed thin branches, they run posteriorly to supply the skin and the proper muscles of back. The posterior branch of the first spinal nerve comprises only the motor fibers; . the rami communicantes (Lat. Id.) associate the spinal nerves with the sympathetic trunk and thus are present in the nerves C8 through L2. They sometimes referred to as the white rami communicantes (called so because of whitish color). The rami communicantes albi comprise the sympathetic preganglionic fibers that arise from the intermediolateral nucleus and reach the ganglia of the sympathetic trunk to synapse with pertaining neurons. The postganglionic fibers from the sympathetic trunk return to the spinal nerve as the grey rami communicantes (also called so because of color) that join the anterior and the posterior rami together with the meningeal branches; ■ the meningeal branch, ramus meningeus returns to the vertebral canal to supply the spinal meninges. THE POSTERIOR RAMI OF THE SPINAL NERVES The posterior rami detach from he respective spinal nerve and pass between the spinal processes of the neighboring vertebrae. Within the destination point, the nerves split into he medial and the lateral branches hat supply the skin of the dorsal area of the trunk from back of the head lown to the gluteal regions, the occipital muscles and the proper muscles of back. Few posterior rami have proper lames: . the suboccipital nerve, nervus suboccipitalis is a purely motor posterior branch of the first cervical nerve. It supplies the suboccipital muscles and the semispinalis capitis; ■ the greater occipital netve, nervus occipitalis major is a mixed posterior branch of the second cervical nerve. It supplies the skin of the occipital region and the posterior cervical muscles like the splenius capitis, the splenius cervicis, the semispinalis capitis and the lon- gissimus capitis; ■ the superior cluneal nerves, nervi clunium superiores are the posterior branches of the lumbar and the sacral nerves. They supply the skin of the gluteal region. THE ANTERIOR RAMI OF THE SPINAL NERVES The anterior rami of the spinal nerves are much thicker and longer than the posterior rami. They form the plexuses (except for the thoracic nerves) where the nerves interlace and allow fibers swap. The plexuses arise as the result of complex development of the limbs. Four known nervous plexuses are the cervical plexus, the thoracic plexus, the lumbar plexus and the sacral plexus. The last two have no clear demarcation line and may join into one lumbosacral plexus, plexux lumbosacralis. THE CERVICAL PLEXUS, PLEXUS CERVICALIS (Cl - C4) The cervical plexus arises from anterior branches of four upper cervical nerves (Cl — C4). It lies on the deep cervical muscles anterior to the transverse processes of cervical verte-brae, below the sternocleidomastoid. The plexus gives rise to the sensory, the motor and the mixed branches. The cutaneous (sensory) branches from under the posterior margin of the sternocleidomastoid: ■ the lesser occipital nerve, nervus occipitalis minor ascends to the skin of the occipital region; ■ the great auricular nerve, nervus auricularis magnus ascend along the sternocleidomastoid to the auricle and the external acoustic opening; ■ the transverse cervical nerve, nervus transversus colli runs transversely to the anterior and lateral cervical areas; ■ the supraclavicular nerves, nervi supraclaviculares descend to the upper thoracic regions and shoulder along the lateral cervical triangle. On the way to destination point, the nerves cross the clavicle. The ansa cervicalis is a purely motor branch. It is formed of the superior and the inferior roots. The superior root arises from the hypoglossal nerve yet it constitutes the motor fibers from the Cl. The inferior root arises from the cervical plexus (C2 — C3) and joins the superior root thus forming the ansa. It resides anterior to the internal jugular vein below the sternocleidomastoid. The ansa gives off some branches to the infrahyoid muscles (the sternohyoid, the sternothyroid, the thyrohyoid and the omohyoid). The muscular (motor) branches supply the deep cervical muscles like the longus colli, the longus capitis, the scaleni muscles, the rectus capitis anterior and the rectus capitis lateralis and the levator scapulae. The phrenic nerve, nervus phrenicus is the greatest nerve of the cervical plexus and the sole mixed-type nerve of the group. It runs downwards along the anterior scalene, musculuus sca-lenus anterior to reach the thoracic cavity. The right nerve enters the thoracic inlet between the subclavian artery and the subclavian vein and runs further on anterior to the root of lung between the respective pleura and the pericardium. The left nerve enters the thoracic inlet posterior to the subclavian vein along the subclavian artery. The nerve crosses the aortic arch and proceeds anteriorly and leftwards along the pericardium to reach the respective portion of the diaphragm. The motor branches terminate within the diaphragm to provide motor nerve supply to the muscle (C3 — C5). The phrenic nerve also comprises the sensory fibers to the pleura and the pericardium — the pericardial branch, ramus pericardiacus. The sensory phrenico- abdominal branches, rami phrenicoabdominales penetrate the diaphragm to supply the related peritoneum. The sensory branches of the right phrenic nerve traverse the coeliac plexus and reach the liver; they provide sensory nerve supply to the peritoneal investment and the fibrous capsule of liver. Clinical applications Some liver diseases may result in painful sensations along the right phrenic nerve. The pain in this case expands onto the cervical region and concentrates between the crura of the sternocleidomastoid (thus providing easily distinguishable ‘phreni- cus-symptom’). The phrenic nerve is a vital nerve that sets the diaphragm to motion. The nuclei of the phrenic nerve reside within the anterior grey columns of the segments C3 through C6. Injury to the nuclei or to the nerves may result in diaphragm paralysis. Materials for self-check: A. Tasks for self-check: specify the forming of the spinal nerve, its division, branches of cervical plexus using models, tables, preparations. B. Situational tasks. 1. What nerve is mixed branch of cervical plexus? *A. Phrenic nerve B. Lesser occipital nerve C. Great auricular nerve D. Supraclavicular nerves E. Suboccipital nerves 2. What anatomical structures form a spinal nerve? A. Posterior funiculus of spinal cord B. Lateral funiculus of spinal cord *C. Anterior and posterior roots of spinal cord D. Posterior horn of spinal cord E. Anterior funiculus of spinal cord 3. What anatomical structures form the elementary reflex arch? A. Afferent neuron, intermediate neuron, efferent neuron B. Anterior root of the spinal nerve C. Conductor neuron D. Efferent neuron E. Central nucleus 4. Indicate anatomical structures relating to peripheral nervous system *A. Cranial nerves B. Pons C. Mesencephalon D. Medulla oblongata E. Spinal cord 5. Indicate nervous fibres in spinal nerves. A. Postganglionic parasympathetic B. Sensory, motor, postganglionic sympathetic C. Preganglionic sympathetic D. Cranial nerves E. Anterior root of the spinal cord 6. Indicate anatomical structure, supplied by posterior branches of spinal nerves. *A. Deep muscles of back B. Skin of the occipital region C. Superficial muscles of neck D. Infrahyoid muscles of the neck E. Scalene muscles 7. Indicate spinal nerves, having white communicating branches. *A. Thoracic nerves B. Cervical nerves C. Coccygeal nerves D. Sacral nerves E. Lumbar nerves 8. Indicate sites of passage of greater occipital nerve? A. Foramen magnum B. Between occipital bone and atlas *C. Between atlas and axis D. Through deltoid E. Interscalenal space 9. Indicate anatomical structures, innervated by transverse cervical nerve. A. Trapezius B. Sternocleidomastoid *C. Skin of anterior and lateral cervical regions D. Skin of posterior cervical region E. Deltoid 10. These are cutaneous branches of cervical plexus, EXEPT. A. Great auricular nerve B. Transverse cervical nerve C. Lesser occipital nerve D. Supraclavicular nerve *E. Cervical ansa Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 23. The brachial plexus. 1. Relevance of the topic. The branches of brachial plexus innervate upper extremity (girdle and free extremity). From the proper function of the branches of brachial plexus depends the work of the upper extremity. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Histology Structure of nerve fibers. Neurology Topography of the nervous branches. Physics Describe the mechanism of nerve impulse. Anatomy Structure of the spinal cord, internal and external structures. 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi spinаles Spinal nerves Plexus brachialis Brachial plexus Truncus superior, medius et inferior Trunk upper, middle and lower 4.2. Theoretical questions for the class: 1. Formation of the brachial plexus. 2. The structure of the brachial plexus, trunks and their topography. 3. Classification of the nerves originating from the brachial plexus. 4. Short nerves of the brachial plexus, the course and their areas of innervation. 5. Long brachial plexus nerves, the course and areas of innervation of the lateral, medial and posterior cords. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the brachial plexus on the groups, regions of their inervation using preparations, models, tables. Content of the topic. THE BRACHIAL PLEXUS, PLEXUS BRACHIALIS (C5-C8 and Thl) The brachial plexus arises from anterior branches of four lower cervical nerves (C4 — C8) and greater portion of the anterior branch of the first thoracic nerve (Thl). The brachial plexus features the supraclavicular and the infraclavicular parts. 1) the supraclavicular part, pars supraclavicularis appears as three trunks that pass between the anterior and the middle scaleni muscles. The trunks are the superior trunk, truncus superior, the middle trunk, truncus medius and the inferior trunk, truncus inferior; 2) the infraclavicular part, pars infraclavicularis is the part situated within the axillary fossa where the trunks regroup into the cords, faciculi that surround the brachial artery. The cords are as follows: the lateral cord, fasciculus lateralis runs laterally along the artery; the medial cord, fasciculus medialis runs medially along the artery; the posterior cord, fasciculus posterior runs posteriorly along the artery. The branches of the supraclavicular part This part gives rise to the short branches related to the pectoral girdle; ■ the dorsal scapular nerve, nervus dorsalis scapulae runs to the levator scapulae and the rhomboid muscles; ■ the long thoracic nerve, nervus thoracicus longus supplies the neighboring serratus anterior; ■ the suprascapular nerve, nervus suprascapularis crosses the suprascapular notch and reaches supraspinous and infraspinous fossae. It supplies the respective muscles and the joint capsule of the shoulder joint; ■ the subclavian nerve, nervus subclavius supplies the muscle of the same name; ■ the lateral and medial pectoral nerves, nervi pectorales lateralis et medialis supply the pectoralis major and the pectoralis minor; ■ the subscapular nerve, nervus subscapularis supplies the subscapularis and the teres major, ■ the thoracodorsal nerve, nervus thoracodorsalis runs along the lateral border of scapula; it supplies the latissimus dorsi; • the axillary nerve, nervus axillaris is the greatest of the short branches. It arises from the posterior cord and proceeds to the quadrangular foramen. Upon passing the foramen, the nerve loops around the surgical neck of humerus and reaches the posterior surface of shoulder. There it supplies the deltoid and the teres minor. Apart from this, the nerve gives some fibers to the joint capsule of the shoulder joint and to skin of the posterolateral surface of shoulder. The infraclavicular part The cords of the infraclavicular part give rise to the long branches that terminate within the various areas of the arm: ■ the musculocutaneous newe, nervus musculocutaneus arises from the lateral cord then traverses the coracobrachialis and appears in between the biceps brachii, musculus biceps brachii and the brachialis, musculus brachialis. It gives the muscular branches, rami musculares to the entire anterior group of brachial muscles (the coracobrachialis, the biceps brachii and the brachialis). The cutaneous branch of the nerve — the lateral cutaneous nerve of forearm, nervus cutaneous antebrachii lateralis arises from under the lateral margin of the biceps brachii and penetrates the fascia to terminate within the skin of antero-lateral area of forearm; ■ the medial cutaneous nerve of arm, nervus cutaneous brachii medialis a thin nerve that arises from the medial cord and terminates within the skin of medial area of arm; ■ the medial cutaneous nerve of forearm, nervus cutaneous antebrachii medialis also arises from the medial cord. The nerve runs to the forearm and terminates within the skin of its anteromedial area. Three other nerves of the group — the median, the ulnar and the radial nerves are the principal nerves of upper limb. The median nerve, nervus medianus Topography of the median nerve The median nerve arises from two roots given by the medial and the lateral cords (the medial and the lateral roots). In the arm region, the nerve joins the common neurovascular bundle that runs along the medial bicipital groove. In the forearm region, the nerve enters the cubital fossa and quits it via the space between the heads of the pronator teres. Upon escaping from the fossa, the nerve lies in between the flexor digitorum superficial and the flexor digitorum profundus, musculi flexores digi-torum superficialis et profundus. Passing so on, the nerve lies within the median sulcus that leads to the carpal tunnel, canalis carpi. As the nerve appears on the palmar surface of hand, it splits into three common palmar digital nerves, nervi digitales palmares communes that in turn give seven proper palmar digital nerves, nervi digitales palmares proprii. These terminal branches run to both aspects of fingers 1 through 3 and to the radial aspect of the 4th finger. Responsibility areas of the median nerve The median nerve gives no branches in the arm area (namely from origination point down to the cubital fossa). The first branches to arise are the branches to the joint capsule of the elbow joint. In the forearm area, the nerve supplies both pronators (musculi pronatores teres et quadratus) and all flexors except for the flexor carpi ulnaris and the ulnar half of the flexor digitorum profundus, muscu- lus flexor digitorum profundus. The deep muscles of forearm are under responsibility of the anterior interosseous nerve, nervus interosseus anterior that runs along the anterior interosseous membrane. This nerve terminates at the joint capsule of the joint of wrist. In the palmar area, the motor branches supply two lateral lumbricals and all muscles of thumb except for the abductor pollicis and the deep head of the flexor pollicis brevis. The cutaneous branches supply the skin of the thenar, of the median portion of the palmar surface of hand and of the palmar surface of fingers 1 through 3 including the radial aspect of the 4th finger. Apart from this, the nerve gives small twigs to the dorsal surface of the 2nd and the 3rd fingers together with the radial aspect of the 4th finger. Clinical applications Injury to the median nerve results in inability to pronate the forearm and to oppose the thumb. Flexion of the fingers and the wrist gets affected partially because of the ulnar nerve assistance. Atrophy of the thenar muscles caused by such injury gives a characteristic look to the hand (the ape’s wrist). Motor disorders are usually accompanied by the sensory disorders within the respective areas of responsibility. The ulnar nerve, nervus ulnaris Topography of the ulnar nerve The ulnar nerve arises from the medial cord of the brachial plexus. In the beginning of its route, the nerve runs along the medial bicipital groove within the common neurovascular bundle. In the inferior half of the arm, the nerve detaches from the bundle and proceeds to the ulnar groove situated on the posterior surface of the medial epicondyle, epicondylus medialis of the humerus. There the nerve runs covered by fascia and skin only. Within the forearm region, the nerve runs along the ulnar groove of forearm together with the ulnar artery. On reaching the lower third of the forearm, the nerve splits into the dorsal branch, ramus dorsalis and the palmar branch, ramus palmaris. The branches and responsibility areas of the ulnar nerve Like the median nerve, the ulnar nerve supplies but nothing in the arm area. The first branches given are the branches to the joint capsule of the elbow joint. Within the forearm and the hand, the nerve gives branches as follows: ■ the muscular branches, rami musculares to the flexor carpi ulnaris and the ulnar half of the flexor digitorum profundus; ■ the dorsal branch, ramus dorsalis that arises from the principal trunk within the inferior third of the forearm. The branch runs below the tendon of the flexor carpi ulnaris to reach the dorsal surface of the hand where it splits into the dorsal digital nerves (they arise as three branches that further split into five terminal branches); ■ the dorsal digital nerves, nervi digitales dorsales supply the skin of the medial aspect of the hand and the skin of the dorsal surface of the 4th and the 5th fingers including the ulnar half of the 3rd finger; ■ the palmar branch, ramus palmaris arises at the same level as the dorsal yet it runs on along the ulnar groove with the neighboring ulnar blood vessels. On reaching the pisiform bone, the nerve gives off the superficial and the deep branches; ■ the superficial branch, ramus superficialis supplies the skin of hypothenar and the medial aspect of hand together with underlying palmaris brevis. The branch gives off three proper palmar digital nerves, nervi digitales palmares proprii to the skin of the palmar surface of the 5th finger and of the ulnar aspect of the 4th finger; ■ the deep branch, ramus profundus reaches the deeper palmar layers where it runs along the deep palmar arch. It supplies all hypothenar muscles, all interossei muscles, the third and the fourth lumbricals and two thenar muscles — the adductor pollicis and the deep head of the flexor pollicis brevis. Clinical applications. Injury to the ulnar nerve results in impaired flexion in the joint of wrist and in inability to abduct the fingers (including the thumb). Because of prevailing extensors and paralyzed interossei, the hand acquires a look of the bird’s foot. Sensory disorders within the respective areas are also observed. The radial nerve, nervus radialis Topography and branches of the radial nerve The radial nerve is rather a large nerve that arises from the posterior cord of brachial plexus. In the arm region, the nerve passes within the radial canal, canalis nervi radialis seu canalis humeromuscularis along with the deep artery of arm. Both artery and nerve run spirally down along the radial groove. Here the nerve is covered with the triceps brachii. The nerve quits the canal via its inferior opening (in between the brachialis and the brachioradialis) that leads to the cubital fossa. Here, at the head of radius, the nerve splits into the superficial and the deep branches: ■ the deep branch, ramus profundus runs below the supinator to the posterior surface of forearm where it gives off numerous muscular branches. The longest nerve of this group is the posterior interosseous nerve, nervus interosseus antebrachii posterior that runs along the interosseous membrane to reach the joint of wrist; ■ the superficial branch, ramus superficial runs within the radial groove along with the radial artery. In the lower portion of the forearm, the branch passes in between tbe radius and the brachioradialis to reach the dorsal surface of the hand. There, the branch gives off the dorsal digital branches, nervi digi tales dorsales. Responsibility areas of the radial nerve The radial nerve is responsible for the posterior surface of the upper limb. In the arm region, it supplies the triceps brachii and the anconeus. Here it also gives rise to the posterior cutaneous nerve of arm, nervus cutaneus brachii posterior that supplies the skin of the arm and to the posterior cutaneous neme of forearm, nervus cutaneus antebrachii posterior. The forearm, the deep branch supplies all extensors, the supinator and the brachioradialis. Within the hand, the nerve supplies the skin only. Its superficial branch is responsible for the dorsal surface of hand where it supplies skin of its lateral aspect and skin of the dorsal surface of the 1st and the 2nd fingers and the radial aspect of the 3rd finger. In the 2nd and the 3rd fingers, the nerve supplies the areas related to the proximal phalanges; the rest is under responsibility of the median nerve. Clinical applications Fractures of humerus may result in damage of the canal-related part of radial nerve. High-point injury to the radial nerve results in paralysis of the extensors with typical wrist stack because of inability of the extensors to counteract the flexors. Skin sensitivity within the respective area gets impaired as well. Materials for self-check: A. Tasks for self-check: specify division of the brachial plexus on the groups, regions of their inervation using preparations, models, tables. B. Situational tasks. 1. After a fracture of the upper third of the humerus the paralysis of the posterior group of muscles of the shoulder and forearm developed. Which nerve was damaged? A. Ulnar. *B. Radial. C. Median. D.Musculocutaneous. E. Axillary. 2. Examination of a patient with a knife right hand wound has shown skin sensitivity loss of the lateral part of the hand dorsal surface and proximal phalanxes of the I, II and partially III fingers. Which nerve has been damaged? A. Ulnar. B. Median. *C. Radial. D.Musculocutaneous. E. Lateral cutaneous nerve of forearm. 3. Having hurt the elbow against a table a patient felt burning and pricking on the internal surface of the forearm. Which nerve was traumatized in this case? *A. Ulnar. B. Radial. C. Median. D. Axillary. E. Musculocutaneous. 4. A patient after a trauma has decreased painful and temperature sensitivity in the site of 1.5 fingers on the palmar surface and 2.5 fingers on the dorsal surface from the side of the little finger. Which nerve was injured as a result of the trauma? *A. Ulnar. B. Radial. C. Median. D. Musculocutaneous. E. Medial cutaneous nerve of forearm 5. After an inflammatory process a patient complains of feeling weakness when bending a hand in the site of the I, II, III, and IV fingers, volume reduction of thenar muscles. Examination has shown disorders of pain and temperature sensitivity on palmary surface of the I, II, III fingers and ra¬dial surface of the IV finger. Which nerve has been injured? A. Musculocutaneous. B. Radial. C. Ulnar. *D. Median. E. Medial cutaneous nerve of fore arm. 6. A patient appealed to a doctor with complaints of impossibility to abduce the right hand after a trauma. Examination has shown that passive movements are not limited. Deltoid muscle atrophy has been detected. Which nerve has been injured? A. Suprascapular. B. Radial. C. Ulnar. D. Median. *E. Axillary. 7. After a trauma in the site of a shoulder a patient can not extend a hand. Examination has also shown a decrease of pain and temperature sensitivity in the site of 2.5 fingers of the hand's dorsal surface from the side of the thumb. Which nerve has been injured as a result of the trauma? *A. Radial. B. Median. C. Ulnar. D. Axillary. E. Musculocutaneous. 8. Examining a patient a neuropathologist detected increased pain skin sensitivity on the palmary surface of the I, II, III and the radial surface of the IV fingers, middle part of the palm and thenar. Which nerve was injured? *A. Median B. Medial cutaneous nerve of forearm C. Ulnar. D. Radial. E. Musculocutaneous. 9. To a traumatology center there was taken a teenager who pinched his arm in a door above the elbow joint during a game. Examination has shown the loss of skin sensitivity on the anteromedial shoulder surface. Indicate with what nerve damage the loss of skin sensitivity of the mentioned site is connected? A. Axillary. B. Radial. *C. Musculocutaneous. D. Ulnar. E. Median. 10. A patient lost skin sensitivity of the little finger. Which nerve is damaged? A. Median. *B. Ulnar. C. Radial. D. Musculocutaneous E. Medial cutaneous nerve of forearm References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/ Topic 24. The intercostal nerves. The lumbar plexus. 1. Relevance of the topic. Lumbar plexus inervates the muscles of the abdominal walls and girdle of lower extremity. Disfunction of this plexus can lead to very serious disorder of the work of locomotor system. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Histology Structure of nerve fibers. Neurology Topography of the nervous branches. Physics Describe the mechanism of nerve impulse. Anatomy Structure of the spinal cord, internal and external structures. 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi spinаles Spinal nerves Plexus lumbalis Lumbar plexus Nervi thoracici Thoracic nerves 4.2. Theoretical questions for the class: 1. Describe formation, branches, topography and responsibility areas of the thoracic nerves. 2. Describe formation, branches, topography and responsibility areas of the intercostal nerves. 3. Describe structural features of the nervous plexuses. 4. Describe the lumbar plexus. 5. Describe the femoral nerve. 6. Describe the obturator nerve. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the lumbar plexus on the groups, regions of their inervation using preparations, models, tables. Content of the topic. The anterior branches of the thoracic nerves retain segmental arrangement as opposed to the anterior cervical branches that form plexuses. These branches are related to the intercostal spaces and thus are referred to as the intercostal nerves. The greater portion of the first thoracic nerve joins the brachial plexus and the smaller portion constitutes rather a thin first intercostal nerve. The anterior ramus of the twelfth thoracic nerve is the subcostal nerve, nervus subcostalis found below the twelfth rib; the nerve gives some fibers to the lumbar plexus. The intercostal nerves, nervi intercostales Topography of the intercostal nerves The intercostal nerves occupy the costal grooves of the bodies of ribs. From the origination point and up to the costal angle each nerve is covered with parietal pleura; the portion related to the body of rib passes in between the external and the internal intercostal muscles. The nerves 1 through 6 reach the sternum; the rest quit the intercostal spaces and reach the anterior abdominal wall. There they run in between the internal oblique and the transversus abdominis to enter the rectus sheath and meet the nerves from the opposite side at the anterior median line. Responsibility areas of the thoracic nerves The intercostal nerves are the mixed nerves i.e. they comprise the sensory and the motor branches: ■ the motor branches supply the muscles of chest proper (both external and internal intercostal muscles, musculi intercostales extemi et intemi, the transversus thoracis and the subcostales) and the abdominal muscles (both external and internal oblique, musculi obliquus extemus et intemus, the transversus abdominis, musculus transversus abdominis, the rectus abdominis, musculus rectus abdominis, the pyramidalis, musculus pyramidalis and the quadratus lumborum, musculus quadratus lumborum); ■ the sensory branches supply the skin of the thorax and the abdomen. Each intercostal nerve gives rise to the anterior and the lateral cutaneous branches (pectoral and abdominal), rami cutanei anterior et posterior (pectoralis et abdominales). The anterior branches supply the medial portion of the respective region and the lateral branches — the lateral portions of the same regions. The anterior branches arise along the margins of sternum and the rectus abdominis and the lateral branches arise along the midaxillary line. THE LUMBAR PLEXUS, PLEXUS LUMBALIS (Thl2 — L4) Topography of the lumbar plexus The lumbar plexus arises from the anterior branches of three upper lumbar nerves and partially from the twelfth thoracic nerve and fourth lumbar nerve. It resides within the lumbar region in between the transverse processes of related lumbar vertebrae posterior and in depth of the psoas major. Inferiorly, the lumbar plexus communicates with the sacral plexus. Most of the rami arise from behind the lateral border of the psoas major; one ramus traverses the muscle (the genitofemoral nerve) and one branch arises from behind the medial border of the muscle (the obturator nerve). The branches of the lumbar plexus The greatest branches of the lumbar plexus are the femoral nerve and the obturator nerve. The plexus also gives rise to several smaller branches that terminate within the skin and the muscles of the abdomen, the lower limb and the external genitals: ■ the muscular branches, rami musculares supply both psoas muscles, the quadratus lumborum and the lumbar intertransversarii; ■ the iliohypogastric nerve, nervus iliohypogastricus arises from behind of the lateral border of the psoas major and runs in between the transversus abdominis and the external oblique. The nerve supplies all abdominal muscles, the skin of hypogastrium and the skin of the gluteal region (its superolateral portion); ■ the ilioinguinal nerve, nervus ilioinguinalis in the beginning of its way runs parallel and below the previous nerve but enters the inguinal canal. Within the canal, the nerve resides anterior to the spermatic cord (the round ligament of uterus); it terminates within the skin of the pubic region and the scrotum (the labia majora) and gives some branches to both oblique muscles and the transversus abdominis; ■ the genitofemoral nerve, nervus genitofemoralis traverses the psoas major and descend along its anterior surface; there it gives the genital branch, ramus genitalis and the femoral branch, ramus femoralis. The genital branch enters the inguinal canal where runs posterior to the spermatic cord (the round ligament of uterus). It supplies the cremaster, the dartos muscle, the skin of scrotum (the labia majora) and the skin of superomedial surface of thigh. The femoral branch passes through the vascular space below the inguinal ligament to a small upper portion of the femoral triangle; ■ the lateral cutaneous nerve of thigh, nervus cutaneus femoris lateralis arises from behind of the lateral border of the psoas major and runs slantwise down to the anterior su-perior iliac spine. On bypassing the spin, the nerve proceeds to the lateral surface of thigh. The obturator nerve, nervus obturatorius is quite a large branch of the lumbar plexus. It arises from behind of the medial border of the psoas major and runs along the lesser pelvis wall to enter the obturator canal that leads the nerve to the thigh. Within the thigh, the nerve resides in between the adductors and splits into the anterior and the posterior branches. The nerve supplies the neighboring adductors, the pectineus, the gracilis, the obturator extemus and the joint capsule of the hip joint. Apart from the obturator nerve, the accessory obturator nerve, nervus obturatorius accesorius is also distinguishable. The femoral nerve, nervus femoralis is the greatest branch of the lumbar plexus. Topography of the femoral nerve The nerve arises from behind the lateral border of the psoas major and proceeds to the thigh region via the muscular space. Within the thigh region, the nerve resides in the femoral triangle laterally from the femoral artery. The branches of the femoral nerve In the femoral triangle, the femoral nerve fans out to give numerous branches: ■ the muscular branches, rami musculares supply the quadriceps femoris and the pectineus; ■ the anterior cutaneous branches, rami cutanei anteriores penetrate the fascia and terminate in the skin of anteromedial area of thigh; ■ the saphenous nerve, nervus saphenus is the longest branch of the femoral nerve. It enters the adductor canal together with the femoral artery and the femoral vein. Upon escaping from the canal via its anterior opening (the adductor hiatus) the nerve runs along the medial aspect of shin and foot together with the great saphenous vein and reaches the great toe. In the thigh are, the nerve gives no branches; the first branch to arise is the infrapatellar branch, ramus infrapatellaris. It supplies the skin of the medial surface of knee joint and of the patellar area. Apart from this, the nerve supplies the skin of the medial aspect of shin and foot up to the great toe. Clinical applications. Injury to the femoral nerve leads to paralysis of the quadriceps femo- ris and thus to inability to extend the knee joint. When walking, the victim is unable to withhold extension of leg and the foot strikes against the ground with its entire surface. Injury to the obturator nerve affects abduction of thigh and crossing of legs. Materials for self-check: A. Tasks for self-check: specify division of the lumbar plexus on the groups, regions of their inervation using preparations, models, tables. B. Situational tasks. 1. A patient was admitted to a traumatology center with the greater psoas muscle damage. The patient lost possibility to straighten his leg in the knee joint. Which nerve is damaged? *A. Femoral. B. Iliohypogastric. C. Ilioinguinal. D. Genitofemoral. E. Obturator. 2. Examining a patient a neuropathologist detected the following symptom complex: cremasteric reflex extinction (reduction of m. cremaster), disorder of skin sensitivity on the anterior and internal surface of the superior third of the thigh and scrotum. Which nerve was injured? A. Ilioinguinal. *B. Genitofemoral. C. Sciatic. D. Femoral. E. Obturator. 3. A patient has characteristic gait changes, so-called waddling gait, observed: during walking the patient sways. Besides, hip reduction is impossible. Which nerve has been injured? A. Femoral. B. Sciatic. *C. Obturator. D. Tibial. E. Superior gluteal. 4. A patient can not extend a knee joint, knee reflex is not observed, skin sensitivity of the anterior surface of the thigh is damaged. Which nerve is damaged? A. Obturator. B. Superior gluteal. C. Common peroneal. *D. Femoral. E. Inferior gluteal nerve. 5. Which of the following statements on the intercostal neurovascular bundle in the right 5th intercostal space is CORRECT? A. The intercostal nerve, which innervates the intercostal muscles in the space, is a posterior ramus (or primary division) of a thoracic spinal nerve. B. The venous drainage of the space is anteriorly to the internal thoracic veins and posteriorly to the hemiazygous vein. C. The two anterior intercostal arteries that supply the space are branches of the musculophrenic artery. D. The space is supplied by two posterior intercostal arteries,which are branches of the aorta. *E. At a level just anterior to the angle of the ribs, the neurovascular bundle is located between the innermost and internal intercostal muscles 6. A victim can not extend a knee joint, knee reflex is not observed, skin sensitivity of the anterior surface of the thigh is damaged. Which nerve is damaged? A. Obturator. B. Superior gluteal. C. Common peroneal. *D. Femoral. E. Inferior gluteal nerve. 7. Which of the following innervates the tensor fascia lata muscle? *A. Superior gluteal N. B. Inferior gluteal N C. Femoral N. D. Obturator N E. Ilio-inguinal N 8. Skeletotopy of the lumbar plexus. *A. Th12-L4 B. C8-L2 C. S2-S4 D. L3-L4 E. C1-S4 9. Indicate muscles, innervated by the iliohypogastric nerve. *A. Abdominal muscles B. Psoas C. Quadratus lumborum D. Pectineus, gracilis, obturator externus E. Quadriceps femoris 10. Indicate muscles, innervated by the obturator nerve. A. Abdominal muscles B. Psoas C. Quadratus lumborum *D. Pectineus, gracilis, obturator externus E. Quadriceps femoris References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 25. The sacro-coccygeal plexus 1. Relevance of the topic. Sacral plexus innervates the greater part of lower extremity. Disfunction of this plexus can lead to very serious disorder of the work of locomotor system. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Histology Structure of nerve fibers. Neurology Topography of the nervous branches. Physics Describe the mechanism of nerve impulse. Anatomy Structure of the spinal cord, internal and external structures. 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi spinаles Spinal nerves Plexus sacrales Sacral plexus Nervus ischiadicus Sciatic nerve 4.2. Theoretical questions for the class: 1. Formation of the sacral plexus. 2. Topography of the sacral plexus. 3.Short branches of the sacral plexus. 4. Zone innervation of short branches of the sacral plexus. 5. Long branches of the sacral plexus. 6. Zone innervation of long branches of the sacral plexus. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the sacral plexus on the groups, regions of their inervation using preparations, models, tables. Content of the topic. THE SACRAL PLEXUS, PLEXUS SACRALIS (L4 — L5\S1 — S4) Topography of the sacral plexus The sacral plexus is the greatest of all nervous plexuses in the human body. It arises from merged upper four sacral nerves, the fifth lumbar nerve and a part of the fourth lumbar nerve, the fourth and the fifth lumbar nerves merge into a single lumbosacral trunk, truncus lumbosacralis that descends to the lesser pelvis cavity and joins the sacral nerves. The lowest portion of the sacral plexus formed of the fifth sacral nerves (S5) and the coccygeal nerve (Col) is the coccygeal plexus, plexus coccygeus. The sacral plexus appears as a thick triangular plate adherent to the pelvic wall (namely to the piriformis). The branches given quit the lesser pelvis via the suprapiriform and the infrapiriform foramina as the short and the long branches. The greatest nerve of the plexus is the sciatic nerve. The short branches These branches stay within the pelvic girdle region to supply the pertaining muscles and skin: ■ the muscular branches, rami musculares supply the piriformis, the obturator internus, both gemelli and the quadratus femoris; ■ the superior gluteal nerve, nervus gluteus superior runs via the suprapiriform foramen to the gluteus medius, the gluteus minimus and the tensor fasciae latae; ■ the inferior gluteal nerve, nervus gluteus inferior runs via the infrapiriform foramen to the gluteus maximus and the joint capsule of the hip joint; . the pudendal nerve, nervus pudendus quits the lesser pelvis via the infrapiriform foramen, loops around the ischial spine and enters the ischio-anal fossa via the lesser sciatic foramen. The nerve supplies the external anal sphincter and other perineal muscles together with related skin. The terminal branch of the nerve called the dorsal nerve of penis (clitoris), nervus dorsalis penis (clitoridis) runs to the dorsal surface of the penis (clitoris). The nerve supplies the corpora cavernosa of the penis (clitoris), the external urethral sphincter, skin of penis (in males) or skin of both labia majora and minora (in females). The long branches The long branches are the posterior cutaneous nerve of thigh and the sciatic nerve. The posterior cutaneous nerve of thigh, nervus cutaneus femoris posterior runs via the infrapiriform foramen to skin of the posterior surface of thigh. The nerve also gives the inferior cluneal nerves, nervi clunium inferiors to skin of gluteal region. The sciatic nerve, nervus ischiadicus Topography of the sciatic nerve The sciatic nerve is the greatest nerve of the human body. It comprises nearly all branches that participate in formation of the sacral plexus. The nerve quits the lesser pelvis cavity via the infrapiriform foramen and runs on below the gluteus maximus. Somewhat below the escape point, the nerve enters in between the ischial tuberosity and the greater trochanter, proceeds onto the quadratus lumborum surface and finally becomes evident within the thigh region, arising from under the lower border of the gluteus maximus. Within the thigh region, the nerve runs deep in between the neighboring muscles. On reaching the upper angle of the popliteal fossa, the nerve splits into the terminal branches — the tibial nerve and the common fibular nerve. High point branching of the sciatic nerve is of common occurrence. In this case, the terminal branches of the nerve arise within the thigh and run together to responsibility areas. The principal trunk of the nerve gives off the muscular branches to the posterior group of muscles of thigh (to the semitendinosus, the semimembranosus and the long head of biceps femoris). Clinical applications Chilling of the area related to the nerve results in neuritis of the sciatic nerve (sciatica). The state features painful sensation within the ischial area and the posterior portion of the thigh. The condition may even feature sensory and motor disorders. The tibial nerve, nervus tibialis Topography of the tibial nerve The tibial nerve arises directly from the sciatic nerve and runs vertically down to the popliteal fossa. Within the fossa, the nerve occupies the most superficial position with respect to neighboring popliteal artery and popliteal vein. From the popliteal fossa, the nerve proceeds to the cruropopliteal canal. On escaping from the canal, the nerve loops around the medial malleolus and gives some branches to the ankle joint. Below the flexor retinaculum, the nerve gives off its terminal branches — the medial and the lateral plantar nerves. The branches of the tibial nerve The tibial nerve gives the branches as follows: ■ the muscular branches, rami musculares supply all posterior muscles of shin (the igastrocnemius, the soleus, the plantaris, the popliteus etc.); ■ the medial sural cutaneous nerve, nervus cutaneus surae medialis arises from the tibial nerve yet within the popliteal fossa. It runs laterally and merges with the lateral sural cutaneous nerve (from the common fibular nerve) to form the sural nerve; ■ the sural nerve, nervus suralis descends midline along the posterior surface of shin together with the small saphenous vein. Upon reaching the ankle joint, the sural nerve loops around the lateral malleolus, gives the lateral calcaneal branches, rami calcanei laterales and becomes continuous with the lateral dorsal cutaneous nerve, nervus cutaneus dorsalis lateralis. The nerve supplies skin of the posterolateral surface of shin and the lateral aspect of foot up to the little toe; The medial plantar nerve, nervus plantaris medialis runs along the groove of the same name. Within the distal portion of foot, the nerve splits into the common plantar digital nerves, nervi digitales plantar- es communes that in turn branch into the proper plantar digital nerves, nervi digitales plantares proprii. They supply the medial aspect of foot, the toes 1 through 3 and a medial half of the fourth toe. The muscular branches of the nerve supply the flexor digitorum brevis, all muscles of great toe (except for the adductor hallucis and the lateral head of flexor hallucis brevis) and two lumbricals (1 and 2). The lateral plantar nerve, nervus plantaris lateralis also occupies the groove of the same name; it splits into the superficial branch, ramus superficialis and the deep branch, ramus profundus. The superficial branch gives off the common plantar digital newes, nervi digitales plantares communes, which become continuous with the proper plantar digital nerves, nervi digitales plantares proprii. They supply the lateral aspect of foot, the fifth toe and a lateral half of the fourth toe. The deep branch supplies all interossei, two lumbricals, the adductor hal-lucis, and the lateral head of flexor hallucis brevis. Clinical applications Injury to the tibial nerve results in paralysis of pertaining flexors. The foot thus becomes permanently extended and the toes may resemble the claws. The common fibular nerve, nervus fibularis communis Topography of the nerve From the arise point, the nerve runs laterally to reach the head of fibula. At that point, the nerve enters between the heads of the fibularis longus and slits into the superficial and the deep fibular nerves. Yet within the popliteal fossa, the nerve gives the lateral sural cutaneous nerve, nervus cutaneus surae lateralis that merges with the medial sural cutaneous nerve to form the sural nerve. Very often, the nerves merge at the lower third of shin or even run separately. The superficial fibular nerve, nervus fibularis superficial runs within the superior musculoperoneal canal (in between the fibilaris longus and the fibula). The nerve quits the canal in the lower half of shin and runs on superficially down to the dorsal surface of foot. There the nerve terminates with the medial dorsal cutaneous nerve, nervus cutaneus dorsalis medialis and the lateral dorsal cutaneous nerve, nervus cutaneus dorsalis lateralis. Both nerves supply the respective areas of the dorsal surface of foot. It also leaves some muscular branches, rami musculares to the fibulares muscles while running within the musculoperoneal canal. The deep fibular nerve, nervus fibularis profundus passes along the interosseous membrane of shin below the anterior group of pertaining muscles. Just like the superficial nerve, it reaches the dorsal surface of foot yet it is responsible for a small area between the first and the second toes. Within the shin, the nerve supplies the anterior group of muscles (the tibialis anterior, the extensor digitorum longus, the extensor hallucis longus) and the joint capsule of ankle joint. Clinical applications. Injury to the fibular nerve leads to inability to extend and to pronate the foot. The foot in this case hangs down and laterally. Materials for self-check: A. Tasks for self-check: specify division of the sacral plexus on the groups, regions of their inervation using preparations, models, tables. B. Situational tasks. 1. A 30-year-old patient appealed to a neuropathologist complaining of skin sensitivity loss of the middle and inferior third of the posterior region of the leg on the right. Which nerve id damaged? *A. Sural. B. Posterior cutaneous nerve of thigh. C. Genitofemoral. D. Branches of obturator nerve. E. Tibial. 2 Examination of a patient with a cut wound in the inferior third of the right leg anterior area has shown the absence of extension movements in the right ankle joint. Muscles are not injured. Which nerve has been affected? A. Saphenous. B. Common peroneal. C. Superficial fibular. *D. Deep fibular. E. Femoral. 3. Examining a patient the doctor detected the following symptom complex: the paralysis of the digital flexors, the foot thus became permanently extended, the toes resembled the claws. Which nerve was injured? A. Saphenous. B. Common peroneal. C. Superficial fibular. *D. Tibial. E. Femoral. 4. Examining a patient the doctor detected the following symptom complex: the inability to extend and pronate the foot, the foot hangs down and laterally. Which nerve was injured? *A. Fibular. B. Posterior cutaneous nerve of thigh. C. Genitofemoral. D. Branches of obturator nerve. E. Tibial. 5. The nerve supply to the extensor digitorum brevis is the: *A. Deep peroneal N. B. Superficial peroneal N C. Sural N D. Tibial N E. Saphenous N 6. All of the following are branches of the pudendal nerve, EXCEPT: *A. Inferior gluteal N B. Perineal N. C. Inferior rectal N. D. Dorsal nerve of the penis E. Dorsal nerve of the clitoris 7. The nerve supply to the extensor digitorum brevis is the: *A. Deep peroneal N. B. Superficial peroneal N C. Sural N D. Tibial N E. Saphenous N 8. The nerve supply to the extensor digitorum longus is the: *A. Deep fibular N. B. Superficial peroneal N C. Sural N D. Tibial N E. Saphenous N 9. The nerve supply to the tibialis anterior is the: *A. Deep fibular N. B. Superficial peroneal N C. Sural N D. Tibial N E. Saphenous N 10. The nerve supply to the extensor hallucis longus is the: *A. Deep fibular N. B. Superficial peroneal N C. Sural N D. Tibial N E. Saphenous N References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 26. Cranial nerves. The origination, the general features, the featured nuclei, the point of arise, the escape point, the related branches and the responsibility areas of the oculomotor, trochlear and abducent nerves. 1. Relevance of the topic. The peripheral nervous system comprises the spinal and the cranial nerves, the ganglia, the autonomic nervous plexuses and the nerve terminations. Information about oculomotor, trochlear and abducent nerves is helpful for studying the ophthalmology in future. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of cranial nerves. Classification of the neuron. Histology Structure of nerve fibers. Neurology Topography of the cranial nerves. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. Projection of the nuclei of the cranial nerve 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi craniаles Cranial nerves N. oculomotorius Oculomotor nerve N. trochlearis Trochlear nerve N. abducenns Abducens nerve 4.2. Theoretical questions for the class: 1. Name III, IV, VI pairs of cranial nerves. 2. Why III, IV and VI pair of cranial nerves are studied in one class together? 3. Discuss classification of the cranial nerves by fibers content. 4. Discuss classification of the cranial nerves by origin. 5. Describe the III cranial nerves including their origination, the general features, the featured nuclei, the point of arise, the escape point, the related branches and the responsibility areas. 6. Describe the IV cranial nerves including their origination, the general features, the featured nuclei, the point of arise, the escape point, the related branches and the responsibility areas. 7. Describe the VI cranial nerves including their origination, the general features, the featured nuclei, the point of arise, the escape point, the related branches and responsibility areas. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the cranial nerves on the groups, regions of their inervation using preparations, models, tables. Content of the topic. THE CRANIAL NERVES, NERVI CRANIALES There are twelve pairs of cranial nerves that arise directly from the brain: I. The olfactory nerve, nervus olfactorius; II. The optic nerve, nervus opticus; III. The oculomotor nerve, nervus oculomotorius; IV. The trochlear nerve, nervus trochlearis; V. The trigeminal nerve, nervus trigeminus; VI. The abducent nerve, nervus abducens; VII. The facial nerve, nervus facialis; VIII. The vestibulocochlear nerve, nervus vestibulocochlearis; IX. The glossopharyngeal nerve, nervus glossopharyngeus; X. The vagus nerve, nervus vagus; XI. The accessory nerve, nervus accessories; XII. The hypoglossal nerve, nervus hypoglossus. The cranial nerves develop in tight association with several organs: The pairs I, II and VIII develop in association with the sensory organs; the pairs I and II are plain projections of the brain and have no specific relay nuclei; The pairs III, IV and VI supply the extrinsic muscles of eye and develop in association with the cranial myotomes; The pair V is associated with the 1st (mandibular) visceral arch; The pair VII is associated with the 2nd (hyoid) visceral arch; The pairs IX, X and XI constitute the vagus group and develop in association with the branchial arches; The pair XII develops from fused spinal motor roots. The oculomotor nerve, nervus oculomotorius The oculomotor nerve is a mixed nerve, which features the motor and the parasympathetic fibers. The nuclei The nucleus of oculomotor nerve, nucleus motorius nervi oculomotorii resides within the midbrain below the cerebral aqueduct, on the level of the superior colliculi. The accessory nucleus of oculomotor nerve, nucleus accessorius nervi oculomotorii (of Yakubovich), which is the parasympathetic nucleus resides medially from the motor nucleus. Topography The oculomotor nerve becomes evident in the area of the interpeduncular fossa. It arises from the medial surface of the cerebral peduncle. The nerve further traverses the external wall of the cavernous sinus and enters the orbit via the superior orbital fissure. Within the orbit, the nerve gives off two branches: the superior branch, ramus superior and the inferior branch, ramus inferior. The superior branch supplies the superior rectus and the levator palpebrae superioris while the inferior branch supplies the inferior rectus, the medial rectus and the inferior oblique (they all are the extrinsic muscles of eyeball). The parasympathetic fibers The oculomotor nerve comprises the preganglionic fibers from the accessory nucleus of oculomotor nerve. Upon entering the orbit, these fibers part the motor fibers and reach the ciliary ganglion, ganglion ciliare situated laterally from the optic nerve. The ganglion fives off the postganglionic fibers that join the short ciliary nerves, nervi ciliares breves and supply the ciliary muscle and the sphincter pupil lae. Clinical applications Injury to the oculomotor nerve results in squint, ptosis (depression of the superior eyelid), dilation of the pupil and accommodation impairment. The trochlear nerve, nervus trochlearis. The trochlear nerve is the purely motor nerve. The nucleus of trochlear nerve, nucleus nervi trochlearis resides within the tegmentum of cerebral peduncles below the cerebral aqueduct, on the level of inferior colliculi. This thin nerve arises from the dorsal surface of brainstem namely laterally from the frenulum of superior medullary velum. On the way to destination point, the nerve loops around the cerebral peduncle, traverses the lateral wall of the cavernous sinus and enters the orbit via the superior orbital fissure. It supplies solely the superior oblique, musculus obliquus superior. The abducent nerve, nervus abducens The abducent nerve is purely motor nerve that supplies one extrinsic muscle of eyeball. The nucleus of abducens nerve, nucleus nervi abducentis resides within the tegmentum of pons on the level of facial colliculus (dorsally from the genu of facial nerve). The nerve arises from the medullopontine sulcus between the pons and the olives and traverses the cavernous sinus running laterally from the internal carotid artery. The nerve enters the orbit via the inferior orbital fissure and terminates within the lateral rectus. Materials for self-check: A. Tasks for self-check: specify division of the cranial nerves on the groups, regions of their inervation using preparations, models, tables. B. Situational tasks. Postpartum obstetrician found in newborn bilateral squint, which converges. Damage which the nuclei of cranial nerves heppened in newborn after birth trauma? A n. abducens B n. trochlearis C n. oculomotorius D n. trigeminus E n. facialis 2. After a cranial trauma with the damage of the superior wall of the right orbital cavity a patient lost the possibility to lift up the upper eyelid of the right eye (ptosis – depression of the superior eyelid) and look upward. Which nerve was damaged? A n. abducens dexter B r. superior n. oculomotorius C n. inferior n. oculomotorius D n.abducens sinister E n.trochlearis 3. In survey of the patient found the ptosis upper eyelids and dispersing strabismus, enhanced pupil, the limited mobility of the eyeball. What nerve is damaged? A n. trochlearis B n.facialis C n.oculumotorius D n. abducens E n. ophthalmicus 4. After a brain hemorrhage, the patient became stable squint right eye, lost its ability to turn lateral. The core of a cranial nerve damage during hemorrhage? A n. abducens sinister B n. facialis dexter C n.oculomotorius D n.abducens dexter E n.trochlearis 5. A man after brain injury there was right-sided strabismus, which converges. Damage to a cerebral nerve led to such consequences? A n. oculomotorius B n. trochlearis C n. opticus D n. abducens sinister E n. abducens dexter 6. In the patient with rupture of a. carotis interna in the cavernous sinus is observed pulsating exophthalmos (sync pulse), blowing noise is listened (in the eyeball), expansion orbit fissure. Which pair of cranial nerves that pass in sinus cavernosus with damaged vessel, hematoma compressed? A III, IV, VI, I branch of the V. B II, IV, I branch of the V. C IV, VI, a branch of the V. D VI. E VII. 7. A patient with epidemic encephalitis has uni- or bilateral ptosis (blepharoptosis), divergent strabismus (squint), accomodation disorder, dilation pupil (mydriatic pupils). The nuclei of what pair of cranial nerves have been affected? A IV B III C I branch of the V. D VI. E VII. 8. In patients with epidemic encephalitis observed one-or two-sided ptosis (drooping eyelids), strabismus divergent, disturbance of accommodation. The pupils were dilated. Nuclei which pairs of cranial nerves affected? A V B IV. C III. D VI. E VII. 9. The patient turned to the eye doctor with complaints of ptosis. The examination was diagnosed with brain tumors. The core of a pair of cranial nerves affected pathological process? A VII B II C IV D III E VI 10. A patient has appealed with complaints of visual impairment accompanied by blepharoptosis, impossibility to lift the eyeball upwards and to the middle. Examination has shown that the eyeball is diverted outside, the pupil is dilated, does not react to light, the patient can′t see at a short distance. Which nerve has been injured? A n. abducens dexter B n. trochlearis C n. opticus D n. abducens sinister E n. oculomotorius References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 27. The origination, the general features, the featured nuclei, the point of arise, the escape point, the related branches and the responsibility areas of the trigeminal nerve. Nervous pathway of the trigeminal nerve. 1. Relevance of the topic. Knowledge about the formation and structure of the cranial nerves exit site of their brain and skull, innervation zone necessary for students to learn clinical disciplines, and the likelihood of destruction of cranial nerves statistically high. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of cranial nerves. Classification of the neuron. Histology Structure of nerve fibers. Neurology Topography of the cranial nerves. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. Projection of the nuclei of the cranial nerve 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi craniаles Cranial nerves Ganglion trigeminale Trigeminal ganglion Nervus trigeminus Trigeminal nerve Nervus ophtalmicus Ophthalmic nerve Nervus maxillaris Maxillary nerve Nervus mandibularis Mandibular nerve 4.2. Theoretical questions for the class: 1. Describe the V pair of cranial nerve including origination, the general features and intracranial part of the nerve. 2. Describe the sensory ganglion of the V cranial nerve with related topography and fibers. 3. Describe the first branch of the V cranial nerve including formation, escape point, the related branches and responsibility areas. 4. Describe the second branch of the V cranial nerve including formation, escape point, the related branches and responsibility areas. 5. Describe the third branch of the V cranial nerve including formation, escape point, the related branches and responsibility areas. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the trigeminal nerve on the branches, regions of their inervation using preparations, models, tables. Content of the topic. The Vth pair of cranial nerves - trigeminal nerve (nervus trigeminus). This nerve is mixed. Sensory fibers supply skin of the face and frontal part of the head. Also nerve receives sensitivity from receptors of mucous membrane of the mouth, nose, ear, eye. Muscular fibers supply chewing muscles and muscles of the floor of oral cavity. The nuclei of trigeminal nerve The trigeminal nerve features one motor and three sensory nuclei. The motor nucleus of trigeminal newe, nucleus motorius nervi trigemini resides within the tegmentum of pons. Its fibers supply the masticatory muscles and some other. The sensory nuclei are like the following: 1) the principal sensory nucleus of trigeminal nerve, nucleus principalis nervi trigemini situated within the pons. It accepts the fibers that transmit tactile and proprioceptive sensitivity impulses; 2) the spinal nucleus of trigeminal nerve, nucleus spinalis nervi trigemini situated both within the medulla oblongata and the spinal cord. It accepts the fibers that conduct pain and temperature sensitivity; 3) the mesencephalic nucleus of trigeminal nerve, nucleus mesencephalicus nervi trigemini situated within the midbrain laterally from the cerebral aqueduct. The neurons of the nucleus are the sensory pseudounipolar cells identical to the cells of the trigeminal ganglion. Their peripheral processes terminate at muscular proprioceptors. The nucleus thus appears as the sensory ganglion embedded into the brainstem. The roots and the sensory ganglion of the trigeminal nerve The nerve becomes evident between the pons and the middle cerebellar peduncle with two roots — the sensory and the motor: ■ the sensory root, radix sensoria rather thick, it consists of the fibers that arise from the trigeminal ganglion and terminate within the sensory nuclei; ■ the motor root, radix motoria much smaller than the sensory root, it arises from the motor nucleus of the nerve and joins its third branch; ■ the trigeminal ganglion (the Gasserian ganglion), ganglion trigeminale (Gasseri) well distinguishable, it resides on the apex of the petrous part of temporal bone (on the floor of the trigeminal impression). It occupies the cavity formed of split dura mater (the trigeminal cavity). The ganglion comprises the sensory pseudounipolar cells with the central and the peripheral processes featured. The central processes for the sensory root, radix sensoria and the peripheral processes form majority of the nerve branches that reach respective areas of the skin and the mucosa to terminate with the receptor cells. The branches of the trigeminal nerve The trigeminal nerve features three branches as follows: 1) the ophthalmic nerve — the first branch; 2) the maxillary newe — the sec-ond branch; 3) the mandibular newe — the third branch. All these branches comprise the fibers of the trigeminal ganglion and thus are the sensory nerves yet the third branch accepts the entire motor root so the mandibular nerve appears as mixed branch. Before escape from the cranial cavity, each branch gives off thin meningeal branches (like the tentorial branch of the ophthalmic nerve) that supply the related dura mater. Each branch of the nerve is associated with the parasympathetic ganglion via the sensory root. Each parasympathetic ganglion features two more roots — the sympathetic root (given by the neighboring periarterial plexus) and the parasympathetic root (give by the III, VII and IX cranial nerves). All five cranial parasympathetic ganglia are associated with the trigeminal nerve: the ophthalmic nerve maintains association with the ciliary ganglion, ganglion ciliare, the maxillary nerve — with the pterygopalatine ganglion and the mandibular nerve — with the otic, the submandibular and the sublingual ganglia. The ophthalmic nerve, nervus opthalmicus The ophthalmic nerve is purely sensory branch of the trigeminal nerve. It arises from the ganglion and proceeds to the orbit via the superior orbital fissure. Before entering the orbit, the nerve splits into three more nerves — the frontal nerve, the lacrimal nerve and the nasociliary nerve: ■ the frontal nerve, nervus frontalis is the largest of the listed; it runs midline along the superior orbital wall and splits into the supraorbital nerve, nervus supraorbitalis and the supratrochlear nerve, nervus supratrochlearis. The nerves escape from the orbit via the supraorbital notch and the frontal notch respectively and terminate within the skin of forehead, the root of nose, the superior eyelid with related conjunctiva in the medial angle of eye; ■ the nasociliary nerve, nervus nasociliaris, it runs medially and branches into the following nerves: 1) the anterior and posterior ethmoidal nerves, nervi ethmoidales anterior and posterior that supply the ethmoidal cells, the sphenoidal sinus and the anterior portion of the nasal mucosa; 2) the long ciliary nerves, nervi ciliares longi that supply the eyeball tunics; 3) the infratrochlear nerve, nervus infratrochlearis that supplies the skin and related conjunctiva of the medial angle of eye together with deeper lacrimal sac; 4) the sensory root of ciliary ganglion, radix sensoria ganglia ciliaris; 5) the short ciliary nerves, nervi ciliares breves, the sensory fibers to the eyeball tunics (to the fibrous and the vascular layers). The ciliary ganglion, ganglion ciliare The nasociliary nerve is associated with a small parasympathetic ganglion situated within the orbit laterally from the optic nerve. The ganglion accepts the preganglionic parasympathetic fibers that synapse with the pertaining cells. The postganglionic fibers join the short ciliary nerves, nervi ciliares breves and proceed to the eyeball. The ciliary ganglion also passes the sensory fibers that constitute the sensory root of ciliary ganglion, radix sensoria ganglia ciliaris (unlike the autonomic fibers, the sensory fibers simply traverse the ganglion and never synapse within it). Upon traversing the ganglion, the sensory fibers also join the short ciliary nerves to provide sensory nerve supply to the fibrous and the vascular layers of the eyeball. ■ the lacrimal nerve, nervus lacrimalis, the last of the group, runs laterally to traverse the lacrimal gland and to terminate within the skin and conjunctiva of the lateral angle of the eye. Before entering the gland, the nerve anastomoses with the zygomatic nerve (of the maxillary nerve) via the communicating branch with zygomatic nerve, ramus communicans cum nervo zygomatico that carries the parasympathetic secretion fibers (from the facial nerve) to the lacrimal gland. Before entering the orbit, the ophthalmic nerve gives the tentorial nerve, ramus tentorius that supplies the tentorium cerebelli. 2. The maxillary nerve, nervus maxillaries The maxillary nerve is the second purely sensory branch of the trigeminal nerve. It also arises from the trigeminal ganglion and escapes from the cranial cavity via the foramen rotundum, which leads to the pterygopalatine fossa, fossa pterygopalatina. In the fossa, the nerve gives off its principal branches that run to the orbit and to the walls of the nasal and the oral cavities. The branches of the maxillary nerve: ■ the infra-orbital nerve, nervus infraorbitalis the largest nerve in the group. It arises immediately from the maxillary nerve and enters the orbit via the inferior orbital fissure. Within the orbit, the nerve runs along the infra-orbital groove then enters the infra-orbital canal, canalis infraorbitalis and reaches its responsibility area via the infra-orbital foramen, foramen infraorbitale. In the destination point, the nerve fans out to give numerous branches that supply the lower eyelid, the cheek, the nose and the upper lip. The branches are the inferior palpebral branches, the external nasal branches and the superior labial branches. Before reaching the superior orbital fissure the nerve gives off the posterior superior alveolar branches, rami alveolares superiores posteriors that reach the posterior teeth via the alveolar foramina of the maxillary tuberosity. Within the infraorbital canal, the nerve gives off the middle and the anterior superior alveolar branches, rami alveolares superiores ipedii et anteriores that also reach the upper teeth via the respective alveolar foramina. These branches constitute the superior alveolar nerves group. On reaching the destination point, the branches anastomose to form the superior dental plexus, plexus dentalis superior that in turn gives the superior dental branches, rami dentales superiores and the superior gingival branches, rami gingivales superiores that supply the upper teeth with related gums. ■ the zygomatic nerve, nervus zygo- maticus, a smaller nerve that also enters the orbit. The nerve splits into the branches as follows: 1) the communicating branch with zygomatic nerve carries the parasympathetic postganglionic fibers from the pterygopalatine ganglion to the lacrimal gland; 2) the zygomaticofacial branch, ramus zygomaticofacialis escapes from the orbit via the opening of the same name. The branch supplies the skin of the zygomatic and the buccal regions; 3) the zygomaticotemporal branch, ramus zygomaticotemporalis also escapes from the orbit via the foramen of the same name. The nerve supplies the skin of the anterior portion of the temporal region; ■ the ganglionic branches to pterygopalatine ganglion, rami ganglionares ad ganglion pterygopalatinum, the thin branches that traverse the pterygopalatine ganglion. The sensory branches from the ganglion take two principal routes: 1) the posterior superior medial and lateral nasal branches, rami nasals posteriores superiores mediales et laterals that supply the mucosa of the posterior portion of nasal cavity; 2) the greater palatine nerve and the lesser palatine nerves, nervus palatinus major et nervi palatini minors that pass through the respective foramina and supply the mucosa of the palate. Clinical applications. Anesthetizing of the upper anterior teeth is possible via the infra-orbital foramen while the upper posterior teeth may be anesthetized by infiltration of the maxillary tuberosity area. The middle teeth require both methods because of the dental plexus. 3. The mandibular nerve, nervus madibularis The mandibular nerve is the third mixed branch of the trigeminal nerve; it features both sensory and the motor fibers that arise from the respective nuclei. The nerve escapes from the cranial cavity via the foramen ovale and reaches the infratemporal fossa, fossa infratemporalis where splits into the principal branches (the sensory, the motor and the mixed): a) The sensory and the mixed branches: ■ the meningeal branch, ramus meningeus returns to the cranial cavity via the foramen spinosum (together with the middle meningeal artery). The nerve supplies the dura mater of the middle cranial fossa; ■ the inferior alveolar nerve, nervus alveolaris inferior, the greatest mixed branch of the nerve. It passes within the mandibular canal that terminates with the mental foramen, formen mentale. The terminal branch of the nerve — the mental newe, nervus mentalis — supplies the skin of the chin and the lower lip. Within the canal, the nerve gives off the branches similar to those of the maxillary nerve. These branches form the inferior dental plexus, plexus dentalis inferior that gives the inferior dental and the gingival branches. Before entering the mandibular canal, the mandibular nerve gives the nerve to mylohyoid, nervus mylohyoideus that supplies the posterior belly of the digastric and the entire mylohyoid. Clinical applications. Anesthetizing of the lower teeth is possible via the mental foramen. ■ the lingual nerve, nervus lingualis, rather thick, is the sensory nerve. The nerve gives off the lingual branches, rami linguales to anterior two thirds of the lingual mucosa. The nerve transmits the impulses of pain, temperature and tactile sensitivity. The nerve also supplies the oral cavity floor mucosa and the lower gums (the sublingual nerve) and gives off the ganglionic branches to submandibular and sublingual ganglia, rami ganglionares ad ganglia submandibularis et sublingualis. The ganglia neighbor the respective salivary glands. Upon traversing the gan-glia, the sensory fibers supply the respective salivary gland. Within the passage between the lateral and the medial pterygoid muscles, the lingual nerve accepts the chorda tympani that originates from the facial (intermediate) nerve. The chorda tympani carries the sensory (gustatory) fibers to the lingual papillae (anterior two thirds of the tongue) and the parasympathetic fibers to the submandibular and the sublingual salivary glands. ■ the auriculotemporal nerve, nervus auriculotemporalis is the last sensory nerve of the group. It arises with two roots that enfold the middle meningeal artery and reassemble into the single trunk that loops around the neck of mandible. The nerve penetrates the parotid gland, glandula parotidea to provide sensory nerve supply. The terminal branches supply the skin of the posterior portion of temporal region, the auricle and the tympanic membrane. The auriculotemporal nerve also accepts the postganglionic parasympathetic fibers from the otic ganglion that supply the parotid gland. The otic ganglion, ganglion oti- cum resides below the foramen ovale medially from the mandibular nerve that gives the branches to otic ganglion, rami ganglionares ad ganglion oticum. ■ the buccal newe, nervus buccalis the small sensory nerve that penetrates the buccinator and terminates within the buccal mucosa the mucosa of the angle of mouth. b) The motor branches The motor branches of the mandibular nerve supply the masticatory muscles. These branches are like the following: 1) the masseteric nerve, nervus massetericus that supplies the masseter; 2) the deep temporal nerves, nervi temporalis profundi that supply the temporal muscle; 3) the nerve to medial pterygoid, nervus pterygoideus medialis that supplies the medial pterygoid; 4) the nerve to lateral pterygoid, nervus pterygoideus lateralis that supplies the lateral pterygoid respectively. Apart from the aforesaid fibers, the mandibular nerve supplies the tensor veli palatini (the nerve to tensor veli palatini), and the tensor tympani (the nerve to tensor tympani). The inferior alveolar nerve gives the motor fibers (the nerve to mylohyoid) to the posterior belly of digastric and the mylohyoid. Responsibility areas of the trigeminal nerve Summing up the trigeminal nerve, one may define its responsibility areas: 1) the facial skin above the palpebral fissure (the forehead and the upper eyelid) is under responsibility of the first branch: the facial skin between the palpebral fissure and the oral fissure (the lower eyelid, the upper lip, the nose, the cheeks and the anterior portion of the temporal region) is under responsibility of the second branch; the facial skin below the oral fissure (the chin and the lower lip) together with the posterior portion of temporal region and the auricle is under responsibility of the third branch: 2) the trigeminal nerve provides sensory nerve supply to the nasal mucosa, the mucosa of paranasal sinuses, the oral mucosa, the anterior two thirds of the lingual mucosa and the vascular layer of the eyeball; 3) both upper and lower teeth with related gums feature specific sensory nerve supply; 4) the motor fibers supply the masticatory muscles, several muscles of the oral cavity floor and specifically the tensor veli palatini and the tensor tympani; 5) the cranial dura mater also receives the sensory nerve supply from the trigeminal nerve (except for the posterior cranial fossa); 6) the major cranial glands like the lacrimal gland, the parotid gland, the submandibular gland and the sub-lingual gland receive targeted sensory nerve supply (from the sensory roots of pertaining parasympathetic ganglia). Clinical applications. Neuralgia of trigeminal nerve belongs to one of the common disorders. It is manifested as pain attacks without prior external stimulation localized within the respective responsibility areas. Pain sensation arises in the areas of major nerve terminations — around the supraorbital notch, the infraorbital foramen and the mental foramen. One of the possible causes of the state constitutes closing of the cranial openings that pass the principal branches of the nerve. Materials for self-check: A. Tasks for self-check: specify division of the trigeminal nerve on the branches, regions of their inervation using preparations, models, tables. B. Situational tasks. 1. In the patient with diabetes recurrent inflammation of the sebaceous glands of the upper eyelid (Glandulae sebaceae (Zeis)) with damage to eye, causing the pain and itching. What nerve innervate the skin of the upper eyelid? A. N. ophtalmicus. B. N. oculomotorius. C. N abducens. D. N. trochlearis. E. N. infraorbitalis. 2. The patient was admitted to a neurological department with complaints that after acute viral respiratory disease she lost her sense of touch and temperature to in front 2/3 of tongue, she suffers from pain in this area (has burnt tongue hot tea). Indicate which of the branches of a nerve was damaged? A. The auriculotemporal nerve of the mandibular nerve of the trigeminal nerve B. The lingual nerve of the mandibular nerve of the trigeminal nerve C. The infraorbital nerve of the maxillary nerve of the trigeminal nerve D. The frontal nerve of the ophtalmic nerve of the trigeminal nerve E. The infratrochlear nerve of the ophtalmic nerve of the trigeminal nerve 3. The doctor-neurologist examined the patient with complaints of loss of skin sensation in the area of the lower eyelids, nasal area and upper lip. Which nerve is damaged? A. The ophthalmic nerve B. The frontal nerve C. The maxillary nerve D. The mandibular nerve E. The lacrimal nerve 4. The patient complains of sharp pain along the entire lower jaw. Authentically which nerve is damaged? A.The masseteric nerve of the mandibular nerve B. The lingual nerve of the mandibular nerve C. The deep temporal nerves of the mandibular nerve D. The inferior alveolar nerve of the mandibular nerve E. The zygomatic nerve of the maxillary nerve 5. The patient has acute pain in canine fossa. Defeat what nerve takes place? A. The oculomotor nerve B. The facial nerve C. The trigeminal nerve, the third branch D. The trigeminal nerve, the first branch E. The trigeminal nerve, the second branch 6. A patient has maxillary nerve inflammation. Through what foramen the maxillary nerve leaves a skull? A. Foramen rotundum B. Foramen ovale C. Jugular foramen D. Superior orbital fissure E. Optic canal 7. The doctor examined the patient complaining of pain when he chews. The doctor found atrophy of masticatory muscles located below the zygomatic arch. Branches which cranial nerves innervate the specified muscle group? A. The zygomatic nerve of the maxillary nerve B. The mandibular nerve C. The lacrimal nerve D. The oculomotor nerve E. The maxillary nerve 8. The patient is observed with pain and numbness in the mucosa of the gums of the upper jaw. Which of the nerves may be damaged? A. The zygomatic nerve of the maxillary nerve B. The mandibular nerve C. The maxillary nerve D. The oculomotor nerve E. The lacrimal nerve 9. Which of these nerves may be damaged with sinusitis and surgical interventions on the maxillary cavity? A. N. mandibularis. B. N. facialis C. N. oculomotorius D. Nn. alveolares superiors E. N. lingualis 10. A patient has the mandibular nerve inflammation. Through what foramen the maxillary nerve leaves the skull? A. Foramen rotundum B. Foramen stylomastoideum C. Jugular foramen D. Superior orbital fissure E. Foramen ovale References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 28. The facial nerve. The intermediate nerve. The origination, the general features, the featured nuclei, the point of arise, the escape point, the related branches and the responsibility areas. 1. Relevance of the topic. Knowledge about the formation and structure of the cranial nerves exit site of their brain and skull, innervation zone necessary for students to learn clinical disciplines, and the likelihood of destruction of cranial nerves statistically high. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of cranial nerves. Classification of the neuron. Histology Structure of nerve fibers. Neurology Topography of the cranial nerves. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. Projection of the nuclei of the cranial nerve 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi craniаles Cranial nerves Nervus facialis Facial nerve Ganglion geniculi Geniculate ganglion Canalis nervi facialis Facial canal Nervus petrosus major Greater petrosal nerve 4.2. Theoretical questions for the class: 1. Describe the VII cranial nerves (with the intermediate nerve) including their origination, the general features. 2. The related nuclei. 3. The point of arise, the escape point and the responsibility areas. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the facial nerve on the branches, regions of their inervation using preparations, models, tables. Content of the topic. The nuclei of the facial nerve The facial nerve comprises mostly the motor fibers that arise from the motor nucleus of facial nerve, nucleus nervi facialis. These fibers supply the facial muscles. The nucleus resides within the tegmentum of pons ventrally from the nucleus of abducent nerve somewhat below the facial colliculus. The parasympathetic fibers arise from the superior salivatory nucleus, nucleus salivatorius superior. They supply the lacrimal, the parotid, the submandibular and the sublingual glands. The sensory nucleus is the nucleus of solitary tract, nucleus tractus solitarii that accepts the central processes of the sensory pseudounipolar cells of the geniculate ganglion, ganglion geniculi. Topography The facial nerve arises from the medullopontine sulcus laterally from the abducent nerve with two roots. The greater root is the facial nerve itself; it comprises the motor fibers. The lesser root is called the intermediate nerve. The intermediate nerve, nervus intermedius comprises the sensory (gustatory) and the parasympathetic fibers and thus features two nuclei — the superior salivatory nucleus, nucleus salivatorius superior (the parasympathetic nucleus) and the nucleus of solitary tract, nucleus tractus solitarii (the sensory nucleus). The two nerves join in the facial area of the internal acoustic meatus. The part in facial canal The facial and the intermediate nerves form a single trunk that enters the facial canal, canalis nervi facialis. The nerve configures to the facial canal i.e. first it runs anteriorly and laterally to reach the genu of facial canal. At this point, the nerve bends posteriorly to form the geniculum and proceeds in posteroinferior direction along the mastoid wall of the tympanic cavity (here the facial canal becomes evident as the prominence of facial canal). Upon passing the tympanic cavity, the nerve runs vertically down to escape via the stylomastoid foramen, foramen stylomastoideum. The genu of facial canal houses the geniculate ganglion, ganglion geniculi made up of the sensory pseudounipolar cells. Their central processes enter the brainstem and synapse with the cells of the nucleus of solitary tract, while the peripheral processes run to their responsibility areas. The branches of the part in canal The part in canal gives off two branches that belong to the intermediate nerve. They are the greater petrosal nerve and the chorda tympani (the nerve to stapedius belongs to the facial nerve): ■ the greater petrosal nerve, nervus petrosus major escapes from the facial canal via the hiatus for greater petrosal nerve and runs along the groove of the same name on the anterior surface of the petrous part of temporal bone. The nerve traverses the cartilaginous sealing of the foramen lacerum and becomes evident on the external cranial base. Then, the nerve proceeds to the pterygoid canal where joins the deep petrosal newe, nervus petrosus profundus (it arises from the internal carotid plexus). The two nerves form the nerve of pterygoid canal nervus canalis pterygoidei that reaches the pterygopalatine fossa with featured pterygopalatine ganglion. The nerve carries the parasympathetic preganglionic fibers that synapse with the pter- ygopalatine ganglion cells. The postganglionic fibers further take their routes as follows: 1) the fibers to the nasal cavity join the posterior nasal branches (of the trigeminal nerve); they supply the minor glands of nasal mucosa; 2) the fibers to the palatine mucosa join the respective branches of the maxillary nerve (the palatine nerves); they supply the minor glands of the palatine mucosa; 3) the fibers to the lacrimal gland take quite a complex route. Initially they join the maxillary nerve to reach the inferior orbital fissure. There the fibers pass to the zygomatic nerve, which carries them to the lateral wall of the orbit. At that point, the fibers detach from the vehicle and run alone as the communicating branch with zygomatic newe that finally joins the lacrimal nerve; the fibers provide secretory nerve supply to the lacrimal gland. ■ the chorda tympani detaches from the facial nerve in the area of the stylomastoid foramen and enters the canaliculus for chorda tympani to return to the tympanic cavity. Arching superiorly, the nerve runs along the medial surface of the tympanic membrane (that gives the name to the nerve) within the mucosa fold. Note that the chorda tympani supplies but nothing within the tympanic cavity and simply proceed to the canaliculus outlet — the petrotympanic fissure, fissura petrotympanica. The nerve joins the lingual nerve and proceeds to its responsibility area. The chorda tympani contains the preganglionic parasympathetic fibers and the sensory taste fibers from the geniculate ganglion. The preganglionic fibers run to the submandibular and sublingual ganglia to synapse with pertaining cells. The postganglionic fibers provide sensory nerve supply to the respective salivary glands. The sensory taste fibers run within the lingual nerve and supply the lingual papilla of the anterior two thirds of lingual mucosa. The facial part of the nerve After escaping from the facial ca-nal, the nerve appears to have only motor fibers. The nerve penetrates the parotid gland where forms the parotid plexus, plexus intraparotideus. The branches of the plexus fan out and take five routes to responsibility areas. These branches supply the mimic muscles: ■ the temporal branches, rami temporales terminate at the temporal region and supply the muscles of forehead and the orbicularis oculi; ■ the zygomatic branches, rami zygomatici supply the orbicularis oculi and both zygomatic muscles; ■ the buccal branches, rami buccales supply the buccinators and the muscles related to the mouth and the nose; ■ the marginal mandibular branch, ramus marginalis mandibulae runs along the base of mandible to the mental and the oral muscles; ■ the cervical branch, ramus colli descends to the cervical region. It supplies the platysma. Apart from the branches listed, the facial nerve gives the branches to the auricular muscles, to the occipital belly of epicranius, to the posterior belly of digastric and to the stylohyoid. Clinical applications. Conductivity disorders in the facial nerve result in paralysis of the facial muscles. This may be caused by chilling that develops into neuritis. The state is manifested by facial asym-metry. The central paralysis results from brain hemorrhages. Facial nerve disorders may also manifest as taste acuity loss or impaired secretion of the lacrimal and the salivary glands. Materials for self-check: A. Tasks for self-check: specify division of the facial nerve on the branches, regions of their inervation using preparations, models, tables. B. Situational tasks. 1. Which nerve is damaged, if the right nasolabial fold is smoothed, right orbital fissure is dilated (it cannot be screwed up because eyelids don′t close), difficulties arouse while talking and eating (food sticks between the cheek and teeth)? A. N. facialis. B. Nn. alveolaris superiors (n. maxillaris) C. N. oculomotorius D. N. mandibularis. E. N ophthalmicus. 2. A patient can not lift an eyebrow on one half of his face, close eyelids and bare his teeth. Which nerve is injured? A. N ophthalmicus. B. N. facialis. C. N. oculomotorius D. N. mandibularis. E. Nn. alveolaris superiors (n. maxillaris) 3. During the initial examination a patient does not have general sensitive of the anterior 2/3 of the tongue. Gustation is broken. What nerve is injured? A. N ophthalmicus. B. N. facialis. C. N. oculomotorius D. N. mandibularis. E. Nn. alveolaris superiors (n. maxillaris) 4. A patient has lacrimation and increased salivation. In combination with other symptoms this state is considered to be an irritation of fibers of a cranial nerve. Which nerve is this and what fibers are these? A. Parasympathetic fibres of the oculomotor nerve B. Somatic motor fibres of the facial nerve C. Sensory fibres of the trigeminal nerve D. Parasympathetic fibres of the facial nerve E. Somatic motor fibres of the trigeminal nerve 5. A patient has the facial nerve inflammation. Through what foramen the facial nerve leaves the skull? A. Foramen rotundum B. Foramen ovale C. Jugular foramen D. Superior orbital fissure E. Foramen stylomastoideum 6. At survey of the neuropathologist sharp asymmetry of patient′s face is found. The damage part of the face is as a mask, the nasolabial cord is smoothed, the mouth angle is alighted, impossible whistle, speech is a little complicated. What nerve is damaged? A. Facial nerve (rami buccales) B. Facial nerve (rami zygomatici) C. Facial nerve (rami temporales) D. N. Perosus major E. N. Chorda tympani 7. At survey of the patient the neuropathologist has found the unpleasant, enhanced perception of a note, especially low tints. What nerve was injured? A. Facial nerve (rami buccales) B. N. stapedius C. N. auricularis posterior D. N. perosus major E. N. Chorda tympani 8. At survey of the patient the neuropathologist has found sharp asymmetry of the face. The damage part of the face looked as a mask, forehead cords were smoothed. Venter frontalis m. epicranii was damaged. Which nerve was injured? A. Facial nerve (rami buccales) B. Facial nerve (rami zygomatici) C. Facial nerve (rami temporales) D. N. perosus major E. N. Chorda tympani 9. A patient has the intermediate nerve inflammation. Through what foramen the intermediate nerve leaves the skull? A. Foramen rotundum B. Foramen ovale C. Jugular foramen D. Fissura petrotympanica E. Foramen stylomastoideum 10. Which nerves form nerve of pterygoid canal? A. Facial nerve and n. stapedius B. N. stapedius and n. petrosus profundus C. N. auricularis posterior and n. chorda tympani D. Rami zygomatici and rami temporales E. N. perosus major and n. petrosus Profundus References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/ Topic 29. The glossopharyngeal nerve. The related branches and the responsibility areas. 1. Relevance of the topic. Knowledge about the formation and structure of the cranial nerves exit site of their brain and skull, innervation zone necessary for students to learn clinical disciplines, and the likelihood of destruction of cranial nerves statistically high. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of cranial nerves. Classification of the neuron. Histology Structure of nerve fibers. Neurology Topography of the cranial nerves. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. Projection of the nuclei of the cranial nerve 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi craniаles Cranial nerves Nervus glossopharyngeus Glossopharyngeal nerve Nervus petrosus minor Lesser petrosal nerve 4.2. Theoretical questions for the class: 1. Name number, function and location of nuclei of the glossopharyngeal nerve in the brain? 2. Describe the IX pair of cranial nerve including their origination, the general features, the point of arise, the escape point, the responsibility areas. 3. Describe the sensory ganglion of the IX pair of cranial nerve with related topography and fibers. 4. Describe the sources of innervation of salivary glands. 5. Describe the sources of innervation of the tongue. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the glossopharyngeal nerve on the branches, regions of their inervation using preparations, models, tables. Content of the topic. The glossopharyngeal nerve is the mixed-type nerve. The nuclei of the glossopharyngeal nerve The glossopharyngeal nerve comprises the motor, the sensory and the autonomic fibers that arise from three respective nuclei situated within the medulla oblongata. The motor fibers arise from the nucleus ambiguus, the sensory fibers terminate within the nucleus of solitary tract, nucleus tractus solitarii and the autonomic fi-bers arise from the inferior salivatory nucleus, nucleus salivatorius inferior. Topography of the nerve The nerve arises as numerous rootlets from the posterolateral sulcus of the medulla oblongata right behind the inferior olive. It escapes from the cranial cavity via the anterior portion of the jugular foramen and proceeds to the cervical region. There the nerve loops around the internal carotid artery and the stylopharyngeus and proceeds to the root of tongue where it splits into the terminal branches — the lingual branches, rami linguales. The nerve features two ganglia — the superior ganglion, ganglion superius situated in the area of the jugular foramen and the inferior ganglion, ganglion inferius situated right below the outlet of the foramen. Both ganglia comprise the sensory pseudounipolar cells. Their central processes run to the nucleus of solitary tract and the peripheral processes join the branches of the nerve and proceed to responsibility areas (the pharyngeal mucosa, the tympanic mucosa, the posterior third of the tongue and the carotid sinus). The branches of the glossopharyngeal nerve: ■ the tympanic nerve, nervus tympanicus comprises the sensory and the parasympathetic fibers. It arises from the inferior ganglion and enters the tympanic cavity via the tympanic canaliculus where it leaves all sensory fibers to form the tym¬panic plexus, plexus tympanicus. The plexus supplies the tympanic mucosa, the mastoid air cells mucosa and the auditory tube mucosa. The autonomic fibers proceed to the hiatus for lesser petrosal nerve where they form the lesser petrosal nerve, nervus petrosus minor. This purely parasympathetic nerve runs along the groove for lesser petrosal nerve and escapes from the cranial cavity via the sphenopetrosal fissure, fissura sphenopetrosa. Upon reaching the inferior cranial base, the nerve enters the otic ganglion, ganglion oticum associated with the mandibular nerve. The postganglionic fibers join the auriculotemporal nerve and proceed to the parotid gland; ■ the lingual branches, rami linguales run to the posterior third of lingual mucosa. The nerve comprises the fibers of general sensitivity and the gustatory fibers that supply the taste buds of the vallate papillae; ■ the pharyngeal branches, rami pharyngei participate in formation of the pharyngeal plexus; these fibers provide sensory nerve supply to the pharyngeal mucosa; ■ the stylopharyngeal branch, ramus musculi stylopharyngei is the motor branch to the stylopharyngeus; ■ the tonsillar branches, rami tonsillares supply the mucosa of the palatine tonsils and the related arches; ■ the carotid branch, ramus sinus ca-rotid runs to the carotid sinus and the carotid body. This branch con-ducts the impulses from the carotid sinus to the medulla oblongata participating thus in regulation of the blood pressure and heart rate. Materials for self-check: A. Tasks for self-check: specify division of the glossopharyngeal nerve on the branches, regions of their inervation using preparations, models, tables. B. Situational tasks. 1. A patient has the glossopharyngeal nerve inflammation. Through what foramen the glossopharyngeal nerve leaves the skull? A. Jugular foramen B. Foramen stylomastoideum C. Foramen rotundum D. Superior orbital fissure E. Foramen ovale 2. During reception in clinic, at the patient was disturbance of gustatory receptors that accept bitter is revealed, tactile sensitivity of a back 1/3 of tongue is not broken. What nerve is involved in pathological process? A. The glossopharyngeal (rami tonsillares) B. The glossopharyngeal (rami linguales) C. The glossopharyngeal (rami pharyngei) D. The intermediate (n. chorda tympani) E. The trigeminal (n. lingualis) 3. The patient complains of a pain in a root of tongue and in a field of palatine tonsils. What nerve supplies these fields? A. The glossopharyngeal (rami pharyngei) B. The glossopharyngeal (rami linguales) C. The glossopharyngeal (rami tonsillares) D. The intermediate (n. chorda tympani) E. Trigeminal (n. lingualis) 4. The patient suffer from dysfunction of the parotid salivary gland. What nerve increases its secretion? A. N auricularis major B. N petrosus major. C. N. petrosus profundus D. N. petrosus minor. E. N. auricularis minor 5. In a neurology department the patient has arrived with the complaint to spastic strictures at swallowing. Of what damage of a nerve it is possible to think? A. The glossopharyngeal (n. tympanicus) B. The glossopharyngeal (rami linguales) C. The glossopharyngeal (rami tonsillares) D. The intermediate (n. chorda tympani) E. The glossopharyngeal (rami pharyngei, ramus m. stylopharyngei) 6. Through what foramen the lesser petrosal nerve leaves a head cavity? A. Foramen lacerum B. Foramen stylomastoideum C. Foramen rotundum D. Superior orbital fissure E. Foramen ovale 7. In a neurology department the patient has arrived with the thympanitis phenomena (an inflammation of the mucous membrane of tympanic cavity). What nerve is damaged? A. The glossopharyngeal (rami linguales) B. The glossopharyngeal (n. tympanicus) C. The glossopharyngeal (rami tonsillares) D. The intermediate (n. chorda tympani) E. The glossopharyngeal (rami pharyngei, ramus m. stylopharyngei) 8. Where nuclei of the glossopharyngeal nerve are located? A. In the pons B. In the cerebellum C. In the medulla oblongata D. In the midbrain E. In the diencephalon 9. Name nuclei of the glossopharyngeal nerve. A. Nucleus of the tractus solitarius B. The superior salivatory nucleus C. Spinal nucleus D. Main motor nucleus E. The inferior salivatory nucleus 10. After an oral cavity soft tissues injure a patient lost gestation of the posterior third of the tongue. What nerve was injured? A. The glossopharyngeal (n. tympanicus) B. The glossopharyngeal (rami pharyngei, ramus m. stylopharyngei) C. The glossopharyngeal (rami tonsillares) D. The intermediate (n. chorda tympani) E. The glossopharyngeal (rami linguales) References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 30. The vagus nerve. The origination, the general features, the featured nuclei, the point of arise, the escape point, the related branches and the responsibility areas. 1. Relevance of the topic. Knowledge about the formation and structure of the cranial nerves exit site of their brain and skull, innervation zone necessary for students to learn clinical disciplines, and the likelihood of destruction of cranial nerves statistically high. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of cranial nerves. Classification of the neuron. Histology Structure of nerve fibers. Neurology Topography of the cranial nerves. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. Projection of the nuclei of the cranial nerve 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi craniаles Cranial nerves Nervus vagus Vagus nerve Rami cardiaci cervicales superiores et Cervical cardiac branches superior and inferiores inferior 4.2. Theoretical questions for the class: 1. What is the name the vagus nerve in Latin and its numbers? 2. Describe the Xth pair of cranial nerve including their origination, the general features, nuclei, the point of arise, the escape point, the responsibility areas. 3.The branches of the vagus nerve. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the vagus nerve on the branches, regions of their inervation using preparations, models, tables. Content of the topic. The vagus nerve, nervus vagus The vagus nerve is the principal parasympathetic nerve of the human body that supplies the cervical, the thoracic and the abdominal viscera (except for the lesser pelvis viscera). The vagus nerve comprises numerous visceral sensory fibers that conduct the impulses from the related viscera. It also features the motor fibers that supply the striated muscles of the upper portions of the alimentary and the respiratory tracts. The nuclei of the vagus nerve The largest nucleus of the vagus nerve is the dorsal nucleus of vagus nerve, nucleus dorsalis nervi vagi that gives rise to the autonomic fibers. It resides within the medulla oblongata at level of the vagal trigone, trigonum nervi vagi. The motor fibers arise from the nucleus ambiguus and the sensory fibers (the fibers that conduct interoceptive sensitivity fibers and the taste fibers) terminate within the nucleus of solitary tract, nucleus tractus solitarii. The exteroceptive sensitivity fibers from the skin and the mucous membranes terminate within the inferior portion of the spinal nucleus of trigeminal nerve. The vagus nerve has a wide responsibility area so it is subdivided into the cranial, the cervical, the thoracic and the abdominal parts. The cranial part (between the origination point and the superior ganglion) Topography of the nerve The vagus nerve arises with 10-15 rootlets from the posterolateral sulcus of the medulla oblongata posterior to the inferior olive (right below the glossopharyngeal nerve). The rootlets merge into a single trunk that escapes from the cranial cavity via the jugular foramen, foramen jugulare. The cranial part gives the meningeal branch, ramus meningeus to the dura mater of the posterior cranial fossa and the auricular branch, ramus auricularis. The auricular branch enters the mastoid canaliculus, canaliculus mastoideus that gives escape to the nerve via the tympanomastoid fissure posterior to the auricle. The branch supplies the skin of the auricle and the skin of the posterior wall of the external acoustic meatus. The ganglia of the nerve The vagus nerve features two ganglia much alike those of the glossopharyngeal nerve. The superior gan-glion, ganglion superius resides in the area of the jugular foramen and the inferior ganglion, ganglion inferius resides right below the jugular foramen opening. Both ganglia comprise the sensory pseudounipolar cells. The superior ganglion is responsible for exteroceptive sensitivity while the inferior ganglion is responsible for visceral (interoceptive) sensitivity. The cervical part (between the inferior ganglion and the recurrent laryngeal nerve) Topography of the cervical part In the beginning of its way, the cervical part runs between the internal carotid artery and the internal jugular vein. Below the carotid sinus, the nerve runs between the common carotid artery and the internal jugular vein. The greater cervical vessels and the vagus nerve constitute one neurovascular bundle enfolded into the carotid sheath. Upon entering the thoracic inlet, the right nerve passes between the subclavian artery and the subclavian vein; the left nerve passes between the common carotid artery and the subclavian artery and proceeds onto the anterior surface of the aortic arch. The branches of the cervical part The cervical part gives the branches as follows: ■ the pharyngeal branch, ramus pharyngeus participates in formation of the pharyngeal plexus together with the respective branch of the glossopharyngeal nerve and some sympathetic branches. The plexus supplies the pharyngeal muscles, the pharyngeal mucosa and the muscles of the soft palate (except for the tensor veil palatini), ■ the superior laryngeal nerve, nervus laryngeus superior arises from the inferior ganglion. The nerve descends to the hyoid bone and where splits into two branches — the external branch, ramus extemus and the internal branch, ramus intemus. The external (motor) branch supplies only the cricothyroid and the internal branch (it comprises the sensory and the parasympathetic fibers) supplies the epiglottic mucosa, the laryngeal mucosa above the rima glot- tidis and the mucosa of the root of tongue (partially). The superior laryngeal nerve also comprises the gustatory fibers that run from the taste buds of the root of tongue and the epiglottis; ■ the superior cervical cardiac branches, rami cardiaci cervicales superiores descend along each common carotid artery and joins the cardiac plexus, plexus cardiacus. These branches carry only the parasym-pathetic preganglionic fibers from the dorsal nucleus of vagus nerve. The fibers reach synapse within the ganglia of the cardiac plexus. The cardiac branches also feature the interoceptive sensory fibers that participate in regulation of blood pressure; . the recurrent laryngeal nerve, nervu laryngeus recurrens arises within the upper portion of the thoracic cavity yet its branches terminate in the cervical region. The left nerve loops around the aortic arch, the right nerve loops around the subclavian artery. Both nerves return to the cervical region where they reside between the trachea and the esophagus. The nerve comprises all types of fibers and supplies the trachea (the tracheal branches, rami tracheales), the esophagus (the esophageal branches, rami oesophageales), all laryngeal muscles (except for the cricothyroid) and the laryngeal mucosa below the rima glottidis. The laryngeal nerves also supply the thyroid gland with the sensory and the secretory nerve fibers; the inferior cervical cardiac branches, rami cardiaci cervicales inferiors may arise either from the recurrent laryngeal nerves or directly from the vagus nerves on each side. They carry the sensory and the preganglionic parasympathetic fibers to the cardiac plexus. Clinical applications The recurrent laryngeal nerve runs posterior to the lobes of the thyroid gland, which becomes a concern in thyroid gland surgery. Injury to the recurrent laryngeal nerve results in aphonia because of laryngeal muscles paralysis. The thoracic part of the vagus nerve (between the recurrent laryngeal nerve and the esophageal hiatus of the diaphragm) Topography of the thoracic part Within the thoracic cavity, the right vagus nerve runs anterior to the subclavian artery while the left nerve runs anterior to the aortic arch. Both nerves then bypass the roots of lungs posteriorly and enter the posterior mediastinum where they run along the esophagus. The left nerve passes onto the anterior surface of the esophagus and the right — on the posterior surface. The nerves branch off within the wall of the esophagus thus forming the esophageal plexus, plexus oesophagealis. The lower portion of the plexus gives rise to the anterior and the posterior vagal trunks, trunci vagales anterior et posterior that enter the abdominal cavity via the esophageal hiatus. The branches of the thoracic part Within the thoracic cavity, the nerve gives the following branches: ■ the tracheal branches, rami tracheales that form the tracheal plexus (together with the sympathetic fibers); ■ the thoracic cardiac branches, rami cardiac thoracici comprise the sensory and the parasympathetic fibers that join the cardiac plexus; ■ the bronchial branches, rami bronchiales run to the bronchi to form the pulmonary plexus, plexus pulmonalis together with the sympathetic fibers. These branches also contain the visceral sensory fibers that supply the bronchial mucosa; ■ the oesophageal plexus, plexus esophagealis arises from the branches of both nerves and from the visceral branches of the thoracic compartment of the sympathetic trunk. The abdominal part (between the esophageal hiatus and the sigmoid colon) Topography of the abdominal part Upon reaching the abdominal cavity, the anterior vagal trunk branches within the anterior wall of stomach. The posterior vagal trunk branches within the posterior wall of stomach and finally joins the coeliac plexus. The parasympathetic fibers of the vagus nerve reach the viscera along the related arteries and form the autonomic plexuses together with the sympathetic fibers. The branches of the vagus nerve contain numerous visceral sensory fibers that supply the respective abdominal viscera. The branches of the abdominal part Within the abdominal cavity, the vagus nerve gives the branches as follows: ■ the anterior gastric branches, rami gastrici anteriores arise from the anterior trunk and run along the lesser curvature of stomach to reach its anterior wall; ■ the hepatic branches, rami hepatici also arise from the anterior trunk and run along the common hepatic artery to reach the liver. The branches run between the layers of the lesser omentum; ■ the posterior gastric branches, rami gastrici posteriors arise from the posterior trunk and run along the lesser curvature of stomach to reach its posterior wall; ■ the renal branches, rami renales and run along the renal arteries to reach the kidneys; ■ the coeliac branches, rami coeliaci are the last branches of the group. They join the coeliac plexus yet never synapse within its ganglia. The fibers spread along the arteries and reach the spleen, the pancreas, the small and the large intestines (up to the sigmoid colon). The parasympathetic fibers synapse within the intramural ganglia of the respective viscera. Clinical applications. Bilateral destruction of the vagus nerve is fatal while unilateral partial lesion may result in deranged deglutition and phonation because of paralyzed palatine, pharyngeal and laryngeal muscles. The state may be accompanied by various autonomic disorders related to cardiac activities, respiration, digestion etc. Materials for self-check: A. Tasks for self-check: specify division of the vagus nerve on the branches, regions of their inervation using preparations, models, tables. B. Situational tasks. 1. Carrying out neurologic inspection of the patient, 22 years, the doctor has asked it to open a mouth and to utter a note of "Aaaa", thus estimated, whether the soft palate symmetrically rises. Then the doctor has touched a cotton plug to a soft palate and in the answer there was a vomitive jerk that is accompanied by locomotion of the palate and the pharynx. What cranial nerves were investigated by the doctor? A. 10,11 and 12 B. 5,7 and 9 C. 7,8 and 9 D. 9 and 10 Е. 9 and 12 2. At the patient on a X-ray the enlarged lymph nodes in a field of a root lungs are taped. The patient complains of retardation of a warm rhythm and pain sensation in heart. The doctor considers that symptoms from heart are invoked by pressure upon its nerves of the enlarged knots. What of nerves are compressed by the enlarged lymph nodes? A. N. splanchnicus major B. Rr. cardiaci n. vagus C. Nn. intercostals D. Truncus sympaticus E. N. Phrenicus 3. At the patient with the aneurism of the subclavial artery hoarseness of a voice is observed. To what of a cranial nerve it can be bound? A. N. laryngeus inferior sinister B. N. laryngeus superior dexter C. N. laryngeus reccurens dexter D. N. laryngeus superior sinister E. N. laryngeus reccurens sinister 4. At the patient the dacryagogue, the raised salivation is observed. This state, in the ratio with the second symptoms, is regarded as a boring of fibers of one of cranial nerves. What nerve and what its fibers? A. Parasympathetic fibers of the facial nerve B. Parasympathetic fibers of the oculomotor nerve C. Somatic motor fibers of the oculomotor nerve D. Parasympathetic fibers of the vagus nerve Е. Parasympathetic fibers of the intermediate nerve 5. After operation on a stomach at the patient complication in the form of weakening of its peristalsis, reduction of secretion of glands and weakening of the pyloric sphincter has educed. What nerve has suffered at an operative measure? A. The trigeminal B. The facial C. The oculomotor D. The intermediate (n. chorda tympani) E. The vagus 6. To the patient the subtotal subfascial resection of a thyroid gland is spent. Long time is stored in the postoperative season hoarseness of a voice. What nerve is damaged? A. N. laryngeus reccurens B. N. laryngeus superior C. N. splanchnicus major D. N. laryngeus inferior E. N. petrosus profundus 7. To the doctor the patient with the complaint to complication of dense bond of jows at chewing has addressed. The doctor has established an atrophy of the masseters placed below a zygomatic arch. What branches of a cranial nerve innervate noted bunch of muscles? А. N. vagus. B. N. facialis. C. N. glossopharyngeus. D. N. trigeminus E. N. ophthalmicus. 8. In a neurological department the patient with complaints to change of a voice which has got a nasal, nasal shade has arrived, voice changes can sometimes reach a full aphonia (silent speech). Of what damage of a nerve it is possible to think? A. N. splanchnicus major B. N. lingualis C. N. laryngeus reccurens D. N. trigeminus E. N. petrosus profundus 9. In the therapeutical department the patient has arrived with complaints to a dyspnea to an expiration, constrained («asthmatic breath»), fear for the life. About what prevalence of a nerve it is possible to speak? A. The vagus (n. laryngeus superior) B. The vagus (ramus cardiacus inferior) C. The vagus (rami cardiaci superiores) D. The vagus (rami bronchiales et tracheales) E. The vagus (rami pharyngei) 10. In a neurological department the patient with the complaint to pouring out of liquid nutrition through a nose (a soft palate paralysis) has arrived. Of what damage of a nerve it is possible to think? A. The vagus (rami pharyngei) B. The vagus (ramus cardiacus inferior) C. The vagus (rami cardiaci superiores) D. The vagus (rami bronchiales et tracheales) E. The vagus (n. laryngeus superior) References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 31 The accessory, hypoglossal nerves. The related branches and the responsibility areas. 1. Relevance of the topic. Knowledge about the formation and structure of the cranial nerves exit site of their brain and skull, innervation zone necessary for students to learn clinical disciplines, and the likelihood of destruction of cranial nerves statistically high. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of cranial nerves. Classification of the neuron. Histology Structure of nerve fibers. Neurology Topography of the cranial nerves. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. Projection of the nuclei of the cranial nerve 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Nervi craniаles Cranial nerves N. accessorius Accessory nerve N. hypoglossus Hypoglossal nerve 4.2. Theoretical questions for the class: 1. Describe the XI pair of cranial nerve including their origination, the general features, the point of arise, the escape point, the responsibility areas. 2. Describe the XII pair of cranial nerve including their origination, the general features, the point of arise, the escape point, the responsibility areas. 3. The structure of the tongue. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the accessory and hypoglossal nerves on the branches, regions of their inervation using preparations, models, tables. Content of the topic. The accessory nerve comprises only motor fibers that arise from two nuclei: 1 — the nucleus ambiguus resides within the medulla oblon-gata. The fibers of the accessory nerve arise from the caudal portion of the nucleus. The rest is shared by the IX and the X pairs; 2 — nucleus of accessory nerve, nucleus nervi accessorii resides within the posterolateral portion of the anterior grey column of the spinal cord. The nucleus occupies the segments Cl through C6. The fibers from the nucleus ambiguus take a short route within the accessory nerve and then detach to join the vagus nerve. Within the vagus nerve, they run as the superior laryngeal nerve. The spinal fibers supply the trapezius and the sternocleidomastoid. Topography of the nerve and related branches The accessory nerve features the cranial roots and the spinal roots: ■ the spinal roots, radices spinales arise from the spinal cord between the anterior and the posterior roots and merge into a single trunk, which ascends to the cranial cavity and joins the cranial roots; ■ the cranial roots, radices craniales arise from the posterolateral sulcus of the medulla oblongata posterior to the inferior olive. Both cranial and spinal roots merge into one trunk of accessory nerve, truncus nervi accessorii, which escapes from the cranial cavity via the jugular foramen and proceeds to the cervical region. Within the cervical region, the nerve splits into the external branch, ramus extemus and the interval branch, ramus intemus. The internal branch comprises the fibers from the nucleus ambiguus that join the vagus nerve. The external branch, which is the accessory branch itself, supplies the trapezius and the sternocleidomastoid. The hypoglossal nerve, nervus hypoglossus The hypoglossal nerve comprises the motor fibers to the lingual muscles. The fibers arise from the nucleus of hypoglossal nerve, nucleus nervi hypoglossi situated within the medulla oblongata at level of the hypoglossal trigone. The nerve arises from the brainstem as numerous rootlets that join into a single trunk. The nerve escapes from the cranial cavity via the hypoglossal canal canalis nervi hypoglossi and reaches the cervical region. Upon reaching the tongue, the nerve branches off to give the lingual branches, rami linguales that supply all muscles of tongue. The hypoglossal nerve also gives the descending branch, ramus descendens that comprises the motor fibers from the first spinal nerve. The branch anastomoses with the branches of the cervical plexus to form the ansa cervicalis. The ansa supplies the infrahyoid muscles of neck (the sternohyoid, the sternothyroid, the thyrohyoid and the omohyoid). Clinical applications. Unilateral injury to the hypoglossal nerve results in paralysis of the lingual muscles on the respective side with further atrophy. Bilateral injury results in complete immobility of the tongue accompanied by deranged speech, deglutition and mastication. Materials for self-check: A. Tasks for self-check: specify division of the accessory and hypoglossal nerves on the branches, regions of their inervation using preparations, models, tables. B. Situational tasks. 1. A patient has a tongue motor function disorder. Which nerve was injured? А. N. vagus B. N. facialis C. N. glossopharyngeus D. N. trigeminus E. N. hypoglossal 2. A patient has the hypoglossal nerve inflammation. Through what foramen the hypoglossal nerve leaves the skull? A. Jugular foramen B. Foramen stylomastoideum C. Foramen rotundum D. Hypoglossal canal E. Foramen ovale 3. At the man as a result of a craniocerebral trauma 9-12 pairs cranial nerves have been damaged. Define, how there could pass a fracture line on basilar department of an occipital bone which has led to damage of nerves? А. Through foramen lacerum et canalis condylaris B. Along linea superios et foramen ovale C. Through foramen magnum et fossa jugularis D. Along linea nuchae inferior et foramen rotundum E. Along sutura sagittalis et foramen spinosum 4. The patient complains of difficulty of a raising of the right arm above horizontal level. Which nerve was injured? А. N. vagus B. N. accessory (internal branch) C. N. glossopharyngeus D. N. hypoglossal E. N. accessory (external branch) 5. A patient was admitted to a neurological department with deflection of the tongue to the side when extruded, atrophic changes of the half of the tongue, logopathy, deglutitive problem. Which of the nerves may be damaged? А. N. hypoglossal B. N. accessory (internal branch) C. N. glossopharyngeus D. N. vagus E. N. accessory (external branch) 6. The patient complains of difficulties at turns of a head and its deflection back. Which of the nerves may be damaged? А. N. hypoglossal B. N. accessory (external branch) C. N. glossopharyngeus D. N. vagus E. N. accessory (internal branch) 7. Name nuclei of the accessory nerve. A. Nucleus of the tractus solitarius B. The superior salivatory nucleus C. Nucleus of accessory nerve D. Nucleus ambiguus E. The inferior salivatory nucleus 8. Name nuclei of the hypoglossal nerve. A. Nucleus of the tractus solitarius B. Nucleus nervi gypoglossi C. Nucleus of accessory nerve D. Nucleus ambiguus E. The inferior salivatory nucleus 9. At objective survey the neuropathologist has found such disturbances at the woman of 50 years: the patient cannot reduce a scapula, turns of the head in the healthy side is complicated, the shoulder on the sick side is alighted. At the patient lifting of an arm above a horizontal line is complicated. Which nerve was injured? А. N. accessory (internal branch) B. N. hypoglossal C. N. glossopharyngeus D. N. vagus E. N. accessory (external branch) 10. In neurology the man has arrived with complaints to disturbance of speech which is almost impossible (anarthria), ainesia of tongue which cannot be will put out from a mouth, sharp difficulty of food intake (the alimentary lump cannot be moved in a mouth for chewing process, will move to a pharynx for swallowing). А. N. vagus B. N. facialis C. N. glossopharyngeus D. N. trigeminus E. N. hypoglossal References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 32. Submodule on peripheral nervous system. The spinal and cranial nerves. Situation problems. Control questions to module control: 1. Name the principal components of the peripheral nervous system and give their general characteristics. 2. Describe formation, topography and branches of the spinal nerves. Explain relations of the spinal nerves to the spinal segments. 3. Describe contents, topography and responsibility areas of the posterior branches of spinal nerves. 4. Describe the posterior branch of the first cervical nerve including contents, topography and responsibility areas. 5. Describe the posterior branch of the second cervical nerve including contents, topography and responsibility areas. 6. Describe the anterior branches of spinal nerves with featured structural and topographical regularities. 7. Describe formation, branches, topography and responsibility areas of the thoracic nerves. 8. Describe formation, branches, topography and responsibility areas of the intercostal nerves. 9. Describe structural features of the nervous plexuses. 10. Describe formation, branches, topography and responsibility areas of the cervical plexus. 11. Describe formation, branches, topography and responsibility areas of the phrenic nerve. 12. Describe formation, topography, parts and classification of branches of the brachial plexus. 13. Describe the trunks and the cords of the brachial plexus. 14. Describe the supraclavicular part of the brachial plexus. 15. Describe the short branches of the brachial plexus with featured topography and responsibility areas. 16. Describe the axillary nerve. 17. Describe the infraclavicular part of the brachial plexus. 18. Describe the long branches of the brachial plexus with featured topography and responsibility areas. 19. Describe the musculocutaneous nerve. 20. Describe the median nerve. 21. Describe the ulnar nerve. 22. Describe the radial nerve. 23. Describe the long cutaneous branches of the brachial plexus. 24. Describe the lumbar plexus. 25. Describe the femoral nerve. 26. Describe the obturator nerve. 27. Describe the sacral and the coccygeal plexuses. 28. Describe the short branches of the sacral plexus. 29. Describe the pudendal nerve. 30. Describe the long branches of the sacral plexus. 31. Describe the sciatic nerve. 32. Describe the tibial nerve. 33. Describe the common fibular nerve. 34. Describe the coccygeal plexus. 35. Name all pairs of the cranial nerves. 36. Discuss classification of the cranial nerves by fibers contents. 37. Discuss classification of the cranial nerves by origin. 38. Describe the III cranial nerves including their origination, the general features, the featured nuclei, the point of arise, the escape point, the related branches and the responsibility areas. 39. Describe the IV cranial nerves including their origination, the general features, the nucleus, the point of arise, the escape point and the responsibility areas. 40. Describe the V pair of cranial nerve including origination, the general features and intracranial part of the nerve. 41. Describe the sensory ganglion of the V cranial nerve with related topography and fibers. 42. Describe the first branch of the V cranial nerve including formation, escape point, the related branches and responsibility areas. 43. Describe the second branch of the V cranial nerve including formation, escape point, the related branches and responsibility areas. 44. Describe the third branch of the V cranial nerve including formation, escape point, the related branches and responsibility areas. 46. Describe the VI cranial nerves including their origination, the general features, the nucleus, the point of arise, the escape point and the responsibility areas. 47. Describe the VII cranial nerves (with the intermediate nerve) including their origination, the general features, the related nuclei, the point of arise, the escape point and the responsibility areas. 48. Describe the VIII cranial nerves including their origination, the general features, the nuclei, topography of the nerves and the responsibility areas. 49. Describe the IX cranial nerves including their origination, the general features, the featured nuclei, the point of arise, the escape point and the responsibility areas. 50. Describe the X cranial nerves including their origination, the general features, the nucleus, the point of arise, the escape point, the parts and the responsibility areas. 51. Describe the cranial and the cervical parts of the X cranial nerve including topography, the fibers and responsibility areas. 52. Describe the cervical and the tho-racic parts of the X cranial nerve including topography, the fibers and responsibility areas. 53. Describe the XI cranial nerves including their origination, the general features, the nuclei, the point of arise, the escape point and the responsibility areas. 54. Describe the XII cranial nerves including their origination, the general features, the nuclei, the point of arise, the escape point and the responsibility areas. 2. Situational tasks. 1.What nerve is mixed branch of cervical plexus? *A. Phrenic nerve B. Lesser occipital nerve C. Great auricular nerve D. Supraclavicular nerves E. Suboccipital nerves 2. What anatomical structures form a spinal nerve? A. Posterior funiculus of spinal cord B. Lateral funiculus of spinal cord *C. Anterior and posterior roots of spinal cord D. Posterior horn of spinal cord E. Anterior funiculus of spinal cord 3. What anatomical structures form the elementary reflex arch? A. Afferent neuron, intermediate neuron, efferent neuron B. Anterior root of the spinal nerve C. Conductor neuron D. Efferent neuron E. Central nucleus 4. Indicate anatomical structures relating to peripheral nervous system *A. Cranial nerves B. Pons C. Mesencephalon D. Medulla oblongata E. Spinal cord 5. Indicate nervous fibres in spinal nerves. A. Postganglionic parasympathetic B. Sensory, motor, postganglionic sympathetic C. Preganglionic sympathetic D. Cranial nerves E. Anterior root of the spinal cord 6. After a fracture of the upper third of the humerus the paralysis of the posterior group of muscles of the shoulder and forearm developed. Which nerve was damaged? A. Ulnar. *B. Radial. C. Median. D.Musculocutaneous. E. Axillary. 7. Examination of a patient with a knife right hand wound has shown skin sensitivity loss of the lateral part of the hand dorsal surface and proximal phalanxes of the I, II and partially III fingers. Which nerve has been damaged? A. Ulnar. B. Median. *C. Radial. D.Musculocutaneous. E. Lateral cutaneous nerve of forearm. 8. Having hurt the elbow against a table a patient felt burning and pricking on the internal surface of the forearm. Which nerve was traumatized in this case? *A. Ulnar. B. Radial. C. Median. D. Axillary. E. Musculocutaneous. 9. A patient after a trauma has decreased painful and temperature sensitivity in the site of 1.5 fingers on the palmar surface and 2.5 fingers on the dorsal surface from the side of the little finger. Which nerve was injured as a result of the trauma? *A. Ulnar. B. Radial. C. Median. D. Musculocutaneous. E. Medial cutaneous nerve of forearm 10. After an inflammatory process a patient complains of feeling weakness when bending a hand in the site of the I, II, III, and IV fingers, volume reduction of thenar muscles. Examination has shown disorders of pain and temperature sensitivity on palmary surface of the I, II, III fingers and radial surface of the IV finger. Which nerve has been injured? A. Musculocutaneous. B. Radial. C. Ulnar. *D. Median. E. Medial cutaneous nerve of fore arm. 11. A patient appealed to a doctor with complaints of impossibility to abduce the right hand after a trauma. Examination has shown that passive movements are not limited. Deltoid muscle atrophy has been detected. Which nerve has been injured? A. Suprascapular. B. Radial. C. Ulnar. D. Median. *E. Axillary. 12. After a trauma in the site of a shoulder a patient can not extend a hand. Examination has also shown a decrease of pain and temperature sensitivity in the site of 2.5 fingers of the hand's dorsal surface from the side of the thumb. Which nerve has been injured as a result of the trauma? *A. Radial. B. Median. C. Ulnar. D. Axillary. E. Musculocutaneous. 13. Examining a patient a neuropathologist detected increased pain skin sensitivity on the palmary surface of the I, II, III and the radial surface of the IV fingers, middle part of the palm and thenar. Which nerve was injured? *A. Median B. Medial cutaneous nerve of forearm C. Ulnar. D. Radial. E. Musculocutaneous. 14. To a traumatology center there was taken a teenager who pinched his arm in a door above the elbow joint during a game. Examination has shown the loss of skin sensitivity on the anteromedial shoulder surface. Indicate with what nerve damage the loss of skin sensitivity of the mentioned site is connected? A. Axillary. B. Radial. *C. Musculocutaneous. D. Ulnar. E. Median. 15. A patient lost skin sensitivity of the little finger. Which nerve is damaged? A. Median. *B. Ulnar. C. Radial. D. Musculocutaneous E. Medial cutaneous nerve of forearm 16. A patient was admitted to a traumatology center with the greater psoas muscle damage. The patient lost possibility to straighten his leg in the knee joint. Which nerve is damaged? *A. Femoral. B. Iliohypogastric. C. Ilioinguinal. D. Genitofemoral. E. Obturator. 17. Examining a patient a neuropathologist detected the following symptom complex: cremasteric reflex extinction (reduction of m. cremaster), disorder of skin sensitivity on the anterior and internal surface of the superior third of the thigh and scrotum. Which nerve was injured? A. Ilioinguinal. *B. Genitofemoral. C. Sciatic. D. Femoral. E. Obturator. 18. A patient has characteristic gait changes, so-called waddling gait, observed: during walking the patient sways. Besides, hip reduction is impossible. Which nerve has been injured? A. Femoral. B. Sciatic. *C. Obturator. D. Tibial. E. Superior gluteal. 19. A patient can not extend a knee joint, knee reflex is not observed, skin sensitivity of the anterior surface of the thigh is damaged. Which nerve is damaged? A. Obturator. B. Superior gluteal. C. Common peroneal. *D. Femoral. E. Inferior gluteal nerve. 20. 1. A 30-year-old patient appealed to a neuropathologist complaining of skin sensitivity loss of the middle and inferior third of the posterior region of the leg on the right. Which nerve id damaged? *A. Sural. B. Posterior cutaneous nerve of thigh. C. Genitofemoral. D. Branches of obturator nerve. E. Tibial. 21. Examination of a patient with a cut wound in the inferior third of the right leg anterior area has shown the absence of extension movements in the right ankle joint. Muscles are not injured. Which nerve has been affected? A. Saphenous. B. Common peroneal. C. Superficial fibular. *D. Deep fibular. E. Femoral. 22. Examining a patient the doctor detected the following symptom complex: the paralysis of the digital flexors, the foot thus became permanently extended, the toes resembled the claws. Which nerve was injured? A. Saphenous. B. Common peroneal. C. Superficial fibular. *D. Tibial. E. Femoral. 23. Examining a patient the doctor detected the following symptom complex: the inability to extend and pronate the foot, the foot hangs down and laterally. Which nerve was injured? *A. Fibular. B. Posterior cutaneous nerve of thigh. C. Genitofemoral. D. Branches of obturator nerve. E. Tibial. 24. A patient has a tongue motor function disorder. Which nerve was injured? А. N. vagus B. N. facialis C. N. glossopharyngeus D. N. trigeminus E. N. hypoglossal 25. A patient has the hypoglossal nerve inflammation. Through what foramen the hypoglossal nerve leaves the skull? A. Jugular foramen B. Foramen stylomastoideum C. Foramen rotundum D. Hypoglossal canal E. Foramen ovale 26. At the man as a result of a craniocerebral trauma 9-12 pairs cranial nerves have been damaged. Define, how there could pass a fracture line on basilar department of an occipital bone which has led to damage of nerves? А. Through foramen lacerum et canalis condylaris B. Along linea superios et foramen ovale C. Through foramen magnum et fossa jugularis D. Along linea nuchae inferior et foramen rotundum E. Along sutura sagittalis et foramen spinosum 27. Carrying out neurologic inspection of the patient, 22 years, the doctor has asked it to open a mouth and to utter a note of "Aaaa", thus estimated, whether the soft palate symmetrically rises. Then the doctor has touched a cotton plug to a soft palate and in the answer there was a vomitive jerk that is accompanied by locomotion of the palate and the pharynx. What cranial nerves were investigated by the doctor? A. 10,11 and 12 B. 5,7 and 9 C. 7,8 and 9 D. 9 and 10 Е. 9 and 12 28. At the patient on a X-ray the enlarged lymph nodes in a field of a root lungs are taped. The patient complains of retardation of a warm rhythm and pain sensation in heart. The doctor considers that symptoms from heart are invoked by pressure upon its nerves of the enlarged knots. What of nerves are compressed by the enlarged lymph nodes? A. N. splanchnicus major B. Rr. cardiaci n. vagus C. Nn. intercostals D. Truncus sympaticus E. N. Phrenicus 29. At the patient with the aneurism of the subclavial artery hoarseness of a voice is observed. To what of a cranial nerve it can be bound? A. N. laryngeus inferior sinister B. N. laryngeus superior dexter C. N. laryngeus reccurens dexter D. N. laryngeus superior sinister E. N. laryngeus reccurens sinister 30. During reception in clinic, at the patient was disturbance of gustatory receptors that accept bitter is revealed, tactile sensitivity of a back 1/3 of tongue is not broken. What nerve is involved in pathological process? A. The glossopharyngeal (rami tonsillares) B. The glossopharyngeal (rami linguales) C. The glossopharyngeal (rami pharyngei) D. The intermediate (n. chorda tympani) E. The trigeminal (n. lingualis) 31. The patient complains of a pain in a root of tongue and in a field of palatine tonsils. What nerve supplies these fields? A. The glossopharyngeal (rami pharyngei) B. The glossopharyngeal (rami linguales) C. The glossopharyngeal (rami tonsillares) D. The intermediate (n. chorda tympani) E. Trigeminal (n. lingualis) 32. 1. Which nerve is damaged, if the right nasolabial fold is smoothed, right orbital fissure is dilated (it cannot be screwed up because eyelids don′t close), difficulties arouse while talking and eating (food sticks between the cheek and teeth)? A. N. facialis. B. Nn. alveolaris superiors (n. maxillaris) C. N. oculomotorius D. N. mandibularis. E. N ophthalmicus. 33. A patient can not lift an eyebrow on one half of his face, close eyelids and bare his teeth. Which nerve is injured? A. N ophthalmicus. B. N. facialis. C. N. oculomotorius D. N. mandibularis. E. Nn. alveolaris superiors (n. maxillaris) 34. During the initial examination a patient does not have general sensitive of the anterior 2/3 of the tongue. Gustation is broken. What nerve is injured? A. N ophthalmicus. B. N. facialis. C. N. oculomotorius D. N. mandibularis. E. Nn. alveolaris superiors (n. maxillaris) 35. The patient was admitted to a neurological department with complaints that after acute viral respiratory disease she lost her sense of touch and temperature to in front 2/3 of tongue, she suffers from pain in this area (has burnt tongue hot tea). Indicate which of the branches of a nerve was damaged? A. The auriculotemporal nerve of the mandibular nerve of the trigeminal nerve B. The lingual nerve of the mandibular nerve of the trigeminal nerve C. The infraorbital nerve of the maxillary nerve of the trigeminal nerve D. The frontal nerve of the ophtalmic nerve of the trigeminal nerve E. The infratrochlear nerve of the ophtalmic nerve of the trigeminal nerve 36. The doctor-neurologist examined the patient with complaints of loss of skin sensation in the area of the lower eyelids, nasal area and upper lip. Which nerve is damaged? A. The ophthalmic nerve B. The frontal nerve C. The maxillary nerve D. The mandibular nerve E. The lacrimal nerve 37. The patient complains of sharp pain along the entire lower jaw. Authentically which nerve is damaged? A.The masseteric nerve of the mandibular nerve B. The lingual nerve of the mandibular nerve C. The deep temporal nerves of the mandibular nerve D. The inferior alveolar nerve of the mandibular nerve E. The zygomatic nerve of the maxillary nerve 38. After a cranial trauma with the damage of the superior wall of the right orbital cavity a patient lost the possibility to lift up the upper eyelid of the right eye (ptosis – depression of the superior eyelid) and look upward. Which nerve was damaged? A n. abducens dexter B r. superior n. oculomotorius C n. inferior n. oculomotorius D n.abducens sinister E n.trochlearis 39. In survey of the patient found the ptosis upper eyelids and dispersing strabismus, enhanced pupil, the limited mobility of the eyeball. What nerve is damaged? A n. trochlearis B n.facialis C n.oculumotorius D n. abducens E n. ophthalmicus 40. After a brain hemorrhage, the patient became stable squint right eye, lost its ability to turn lateral. The core of a cranial nerve damage during hemorrhage? A n. abducens sinister B n. facialis dexter C n.oculomotorius D n.abducens dexter E n.trochlearis References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 33. Introduction in vegetative nervous system. Sympathetic part of autonomic nervous system. 1. Relevance of the topic. The autonomic division of peripheral nervous system regulates physiological processes of the human organism like blood circulation, respiration, digestion, excretion and general metabolism; also, it regulates tissue trophic processes. The autonomic division acts relatively independently from the cerebral cortex and the organs supplied act involuntarily as well. Information about the autonomic nervous system is important for students of all specialties for further study. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of autonomic nervous system. Classification of the neuron. Histology Structure of nerve fibers. Neurology Topography of the sympathetic part of the PNS. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Pars sympathica The sympathetic part Pars parasympathica The parasympathetic part Truncus sympathicus The sympathetic trunk 4.2. Theoretical questions for the class: 1. What the autonomic division of CNS is responsible for? 2. What are the evolutional features of the autonomic division of CNS? 3. Name the parts of the autonomic division of CNS. 4. Name the chief function of the parasympathetic part of the autonomic division of CNS. 5. Name the chief function of the sympathetic part of the autonomic division of CNS. 6. Where do the centers of the sympathetic part of autonomic division of CNS reside? What are they represented with? 7. Where do the superior autonomic centers reside? 8. Give definition of the preganglionic nerve fibers. 9. Give definition of the postganglionic nerve fibers. 10. Name the groups of the autonomic ganglia. 11. Give definition of the sympathetic trunk. 12. Give definition of the white rami communicantes. 13. Give definition of the grey rami communicantes. 14. What are the compartments of the sympathetic trunk? 15. Where do the superior, the middle and the inferior cervical ganglia reside? 16. What branches arise from the superior cervical ganglion? 17. What branches arise from the middle cervical ganglion? 18. What branches arise from the inferior cervical ganglion? 19. Where do the thoracic ganglia of sympathetic trunk reside? 20. What branches arise from the thoracic ganglia of the sympathetic trunk? 21. Describe the greater splanchnic nerve. 22. Describe the lesser splanchnic nerve. 23. What branches arise from the lumbar and the sacral ganglia of sympathetic trunk? 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the autonomic nervous system on the parts, ganglions using preparations, models, tables. Content of the topic. The autonomic division of the nervous system supplies the viscera, the nonstriated muscles, the glands, the heart and the blood vessels. Running along the blood vessels, the autonomic nerves expand into the muscles to provide trophic nerve supply. From the evolutional point of view, the autonomic nervous system is much older than the somatic division and thus it retains some primitive traits. They are the morphological features of the autonomic nervous system ■ the featured neurons reside pre-dominately within the autonomic ganglia outside the CNS; ■ two-neuron efferent pathway from the CNS to the effectors; ■ thin non-myelinated postganglionic fibers (1-4 pm) with low transmission rate; ■ network-type arrangement of the postganglionic fibers that form the autonomic plexuses. According to functional and morphological features, the autonomic nervous system is subdivided into the sympathetic and parasympathetic parts, which in most cases have opposite effects on an organism. Generally, the parasympathetic nervous system guards an organism by maintaining homeostasis, while the sympathetic system regulates adaptation by enhancing the trophic processes. The viscera have double nerve supply that act in accord to optimize functioning of the systems. The blood vessels except for the coronary ones, the skin glands and the skeletal muscles are supplied by the sympathetic part only. The autonomic nervous system comprises the regulatory centers situated within the CNS and the peripheral part represented by the autonomic nerves, the autonomic plexuses and the autonomic ganglia. The regulatory centers of the autonomic nervous system The sympathetic centers occupy the lateral grey columns of the spinal cord (the intennediolateral nucleus) with respect to the segments C8 through L2. The parasympathetic centers reside within the brainstem (the cranial part) and within the sacral compartment of the spinal cord (the sacral part). 1. The cranial part of the para-sympathetic nervous system features the nuclei of cranial nerves as follows: a) the accessory nucleus of oculomotor nerve, nucleus accessorius nervi oculomotorii situated within the midbrain; b) the superior salivatory nucleus, nucleus salivatorius superior situated within the pons; c) the inferior salivatory nucleus, nucleus salivatorius inferior and the dorsal nucleus of vagus nerve, nucleus dorsalis nervi vagi situated within the medulla oblongata. 2. The sacral part is represented with the sacral parasympathetic nuclei, nuclei parasympathici sacrales situated in between the anterior and the posterior grey columns with respect to segments S2 through S4. The superior autonomic centers dominate over the autonomic regulatory centers. They regulate activities of both sympathetic and parasympathetic parts and thus are the suprasegmental centers. They reside within the following compartments of the brain: 1) the medulla oblongata contains the vasculomotor, the respiratory, the vomiting and the deglutition centers; 2) the cerebellum is responsible for skin trophies, wound healing and the arrector muscles of hair; 3) the subthalamus regulates all autonomic functions, metabolism, hunger, thirst, body temperature, sexuality and activities of the endocrine glands. Activities of the subthalamus in turn is under control of the cerebral cortex (mainly from the limbic system); 4) the telencephalon regulates blood pressure, salivation and lacrimation; 5) the cerebral cortex may influence any autonomic function via the cortico-visceral associations. The autonomic ganglia The autonomic ganglia are the relay centers for the efferent fibers. With respect to the relay centers, the efferent fibers are subdivided into the preganglionic and postganglionic types: ■ the preganglionic nerve fibers, neurofibrae preganglionicae are the axons of autonomic regulatory centers situated within the brainstem and the spinal cord. Most of them are myelinated with high transmission rate featured. They synapse within the autonomic ganglia; ■ the postganglionic nerve fibers, neurofibrae postganglionicae are the axons of the autonomic ganglia. They are non-myelinated fibers (and thus are of grey color) with low transmission rate. The autonomic ganglia are the peripheral autonomic centers. They are responsible for impulses multiplication (one ganglionic fiber is in contact with 50 or even more ganglionic neurons) and transmission rate reduction. Classification of the autonomic ganglia Depending on location, the ganglia are subdivided into the groups like the following: ■ the paravertebral ganglia, ganglia paravertebralia that run along the lateral surfaces of the vertebral column (they are the ganglia of the sympathetic trunk); ■ the prevertebral ganglia, ganglia prevertebralia that run along the anterior surface of the vertebral column (they are the ganglia of the thoracic and the abdominal autonomic plexuses). They also belong to the sympathetic nervous system; ■ the terminal ganglia, ganglia terminalia that either neighbor the organ supplied (the external ganglia like the ciliary ganglion, the pterygopalatine ganglion, the submandibular ganglion or the otic ganglion) or reside deeper within the organ (the intramural ganglia). They are the parasympathetic ganglia. The autonomic reflex arc The simplest autonomic reflex arc comprises three types of neurons: The sensory (afferent) neurons of the autonomic division reside within the spinal or the cranial sensory ganglia (these ganglia are shared by somatic and autonomic divisions). The sensory ganglia consist of the pseudounipolar cells with the central and the peripheral processes featured. The peripheral processes reach the viscera (the heart, the lungs, the stomach etc.) and terminate at the interoceptors that accept the stimuli. The central processes run to the autonomic centers (of the spinal cord and the brainstem) via the posterior roots of spinal cord and the cranial nerves. The second neurons reside within the autonomic nuclei of the spinal cord and the brainstem; the axons of the pertaining cells are the preganglionic efferent fibers that quit the CNS within the anterior roots of spinal cord and the cranial nerves and reach the autonomic ganglia. The third neurons form the autonomic ganglia; their axons are the postganglionic efferent fibers that reach the respective organs via the autonomic plexuses. Thus, the efferent autonomic pathway unlike that of the somatic division comprises two neurons. The sympathetic fibers synapse within the prevertebral or the paravertebral ganglia and the parasympathetic fibers synapse within the terminal ganglia (either external or intramural). THE SYMPATHETIC PART, PARS SYMPATHICA The sympathetic part features two compartments — the central and the peripheral. The sympathetic centers are the interme diolateral nuclei situated within the lateral grey columns of spinal cord with respect to the segments C8 through L2. The peripheral compartment com-prises the following portions: ■ the paravertebral sympathetic ganglia that form the sympathetic trunks; ■ the prevertebral sympathetic ganglia situated anterior to the vertebral column. They belong to numerous abdominal autonomic plexuses; the preganglionic sympathetic fibers that run from the sympathetic centers to the autonomic ganglia (they are the white rami communicantes and the interganglionic branches); the postganglionic sympathetic fibers that arise from the sympathetic ganglia and join the plexuses to reach the responsibility areas (the grey rami communicantes, the visceral branches and the sympathetic nerves); ■ numerous thoracic and abdominal plexuses (the periarterial and the visceral plexuses). The sympathetic trunk, truncus sympathicus The paired sympathetic trunk runs from the external cranial base down to the coccyx. It comprises 20-25 ganglia of sympathetic trunk, ganglia trunci sympathici associated by the interganglionic branches, rami interganglionares. Upon reaching the coccyx, the trunks merge into a single ganglion impar. The sympathetic trunk comprises the cervical, the thoracic, the lumbar and the sacral parts. The ganglia of the sympathetic trunk contain the peripheral efferent neurons of the sympathetic part. Morphologically they are referred to as the small multipolar neurons. All thoracic and two upper lumbar ganglia accept the preganglionic sympathetic fibers as the white rami communicantes, rami communicantes albi that arise from the eighth cervical, all thoracic and two upper lumbar segments. They are the axons of the intermediolateral nucleus of the spinal cord. The cervical, the lower lumbar, the sacral and the coccygeal ganglia lack rami communicantes. The preganglionic fibers reach these ganglia directly via the interganglionic branches, rami interganglionares. All ganglia of the sympathetic trunk give rise to two major types of branches: the grey rami communicantes, rami communicantes grisei and the visceral branches that supply the respective organs. The grey rami communicantes are the postganglionic fibers that reach the neighboring spinal nerve and run within all its branches. These postganglionic branches provide trophic nerve supply to the muscles and to skin; they also supply the blood and the lymphatic vessels, the sweat and the sebaceous glands, the nonstriated muscles and the arrector muscles of hair. The visceral branches that arise from all ganglia of the sympathetic trunk form the sympathetic nerves that supply the viscera. Some of them comprise the postganglionic fibers only while some feature both postganglionic and preganglionic fibers; the latter traverse the ganglia of sympathetic trunk and synapse within the prevertebral ganglia i.e. directly with the peripheral efferent neurons of the sympathetic part of autonomic nervous system. The cervical part of sympathetic trunk resides on the deep cervical muscles posterior to the prevertebral layer of cervical fascia. It comprises three ganglia — the superior, the middle and the inferior cervical ganglia. The superior cervical ganglion, ganglion cervicale superius is the largest of the group (2X6 mm). It resides anterior the spinous processes of the vertebra C2-C3. It neighbors the internal carotid artery that runs anteriorly and the vagus nerve together with the internal jugular vein that run laterally. The superior cervical ganglion gives rise to two types of branches formed of the postganglionic fibers: 1) the grey rami communicantes, rami communicantes grisei that join four upper cervical spinal nerves; 2) the visceral branches as follows: ■ the internal carotid nerve, nervus caroticus intemus forms the plexus along the internal carotid artery and related branches. The sympathetic fibers from the nerve supply the glands of nasal and palatine mucosa, the lacrimal glands, the eyeball tunics and the sphincter pupillae; ■ the external carotid nerves, nervi carotid intemi run along the external carotid artery and related branches. They supply the blood vessels, the glands and other cranial organs; ■ the jugular nerve, nervus jugularis ascends along the internal jugular vein to the jugular foramen. There it gives some branches to the ganglia of the glossopharyngeal and the vagus nerves and tot the trunk of the hypoglossal nerve; ■ the laryngopharyngeal branches, nervi laryngopharyngei reach the larynx and the pharynx to form the respective plexuses; ■ the superior cervical cardiac nerve, nervus cardiacus cervicalis superior descends to the thoracic cavity and joins the cardiac plexus. The middle cervical ganglion, ganglion cervicale medium is a smaller ganglion (2X2 mm) found at the level of the spinous process of C4. It maintains a specific association with the cervicothoracic (stellate) ganglion via two interganglionic branches that enfold the subclavian artery anteriorly and posteriorly and reunite below to form the ansa subclavia. Anteriorly, the ganglion is covered by the common carotid artery and the inferior thyroid artery. The middle cervical ganglion gives off the branches as follows: 1) the grey rami communican- tes, rami communicantes grisei that join the fifth and the sixth spinal nerves; 2) the visceral branches: ■ the middle cervical cardiac nerve, nervus cardiacus cervicalis medius that descends to the thoracic cavity and joins the cardiac plexus; ■ the inferior thyroid nerve, nervus thyroideus inferior expands along the inferior thyroid artery and related branches to reach the thyroid gland and the larynx; ■ the common carotid nerve, nervus caroticus communis expands along the common carotid artery and proceeds to both external and internal carotid arteries; In absence of the middle cervical ganglion, all pertaining branches arise from the interganglionic fibers at the level of spinous process of C6. The inferior cervical ganglion, ganglion cervicale inferius in most cases merges with the first thoracic ganglion to form the cervicothoracic (stellate) ganglion, ganglion cervicothoracicum (stellatum). The ganglion resides at the level of the neck of first rib, posterior to the subclavian and the vertebral arteries. The ganglion gives the branches as follows: 1) the grey rami communicantes, rami communicantes grisei that join the seventh and the eighth spinal nerves; 2) the visceral branches: ■ the subclavian branches also given by the ansa subclavia, they form the subclavian plexus that reach the thyroid gland, the parathyroid glands, the mediastinal viscera and expand onto the entire upper limb; ■ the vertebral nerve, nervus vertebralis forms the vertebral plexus. In the area of the foramen transversarium of C6, there is a small vertebral ganglion, ganglion vertebrale related to the nerve, the vertebral plexus supplies the blood vessels of the brain and the spinal cord and the meninges; ■ the inferior cervical cardiac nerve, nervus cardiacus cervicalis inferior descends to the thoracic cavity and joins the cardiac plexus together with other cardiac nerves; ■ the branches to the vagus nerve and the phrenic nerve. The thoracic part of sympathetic trunk comprises 10 to 12 thoracic ganglia, ganglia thoracica situated on the heads of ribs below the parietal pleura. Posteriorly one can distinguish the posterior intercostal arteries and veins. The thoracic ganglia give the following branches: 1) the grey rami communicantes, rami communicantes grisei that join all thoracic spinal nerves; 2) the visceral branches of upper 5-6 ganglia supply the thoracic viscera: ■ the thoracic cardiac branches, rami cardiaci thoracici arise from upper 5-6 ganglia and join the cardiac plexus; ■ the thoracic pulmonary branches, rami pulmonales thoracici form the pulmonary plexus, plexus pulmonalis together with the respective branches of the vagus nerve; ■ the esophageal branches, rami oesophageales form the esophageal plexus, plexus oesophagealis together with the respective branches of the vagus nerve; ■ the thoracic aortic nerves, nervi aortic thoracici form the thoracic aortic plexus, plexus aorticus thoracicus that expands along all branches of the thoracic aorta. The visceral branches of the lower 5-6 thoracic ganglia participate in nerve supply of the abdominal viscera: ■ the greater splanchnic nerve, nervus splanchnicus major arises from the ganglia Th5 through Thl2. It comprises the preganglionic fibers that merge into a single nerve along the lateral surfaces of vertebral bodies. The nerve penetrates the lumbar part of diaphragm and enters the abdominal cavity to synapse within the coeliac plexus. At the level of Thl2 one can distinguish a small thoracic splanchnic ganglion, ganglion thoracicum splanchnicum. The greater splanchnic nerve also carries the sensory fibers from the lower six thoracic spinal nerves; ■ the lesser splanchnic nerve, nervus splanchnicus minor arises from the ganglia Th 10 through Th 11. It also comprises the preganglionic fibers. The nerve descends to the abdominal cavity together with the sympathetic trunk (through the lumbar part of diaphragm) and synapses within the coeliac plexus; ■ the least splanchnic nerve, nervus splanchnicus imus arises from the ganglion ThlO and terminates within the renal plexus. The lumbar part of the sympathetic trunk is a continuation of the thoracic part. It comprises 3 to 5 lumbar ganglia, ganglia lumbales situated on the anterolateral surfaces of the bodies of lumbar vertebrae next to medial border of the psoas major. The ganglia are covered with the peritoneum. They are associated by means of the interganglionic branches that cross the vertebral column posterior to the aorta and the inferior vena cava. The lumbar ganglia give rise to two types of branches: 1) the grey rami communicantes, rami communicantes grisei that join all lumbar spinal nerves; 2) the lumbar splanchnic nerves, nervi splanchnici lumbales that comprise both pre- and postganglionic fibers from the abdominal aortic plexus. The plexus expands along all branches of abdominal aorta. The preganglionic fibers synapse within the prevertebral ganglia of the abdominal autonomic plexuses. The sacral part of the sympathetic trunk comprises four sacral ganglia, ganglia sacralia that reside on the pelvic surface of the sacrum medially from the pelvic sacral foramina. Inferiorly, both trunks merge at a single ganglion impar situated on the anterior surface of the first coccygeal vertebra. The sacral ganglia are associated by means of the transverse interganglionic fibers. The sacral ganglia give rise to the following branches: 1) the grey rami communicantes, rami communicantes grisei that join all sacral spinal nerves; 2) the sacral splanchnic nerves, nervi splanchnici sacrales that comprise both pre- and postganglionic fibers given by the superior and the inferior hypogastric plexuses. The fibers of the inferior hypogastric plexus run along all branches of the internal iliac artery to supply the pelvic viscera. Materials for self-check: A. Tasks for self-check: specify division of the autonomic nervous system on the parts, ganglions using preparations, models, tables. B. Situational tasks. 1. In the patient has been found the tumor process. This morbid condition has involved in process the superior cervical ganglion of sympathetic trunk on the right side. Which of the following symptoms were observed? A. Disturbance of the accommodation′s processes of on the right B. Paralysis of the medial rectus muscle of the right eye C. Sustained expansion of the pupil on the right. D. Violation of lacrimation on the right *E. Strong narrowing of the right pupil 2. In patients with pulmonary tuberculosis has been found the increasing of the tracheobronchial lymph nodes which are located between the aortic arch and the bifurcation of the trachea. This morbid condition was leading to changes in heart rate.What nerves has been compressed by this pathologic process? A. The internal carotid nerve B. The inferior thyroid nerve C. The vertebral nerve *D. The vagus nerve E. The greater splanchnic nerve 3. After subcutaneous entering of adrenaline the patient has been investigated over 10 minutes. In the patient there were the blanching of the skin, the trembling of the hands, the rise of the blood pressure, the increasing of the blood sugar. Excitability which part nerves system lead to these symptoms? A. The vegetative division of the nervous system B. The central nervous system *C. The sympathetic part of the autonomic nervous system D. The parasympathetic part of the autonomic nervous system E. The somatic nervous system 4. You must do the novocaine blockade in the neck by the penetrating wound of the chest cavity to prevent shock. This solution of novocaine has been injected into the space between the superficial and prevertabral layers of the cervical fascia. What nerve formation while that has been blocked? A. The internal carotid nerve *B. The vagus nerve and cervical part of sympathetic trunk. C. The vertebral nerve D. The jugular nerve E. The greater splanchnic nerve 5. After entering into the skin 1 mg of atropine the patient has been investigated after 5-10 min. In the patient there were the dry mouth, the dilated pupils, the accelerated pulse. Excitability which part nerves system lead to these symptoms? *A. Sympathetic fibers B. Parasympathetic centers in the brain C. Sympathetic centers in the spinal cord D. Parasympathetic fibers E. Celiac plexus 6. Sympathetic nerves form a plexus mainly on the way: А. Somatic nerves В. Bones С. Veins D. Cranial nerves *Е. Arteries 7. The muscle dilating a pupil are innervated by: A. Parasympathetic fibers B. The vagus nerve C. Sympathetic fibers from the inferior cervical ganglion *D. Sympathetic fibers from the superior cervical ganglion E. The facial nerve 8. The central (cortical) part of the sympathetic nervous system is in: А. The cerebellum В. The brainstem *С. The spinal cord D. The midbrain Е. The cortex of a limbic brain 9. The unpaired knot of the sympathetic trunk is called: А. Ganglion spinale *B. Ganglion impar C. Ganglion opticum D. Ganglion ciliare E. Ganglion pterigopalatinum 10. The segmentary center of the sympathetic part of vegetative nervous system is at level: *А. С8 - L2 В. S1 - S3 С. С1 - C2 D. L1 – L5 Е. Th1 - Th12 References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 34. Parasympathetic part of autonomic nervous system. 1. Relevance of the topic. The autonomic division of peripheral nervous system regulates physiological processes of the human organism like blood circulation, respiration, digestion, excretion and general metabolism; also, it regulates tissue trophic processes. The autonomic division acts relatively independently from the cerebral cortex and the organs supplied act involuntarily as well. Information about the autonomic nervous system is important for students of all specialties for further study. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of autonomic nervous system. Classification of the neuron. Histology Structure of nerve fibers. Neurology Topography of the parasympathetic part of the PNS. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Pars sympathica The sympathetic part Pars parasympathica The parasympathetic part Nucleus accessories nervi oculomotorii The accessory nucleus of oculomotor nerve Nucleus salivatorius superior The superior salivatory nucleus Nucleus salivatorius inferior The inferior salivatory nucleus Nucleus dorsalis nervi vagi The dorsal nucleus of vagus nerve 4.2. Theoretical questions for the class: 1. Where do the centers of the parasympathetic part of autonomic division of CNS reside? What are they represented with? 2. Describe the route of the preganglionic fibers from the accessory nucleus of oculomotor nerve. 3. Describe the route of the postganglionic fibers from the ciliary ganglion. 4. Describe the route of the preganglionic fibers from the superior salivatory nucleus. 5. Describe the route of the preganglionic fibers from the inferior salivatory nucleus. 6. Describe the route of the post-ganglionic fibers from the pterygopalatine ganglion. 7. What branches of the vagus nerve supply the viscera? 8. Describe the route of the preganglionic fibers from the sacral parasympathetic nuclei. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the autonomic nervous system on the parts, parasympathethic nuclei using preparations, models, tables. Content of the topic. The cranial part of the parasympathetic part of autonomic division of CNS is represented with the centers situated within the brainstem and the fibers that join the cranial nerves. The accessory nucleus of oculomotor nerve, nucleus accessorius nervi oculomotorii gives rise to the preganglionic fibers that join the oculomotor nerve (III pair) and run to the ciliary ganglion; the postganglionic fibers reach the ciliary muscle and the sphincter pupillae as the short ciliary nerves. The superior salivatory nucleus, nucleus salivatorius superior gives rise to the fibers related to the facial nerve (VII pair). Some fibers detach from the main trunk to become continuous with the lesser petrosal nerve. The nerve passes through the pterygoid canal and terminates within the pterygopalatine ganglion. The post- ganglionic fibers reach the lacrimal gland (via the zygomatic nerve and the lacrimal nerve), the nasal mucosa (via the posterior nasal nerves) and the palatine mucosa (via the greater and lesser palatine nerves). Other preganglionic fibers join the chorda tympani, which in turn joins the lingual nerve. The preganglionic fibers reach the submandibular ganglion to synapse within it. The postganglionic fibers proceed to the sublingual gland via the sublingual branches and to the submandibular gland via the glandular branches. The inferior salivatory nucleus, nucleus salivatorius inferior gives rise to the fibers that join the glossopharyngeal nerve (IX pair). The fibers run as the tympanic nerve, which becomes continuous with the lesser petrcsal nerve. The latter terminates within the otic ganglion. The postganglionic fibers join the auriculotemporal nerve and reach the parotid gland. The dorsal nucleus of vagus nerve, nucleus dorsalis nervi vagi is the greatest parasympathetic nucleus. It resides within the medulla oblongata at the level of the vagal trigone. The nucleus gives rise to the preganglionic fibers that reach their responsibility areas alongside with the following branches: 1) the pharyngeal branches, rami pharyngei participate in formation of the pharyngeal plexus; 2) the superior laryngeal nerve, nervus laryngeus superior and the recurrent laryngeal nerve, nervus laryngeus recurrens participate in formation of the laryngeal plexus. The parasympathetic fibers synapse within the laryngeal and the thyroid intramural ganglia; 3) the superior and the inferior cervical cardiac branches, rami cardiaci superiores et inferiores and the thoracic cardiac branches, rami cardiaci thoracici form the cardiac plexus. The preganglionic fibers synapse within the cardiac ganglia, ganglia cardiaca; 4) the bronchial branches, rami bronchiales that take part in formation of the pulmonary plexus; 5) the anterior and the posterior gastric branches, rami gastrici anteriores et posteriores that form the gastric plexus; 6) the hepatic branches, rami hepatici that form the hepatic plexus; 7) the coeliac branches, rami coeliaci to the pancreas. These fibers traverse the coeliac plexus and join the pancreatic plexus; 8) the renal branches, rami renales to the kidneys. These fibers terminate within the respective intramural ganglia; 9) the coeliac branches, rami coeliaci to the small intestine. These fibers traverse the coeliac plexus and join the superior mesenteric plexus. On reaching the intestinal wall, they terminate within the ganglia of the myenteric plexus (Auerbach’s plexus) and the submucous plexus (Meissner’s plexus); 10) the coeliac branches, rami coeliaci to the large intestine (except for the sigmoid colon and the rectum). These fibers also traverse the coeliac plexus and join the superior and the inferior mesenteric plexuses to reach the intestinal wall.

The sacral part of the parasympathetic part of autonomic division of CNS is represented with the sacral parasympathetic nuclei, nuclei parasympathici sacrales. They reside in between the anterior and the posterior grey columns of spinal cord with respect to the segments S2 through S4. The cells of these nuclei give rise to the preganglionic fibers that quit the spinal cord within the anterior roots, enter the sacral spinal nerves S2 through S4 and eventually appear within the sacral plexus. The parasympathetic fibers detach from the sacral plexus and run as the pelvic splanchnic nerves, nervi splanchnici pelvici that join the pelvic autonomic plexuses (the vesical plexus, the prostatic plexus, the uterovaginal plexus, the middle and the inferior rectal plexuses). These fibers also synapse within the intramural ganglia. Materials for self-check: A. Tasks for self-check: specify division of the autonomic nervous system on the parts, parasympathethic nuclei using preparations, models, tables. B. Situational tasks. 1. At the patient on a X-ray the enlarged lymph nodes in a field of a root lungs are taped. The patient complains of retardation of a warm rhythm and pain sensation in heart. The doctor considers that symptoms from heart are invoked by pressure upon its nerves of the enlarged knots. What of nerves are compressed by the enlarged lymph nodes? *A. Rr. cardiaci n. vagus B. N. splanchnicus major C. Nn. intercostales D. Truncus sympaticus E. N. Phrenicus 2. After entering into the skin 1 mg of atropine the patient has been investigated after 5-10 min. In the patient there were the dry mouth, the dilated pupils, the accelerated pulse. What nerve formation while that has been blocked? A. Sympathetic fibers *B. Parasympathetic fibers C. Sympathetic centers in the spinal cord D. Parasympathetic centers in the spinal cord E. Celiac plexus 3. The segmentary center of the parasympathetic part of vegetative nervous system is at level: А. С8 - L2 В. С1 - C2 *С. S2 – S4 D. L1 – L4 Е. Th1 - Th12 4. The muscle narrowing a pupil are innervated by parasympathetic fibers from: A. Nucleus impar B. Nucleus salivatorius inferior C. Nucleus salivatorius superior *D. Nucleus accessorius n. oculomotorii E. Nucleus dorsalis n. vagi 5. At the patient the dacryagogue, the raised salivation is observed. This state, in the ratio with the second symptoms, is regarded as a boring of fibers of one of cranial nerves. What nerve and what its fibers? A. Parasympathetic fibers of the facial nerve B. Parasympathetic fibers of the oculomotor nerve C. Somatic motor fibers of the oculomotor nerve D. Parasympathetic fibers of the vagus nerve *Е. Parasympathetic fibers of the intermediate nerve 6. In the patient has been found the tumor process. This morbid condition has involved in process the accessory nucleus on the right side. Which of the following symptoms were observed? *A. Sustained expansion of the pupil on the right. B. Paralysis of the medial rectus muscle of the right eye C. Disturbance of the accommodation′s processes of on the right D. Violation of lacrimation on the right E. Strong narrowing of the right pupil 7. A patient has appealed with complaints of visual impairment accompanied by blepharoptosis, impossibility to lift the eyeball upwards and to the middle. Examination has shown that the eyeball is diverted outside, the pupil is dilated, does not react to light, the patient can′t see at a short distance. Which nerve has been injured? A n. abducens dexter *B n. oculomotorius C n. opticus D n. abducens sinister E n. Trochlearis 8. The central (cortical) part of the parasympathetic nervous system is in: А. The cerebellum В. The spinal cord *С. The brainstem D. The midbrain Е. The cortex of a limbic brain 9. After operation on a stomach at the patient complication in the form of weakening of its peristalsis, reduction of secretion of glands and weakening of the pyloric sphincter has educed. What nerve has suffered at an operative measure? A. The trigeminal B. The facial C. The oculomotor *D. The vagus E. The intermediate (n. chorda tympani) 10. The patient suffer from dysfunction of the parotid salivary gland. What nerve increases its secretion? A. N auricularis major B. N petrosus major C. N. petrosus profundus D. N. auricularis minor *E. N. petrosus minor References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 35. Autonomic innervation of organs. Autonomic ganglions of head and neck, pelvis, abdomen. 1. Actuality of theme. Doctors of all specialties required detailed study of the anatomy of the autonomic nervous system, the main function of which is the regulation of the internal organs. Knowledge shared innervation of smooth muscle and will require students to further study many clinical disciplines. 2. The specific aims. 2.1.To have general knowledge of the topic studied; 2.2. To understand, to remember and to use the knowledge received; 2.3. To form the professional experience by reviewing, training and authorizing it; 2.4. To be able to find and show studying structures on visual aids. 3. Basic knowledge and skills necessary for study the topic (interdisciplinary integration) The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of autonomic nervous system. Classification of the neuron. Histology Structure of nerve fibers. Neurology Topography of the autonomic nervous system. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. 4. Tasks for students' individual work. 4.1. The list of basic terms, parameters, characteristics which the student should master while preparing for the class: Pars sympathica The sympathetic part Pars parasympathica The parasympathetic part Nucleus accessories nervi oculomotorii The accessory nucleus of oculomotor nerve Nucleus salivatorius superior The superior salivatory nucleus Nucleus salivatorius inferior The inferior salivatory nucleus Nucleus dorsalis nervi vagi The dorsal nucleus of vagus nerve 4.2. Theoretical questions for the class: 1. Name the groups of the autonomic ganglia. 2. Name the autonomic plexuses of the thoracic cavity. 3. Name the autonomic plexuses of the abdominal cavity. 4. What autonomic (sympathetic) ganglia belong to the coeliac plexus? 5. What autonomic plexuses originate from the coeliac plexus? 6. What are the parts of the intestinal plexus? 7. What plexuses arise from the inferior hypogastric plexus? 8. Give definition of the sympathetic trunk. 9. Give definition of the white rami communicantes. 10. Give definition of the grey rami communicantes. 11. What are the compartments of the sympathetic trunk? 12. Where do the superior, the middle and the inferior cervical ganglia reside? 13. What branches arise from the superior cervical ganglion? 14. What branches arise from the middle cervical ganglion? 15. What branches arise from the inferior cervical ganglion? 16. Where do the thoracic ganglia of sympathetic trunk reside? 17. What branches arise from the thoracic ganglia of the sympathetic trunk? 18. Describe the greater splanchnic nerve. 19. Describe the lesser splanchnic nerve. 20. What branches arise from the lumbar and the sacral ganglia of sympathetic trunk? 21. Describe how the preganglionic sympathetic fibers reach the coeliac plexus. 22. Describe the fate of the postganglionic sympathetic fibers. 23. Describe the route of the preganglionic fibers from the accessory nucleus of oculomotor nerve. 24. Describe the route of the postganglionic fibers from the ciliary ganglion. 25. Describe the route of the preganglionic fibers from the superior salivatory nucleus. 26. Describe the route of the preganglionic fibers from the inferior salivatory nucleus. 27. Describe the route of the postganglionic fibers from the pterygopalatine ganglion. 28. What branches of the vagus nerve supply the viscera? 29. Describe the route of the preganglionic fibers from the sacral parasympathetic nuclei. 30. Name the autonomic plexuses of the pelvic viscera. 4.3. Practical task pertaining to the topic and to be completed during the class: specify division of the autonomic nervous system on the parts, parasympathethic nuclei, autonomic plexus using preparations, models, tables. Content of the topic. The autonomic plexuses represent network-type arrangement of the peripheral part of autonomic nervous system. The autonomic fibers group around the blood vessels (and form the periarterial plexuses) and around the viscera (and form the visceral plexuses). The plexuses contain both sympathetic and parasympathetic fibers together with the sensory fibers from the vagus nerve and the spinal nerves. The plexuses contain numerous large and small autonomic ganglia, ganglia autonomica. Some of the autonomic plexuses have been already discussed. They are the thoracic aortic plexus, the cardiac plexus, the esophageal plexus and the pulmonary plexus. The greatest autonomic plexuses reside within the abdominopelvic cavity. The abdominal aortic plexus, plexus aorticus abdominalis enfolds the abdominal aorta and expands onto both parietal and visceral branches of this great blood vessel. The greatest portion of the plexus is the coeliac plexus, plexus coeliacus. Because of size, the plexus is sometimes called the ‘abdominal brain’. It resides on the anterior surface of the aorta next to the coeliac trunk and the superior mesenteric artery. The plexus comprises five large ganglia as follows: ■ the coeliac ganglia, ganglia coeliaca, the crescent-shaped ganglia that enfold the coeliac trunk; ■ the aorticorenal ganglia, ganglia aorticorenalia found next to renal artery arise point; ■ the superior mesenteric ganglion, ganglion mesentericum superius the unpaired ganglion that resides next to the superior mesenteric artery root. The coeliac plexus comprises both greater and lesser splanchnic nerves that arise from thoracic ganglia of the sympathetic trunk and the lumbar splanchnic nerves given by the respective ganglia. The coeliac plexus accepts the fibers from the posterior vagal trunk (both sensory and parasympathetic) and the sensory fibers from the right phrenic nerve. The coeliac plexus gives rise to the nerves that carry the postganglionic sympathetic fibers and the preganglionic parasympathetic fibers. The nerves form the periarterial plexuses that run to their responsibility areas i.e. to the viscera. The second large plexus is the superior mesenteric plexus, plexus mesentericus superior that runs along all branches of the superior mesenteric artery. The fibers of the plexus supply the small intestine, the cecum, the ascending colon and the transverse colon. A segment of the abdominal aortic plexus enclosed between the superior and the inferior mesenteric arteries is called the intermesentricplexus, plexus intermesentericus. This gives rise to the inferior mesenteric plexus, plexus mesentericus inferior that runs along the artery of the same name and related branches. The fibers of the plexus supply the transverse colon, the descending colon, the sigmoid colon and the upper portion of the rectum. The abdominal aortic plexus proceeds onto the common iliac arteries to become continuous with left and right iliac plexuses, plexus iliaci. Some large nerves from the abdominal aortic plexus form the superior hypogastric plexus, plexus hypogastricus superior. It resides below the aortic bifurcation between the common iliac arteries. The plexus also accepts the splanchnic nerves from the lower lumbar ganglia and the upper sacral ganglia of the sympathetic trunks. Within the lesser pelvis, the superior hypogastric plexus splits into left and right inferior hypogastric plexuses, plexus hypogastricus inferior found laterally from the urinary bladder and the rectum. They also comprise the ganglia and association branches. The inferior hypogastric plexus accepts the sacral splanchnic nerves and the parasympathetic fibers from the sacral parasympathetic nuclei, nuclei parasympathici sacrales. The inferior hypogastric plexus supplies the pelvic viscera via the respective plexuses (the superior, the middle and the inferior rectal plexuses, the vesical plexus, the prostatic plexus, the deferential plexus, the uterovaginal plexus etc.). In the neck, the sympathetic trunk on each side extends upward to the skull and downward to the first rib, where it becomes continuous with the thoracic part of the trunk. The trunk lies behind the carotid sheath; it possesses three ganglia: the superior, middle, and inferior cervical. Superior Cervical Ganglion Lies immediately below the skull. Branches 1. Internal carotid nerve accompanies the internal carotid artery and forms the internal carotid plexus. 2. Gray rami communicantes pass to the upper four cervical spinal nerves. 3. Arterial branches to the common and external carotid arteries. 4. Cranial nerve branches to the ninth, tenth, and twelfth cranial nerves. 5. Pharyngeal branches join pharyngeal branches of the ninth and tenth cranial nerves to form the pharyngeal plexus. 6. Superior cardiac branch descends into the thorax to join the cardiac plexus. Middle Cervical Ganglion Lies at level of cricoid cartilage. Branches 1. Gray rami communicantes to the fifth and sixth cervical spinal nerves. 2. Thyroid branches. 3. Middle cardiac branch descends into the thorax to join the cardiac plexus. Inferior Cervical Ganglion In the majority of people, the inferior cervical ganglion is fused to the first thoracic ganglion to form the stellate ganglion. It is located between the transverse process of the seventh cervical vertebra and the neck of the first rib. Branches 1. Gray rami communicantes to the seventh and eighth cervical spinal nerves. 2. Arterial branches to the subclavian and vertebral arteries. 3. Inferior cardiac branch descends into the thorax to join the cardiac plexus. Ansa Subclavia – the portion of the sympathetic trunk that connects the mid- dle to the inferior cervical ganglia is in the form of two or more bundles. The anterior bundle crosses anterior to the first part of the subclavian artery and is called the ansa subclavia. Materials for self-check: A. Tasks for self-check: specify division of the autonomic nervous system on the parts, parasympathethic nuclei, autonomic plexus using preparations, models, tables. B. Situational tasks. 1. The muscle narrowing a pupil are innervated by parasympathetic fibers from: A. Nucleus impar B. Nucleus salivatorius inferior C. Nucleus salivatorius superior D. Nucleus accessorius n. oculomotorii E. Nucleus dorsalis n. vagi 2. At the patient the dacryagogue, the raised salivation is observed. This state, in the ratio with the second symptoms, is regarded as a boring of fibers of one of cranial nerves. What nerve and what its fibers? A. Parasympathetic fibers of the facial nerve B. Parasympathetic fibers of the oculomotor nerve C. Somatic motor fibers of the oculomotor nerve D. Parasympathetic fibers of the vagus nerve Е. Parasympathetic fibers of the intermediate nerve 3. In the patient has been found the tumor process. This morbid condition has involved in process the accessory nucleus on the right side. Which of the following symptoms were observed? A. Sustained expansion of the pupil on the right. B. Paralysis of the medial rectus muscle of the right eye C. Disturbance of the accommodation′s processes of on the right D. Violation of lacrimation on the right E. Strong narrowing of the right pupil 4. A patient has appealed with complaints of visual impairment accompanied by blepharoptosis, impossibility to lift the eyeball upwards and to the middle. Examination has shown that the eyeball is diverted outside, the pupil is dilated, does not react to light, the patient can′t see at a short distance. Which nerve has been injured? A n. abducens dexter B n. oculomotorius C n. opticus D n. abducens sinister E n. Trochlearis 5. The central (cortical) part of the parasympathetic nervous system is in: А. The cerebellum В. The spinal cord С. The brainstem D. The midbrain Е. The cortex of a limbic brain 6. After operation on a stomach at the patient complication in the form of weakening of its peristalsis, reduction of secretion of glands and weakening of the pyloric sphincter has educed. What nerve has suffered at an operative measure? A. The trigeminal B. The facial C. The oculomotor D. The vagus E. The intermediate (n. chorda tympani) 7. The patient suffer from dysfunction of the parotid salivary gland. What nerve increases its secretion? A. N auricularis major B. N petrosus major C. N. petrosus profundus D. N. auricularis minor E. N. petrosus minor References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/

Topic 36. Synthetic classes: vascularization and innervation of the chest cavity, abdominal cavity and the pelvic cavity. See topics № 1-3, 9-11, 14-16, 24, 25, 30, 35

Topic 37. Vascularization and innervation of the head and neck. See topics № 4,5,7, 13, 20, 26-31, 33- 36

Topic 38. Synthetic classes: vascularization and innervation of the limbs. See. See topics № 6,8, 11-12, 14, 15, 19, 20, 22-25, 35

Topic 39. Practical skills from the training material module 3 «Heart. Vessels and nerves of the head, neck, chest cavity and extremities». The list of practical skills, know and be able to show on preparations.

Angiology Bulb of aorta Ascending aorta Arch of aorta Branches of arch of aorta Descending aorta Thoracic aorta Abdominal aorta Brachio-cephalic trunk The right common carotid artery The right subclavian artery The common carotid artery(right and left) External carotid artery Superior thyroid artery Facial artery Lingual artery Occipital artery Posterior auricular artery Ascending pharyngeal artery Superficial temporal artery Maxillary artery Inferior alveolar artery Medial meningeal artery Internal carotid artery Cervical part of internal carotid artery Petrosal part of the internal carotid artery Cavernous part of the internal carotid artery Cerebral part of the internal carotid artery Ophthalmic artery Anterior cerebral artery Posterior cerebral artery Posterior communicative artery Subclavian artery(right and left) Vertebral artery Basilar artery Internal thoracic artery Thyro-cervical trunk Inferior thyroid artery Costo-cervical trunk Arterial circle (ring) of the brain Internal jugular vein Facial vein Retromandibular vein External jugular vein Anterior jugular vein Superior cava vein Brachiocephalic vein (right and left) Thoracic duct Spinal nerves Cervical enlargement of the spinal cord Lumbo-sacral enlargement of the spinal cord Medullary cone of the spinal cord Anterior medial fissure of the spinal cord Posterolateral sulcus of the spinal cord Anterolateral medial sulcus of the spinal cord Posterior medial sulcus of the spinal cord Central canal of the spinal cord Posterior horn of the spinal cord Phrenic nerve Musculocutaneus nerve Median nerve Ulnar nerve Radial nerve Ilioinguinal nerve Obturator nerve Femoral nerve Tibial nerve

Cranial nerves The optic nerve (II pair) Way-out from the skull ( II pair) Way-out from the skull ( I pair) Oculomotor nerve (III pair) Way-out from the brain (III pair) Pathway in the skull( III pair) Trochlear nerve (IV pair) Way-out from the brain (IV pair) Way-out from the skull (IV пары) Trigeminal nerve (V pair) and its ganglion Way-out from the brain (V pair) Ophthalmic nerve (1 branch of the V pair) Way-out from the skull( I branch Vpair) Maxillary nerve (2 branch of the V pair) Way-out from the skull (II branch of the V pair) Mandibular nerve (3 branch of the V pair)) Way-out from the skull( III branch of the V pair) Auriculo-temporal nerve Lingual nerve Inferior alveolar nerve Abducent nerve Way-out from the brain (VI pair) Way-out from the skull (VI pair) Facial nerve (VII pair) Way-out from the brain (VII pair) Way-out from the skull (VII pair) Vestibulocochlear nerve (VIII pair) Way-out from the brain( VIII pair) Way-out from the skull( VIII pair) Glossopharyngeal nerve (IX pair) Way-out from the brain ( IX pair) Way-out from the skull (IX pair) Vagus nerve (X pair) Way-out from the brain (X pair) Way-out from the skull (X pair) Accessory nerve (XI pair) Way-out from the brain (XI pair) Way-out from the skull (XI pair) Hypoglossal nerve (XII pair) Way-out from the brain (XII pair) Way-out from the skull (XII )

Topic 40. Case-control material of the module 1 «Anatomy of the locomotor apparatus». Step 1. Practical skills. Step 1. See topics of the module 1. Osteology: Arch of the vertebra Inferior vertebral notch Spinous process of the vertebra Transverse process of the vertebra Superior articular process of the vertebra Facet for dens Posterior arch of the atlas Lateral mass of the atlas Dens of the axis Transverse foramen of the vertebra Costal facet of the transverse process Auricular articular surface of sacral bone Transverse lines of the sacral bone Posterior sacral foramens Medial sacral crest sacral hiatus Costal neck Jugular fossa of the sternum Body of the sternum Costal notches of the sternum Subscapular fossa Scapular spine Acromion Infraspinal fossa Coracoid process Scapular notc Glenoid cavity Supraglenoid tubercle of the scapula Sternal end of the clavicle, acromial end of the clavicle The neck of humerus Grater tubercle of the humerus The crest of the great tubercle of the humerus Intertubercular crest Surgical neck of the humerus Deltoid tuberosity of the humerus Trochlea of the humerus Olecranon fossa Coronoid fossa Radial fossa Medial epicondyle The head of radius Articular circumference of the radius Radial tuberosity Styloid process of the radial bone olecranon Trochlear notch Coronoid process of the ulna Ulnar tuberosity Styloid process of the ulna Acetabular fossa Lunate surface of acetabulum acetabular notch Iliac wing Iliac crest Anterior superior iliac spine Anterior inferior iliac spine Iliac fossa Auricular articular surface of the hip bone iliac tuberosity Ischiatic tuberosity Sciatic spine Pubic tubercle Symphysial surface of the pubic bone obturator groove Grater trochanter of femoral bone Intertrochanteric crest Pectineal line of the femoral bone Popliteal surface of the femoral bone Lateral condyle of the femoral bone medial condyle of the femoral bone medial epicondyle of the femoral bone Anterior intercondilar area of the tibia Intercondilar eminence of the tibia Tibial tuberosity Medial malleolus The head of fibula The lateral malleolus

CRANIOLOGY Frontal tuber Supercilliary arch glabella Caecum foramen Supraorbital foramen Zygomatic process of the frontal bone Orbital part of the frontal bone Lacrimal fossa Nasal part of the frontal bone frontal sinus magnum foramen Pharyngeal tubercle Clivus Occipital condyle Condylar canal of the occipital bone Condylar fossa of the occipital bone Jugular notch of the occipital bone Jugular process of the occipital bone Hypoglossal canal External occipital crest External occipital protuberance Inferior nucheal line Internal occipital protuberance Cruciate eminence The body of the sphenoid bone The Turkish saddle Hypophysial fossa Dorsum sellae Carotic groove of the sphenoid bone Sphenoid sinus The lesser wing of the sphenoid bone The greater wing of the sphenoid bone Superior orbital fissure The optic canal Rotundum foramen Ovale foramen Spinous foramen Pterygoid process The lateral plate of the pterygoid process The medial plate of the pterygoid process The pterygoid canal Pterygoid fossa Tegmen tympany Trigeminal impression Hiatus of the greater petrosal nerve Groove of the lesser petrosal nerve Internal acoustic meatus Subarcuate fossa Inferior surface of the petrosal part of the temporal bone Jugular fossa of the temporal bone Styloid process of the temporal bone Stylo-mastoid foramen Fossula petrosa Carotic canal Mastoid process of the temporal bone Mastoid notch Zygomatic process of the temporal bone Articular tubercle of the temporal bone Mandibular fossa External acoustic meatus Cribriform plate Superior nasal concha Medial nasal concha Infraorbital canal of maxilla Infraorbital foramen Alveolar cells Maxillary sinus Frontal process of maxilla Zygomatic process of the maxilla Palatine process of maxilla Alveolar process of maxilla Mental foramen of mandible Mental spine of the mandible Digastric fossa Sublingual fossa of mandible Mandibular notch Condylar process of the mandible The head of mandible The neck of mandible Coronoid process of the mandible Mandibular foramen Mandibular canal Inferior nasal concha Lacrimal bone Nasal bone The vomer The palatine bone Zygomatic bone Frontal process of the zygomatic bone Zygomaticoorbital foramen Zygomaticofacial foramen The body of hyoid bone Temporal fossa Infratemporal fossa Zygomatic arch Pterygopalatine fossa Anterior cranial fossa Medial cranial fossa Posterior cranial fossa Lacerum foramen Jugular foramen Musculotubular canal Grater palatine canal Incisive canal Anterior ethmoidal foramen Posterior ethmoidal foramen Inferior orbital fissure

Artrology Temporomandibular joint Atlanto-axial joint Intervertebral disk Anterior longitudinal ligament Posterior longitudinal ligament Interspinous ligamen Flava ligament Supraspinous ligament Zygapophysial joint Medial atlantoaxial joint Lateral atlantoaxial joint Acromioclavicular joint Sternoclavicular joint Interclavicular ligament Anterior sterno-clavicular ligament Shoulder joint Coraco-humeral ligament Humero-ulnar joint Collateral ulnar ligament Collateral radial ligament Interosseous membrane of forearm Radiocarpal joint Obturator membrane Obturator canal Pubic symphysis Ligament of the head of femor Knee joint Transverse ligament of the knee joint Medial menisc of the knee joint Anterior cruciate ligament Collateral tibial ligament Patellar ligament Bifurcate ligament

Myology Trapezius muscle Latissimus dorsi muscle Pectoral minor muscle Anterior serratus muscle Internal intercostal muscle The diaphragm Aortal opening Esophageal opening Vena caval opening Rectus abdominis muscle External oblique muscle Inguinal ligament Transverse abdominis muscle Linea alba Inguinal canal Quadratus lumborum muscle Epicranial muscle Orbicularis oculi muscle Zygomatic major muscle Buccinators muscle Orbicularis oris muscle Temporal muscle Masseter muscle Sterno-cleido-mastoid muscle Digastric muscle Sternohyoid muscle Omohyoid muscle Anterior scalene muscle Submandibular trigon Carotic trigon Infraspinal muscle Teres major muscle Subscapular muscl Long head of the biceps brahii Short head of the biceps brahii Coraco-brachialis muscle Flexor carpi ulnaris muscle Extensor digiti minimi muscle Abductor polices long muscle Axillary fossa Iliopsoas muscle Medial gluteal muscle Sartorius muscle Rectus femoris muscle Intermedial vastus muscle Pectineal muscle Gracilis muscle Long adductor femoris muscle Biceps femoris muscle Semimembranous muscle

Topic 41. Case-control material of the module 2 «Splanchnology. Central nervous system and sense organs». Step 1. Practical skills. See topics of the module 2.

Digestive system Oral cavity Oral vestibule Oral cavity proper Lips Cheeks Hard palate Soft palate Teeth Tongue The parotid gland The submandibular gland The sublingual gland The pharynx The oesophagus The stomach The small intestine The large intestine The liver The pancreas The gallbladder The bile duct The peritoneum

The urinary system The kidney The nephron The ureter The urinary bladder

The genital system The testes The epididymidis The spermatic cord The ductus deferens The seminal gland The prostate The penis The scrotum The male urethra The ovary The uterine tube The uterus The vagina The mons pubis The labia majora The labia minora The clitoris The vestibule The greater vestibular glands The female urethra The perineum

Respiratory system Nasal root Nasal dorsum Nasal tip Ala of nose Choanae Superior nasal concha Middle nasal concha Inferior nasal concha Superior nasal meatus Middle nasal meatus Inferior nasal meatus Maxillary sinus Sphenoidal sinus Frontal sinus Ethmoidal cells Olfactory part of nasal cavity Respiratory part of nasal cavity Thyroid cartilage Superior horn of thyroid cartilage Cricoid cartilage Arch of cricoid cartilage Lamina of cricoid cartilage Arytenoid cartilage Base of arytenoid cartilage Muscular process of arytenoid cartilage Vocal process of arytenoid cartilage Apex of arytenoid cartilage Epiglottis Cricothyroid joint Cricoarytenoid joint Laryngeal vestibule Vestibular fold Aditus of larynx (laryngeal inlet) Vocal fold Ventricles of larynx Rima glottidis Intermembranous part of rima glottidis Intercartilaginous part of rima glottidis Infraglottic region Vocal ligament Cervical part of trachea Thoracic part of trachea Bifurcation of trachea Tracheal cartilages Annular ligaments of trachea Right main bronchus Left main bronchus Base of lung Apex of lung Costal surface of lung Diaphragmatic surface of lung Lingula of left lung Cardiac notch of left lung Hilum of lung Root of lung Oblique fissure of lung Horizontal fissure of right lung Superior lobe of lung (left, right) Middle lobe of lung Inferior lobe of lung (left, right) Visceral pleura (lung) Parietal pleura Pleural cupula Costal pleura Mediastinal pleura Costodiaphragmatic recess of pleural cavity Costomediastinal recess of pleural cavity

Central nervous system Anterior medial fissure of the medulla oblongata Pyramid of the medulla oblongata Decussation of pyramids Anterolateral sulcus of the medulla oblongata The olive Posterolateral sulcus of the medulla oblongata Cuneate fasciculus Cuneate tubercle Gracille fasciculus Gracile tubercle Posterior medial sulcus of the medulla oblongata Medial cerebellar peduncles Superior medullar velum Ventral surface of the pons Median sulcus of the rhomboid fossa Median eminence of the rhomboid fossa Medullar strips (striae) of the fourth ventricle Hypoglossal trigon Vagal trigon Facial colliculus of the rhomboid fossa The roof of the fourth ventricle Superior medullar vellum Superior colliculus of the tectal plate Inferior colliculus of the tectal plate Brachium of inferior colliculus of the tectal plate Aqueduct of the midbrain Cerebellum Vermis of the cerebellum Folia of the cerebellum Dentate nucleus Inferior cerebellar peduncle Superior cerebellar peduncle Pulvinar of thalamus Habenula Lateral geniculate body Medial geniculate body Thalamic adhesion Tuber cinereum Mammillary body The third ventricle Precentral sulcus Precentral gyrus Medial frontal gyrus Postcentral sulcus Postcentral gyrus Inferior temporal sulcus Cingular gyrus Uncus Parahypocampal gyrus Corpus callosum Olfactory bulb Caudate nucleus Lentiform nucleus Claustrum Anterior horn of the lateral ventricle Inferior horn of the lateral ventricle Internal capsule of the hemisphere Dura mater of the brain Fastigium of the cerebellum Transverse sinus Arachnoid mater Pia mater

Sense organs The fibrous layer of the eye ball The sclera The cornea Tunica vasculosa Tunica vasculosa propria Ciliary body The iris The pupil The retina The lens The vitreous body Lateral rectus muscle Superior rectus muscle Medial rectus muscle Inferior rectus muscle Superior oblique muscle Inferior oblique muscle Conjunctiva Lacrimal gland External ear Auricle External acoustic meatus External acoustic opening Tympanic membrane Middle ear Tympanic cavity Tegmental wall of the tympanic cavity Jugular wall of the tympanic cavity Labyrinth wall of the tympanic cavity Mastoid wall of the tympanic cavity Carotid wall of the tympanic cavity Incus Stapes Acoustic tube Internal ear Bony labyrinth Semicircular canals Membranous labyrinth

Topic 42. Final semester certification (exam). Control questions for taking the final semester certification (examinations) in Human Anatomy for students of the 2nd year education, specialty «Medicine». Control questions. 1. Define anatomy as a science. 2. Explain the origin of the word ’anatomy’. 3. 3. How are such methods as analysis and synthesis used for studying anatomy? 4. Why is it essential to study the phylogeny and ontogeny? 5. What are the main principles of the modern anatomical nomenclature? 6. What is the universal body posture accepted in anatomy? 7. Name the axes and planes, which are drawn through the human body. 8. Explain the following terms: medial and lateral, ventral and dorsal, cranial and caudal, proximal and distal. 9. Name basic parts of the skeleton. 10. Name the regions of the vertebral column. 11. Name parts of a typical vertebra. 12. What are the characteristic features of 1) cervical vertebrae; 2) thoracic vertebrae; 3) lumbar vertebrae? 13. What are the characteristic features and clinical applications of the VI and VII cervical vertebra? 14. What are the main distinctions of the atlas from other vertebrae? What is the origin of its name? 15. What are the characteristic features of the second cervical vertebra? 16. Which processes are responsible for the formation of the crests of the sacrum? 17. What is the coccyx? 18. Name parts of the rib. 19. How are the ribs classified based on their attachment to the sternum? 20. What are the characteristic features of the first rib? 21. Name parts of the sternum. 22. What is the sternal angle? Name its function. 23. Why is the sternum widely used for the red bone marrow puncture? 24. Why is the skull divided into two regions? Name these regions. 25. What is the structure of cranial flat bones? 26. What resides in the Turkish saddle? Why is the X-ray examination of the Turkish saddle has clinical importance? 27. What do the mastoid air cells of the temporal bone communicate with? What is its clinical importance? 28. Point out the tegmen tympani. What is its clinical importance? 29. Name major canals of the temporal bone. 30. Describe the path of the facial canal. 31. What does the musculotubal canal contain? What parts is it divided into? 32. Name the sutures of the calvaria. 33. Name the three cranial fossae. 34. What structures bound: 1) temporal fossa; 2) infratemporal fossa; 3) pterygopalatine fossa? 35. Name the opening, through which the pterygopalatine fossa communicates with the other parts of the skull. 36. Name the walls of the orbit. 37. Name the communications of the orbit. 38. Name the walls of the nasal cavity. 39. What bones constitute the shoulder girdle? 40. What surfaces, angles, and borders are present on the scapula? 41. The humerus. The bones of the forearm. The structure, abnormalities. 42. The bones of the hand. The structure, abnormalities. 43. Pelvic and hip bones. Features of the structure, abnormalities. 44. The bones of foreleg and foot. The structure, abnormalities. 45. General syndesmology. Types of connections. Classification of joints. The connection between the vertebrae. Vertebral column as a whole. Curves of the spine. Pathology and abnormalities. Age features. 46. Atlanta-occipital and atlanta-axial joints, strycture, biomechanics of movement. Temporo-mandibular joint, structure, biomechanics of movement. 47. Connections ribs with the sternum. 48. The connections of the upper limb bones. 49. The shoulder and elbow joints. The structure, biomechanics of movement. Connections forearm and hand. 50. The connections of the lower limb bones. Pelvis as a whole. The dimensions of the pelvis. Age and sex characteristics. 51. Hip joint. The structure, biomechanics of movement. 52. Knee joint, structure, biomechanics of movement. Connectings of the foreleg and foot bones. 53. The joints of the foot, the foot as a whole. X-ray anatomy of bones and joints. 54. General miology. Development, structure, classification. 55. The muscles and fascia of the back. Topography. 56. The muscles and fascia of the chest. Diaphragm. 57. The muscles and fascia of the abdomen. Vagina rectus abdominis muscle. Inguinal canal. White line of the abdomen. The topography of the anterior abdominal wall. 58. The muscles and fascia of the neck. Topography of the neck, neck triangles, their border, clinical significance. 59. The muscles and fascia of the head, masticatory and mimic muscles. 60. The muscles and fascia of the shoulder girdle. Axillary cavity. The muscles and fascia of the shoulder. Topography of the shoulder. 61. The muscles and fascia of the forearm and hand. Synovial sheath tendon. Topography of the upper limb. 62. The muscles and fascia of the pelvis. Topography. The muscles and fascia of the thigh. Femoral canal. Muscular and vascular lacunae. Topography of the thigh. 63. Muscles of the foreleg and foot. Topography. 64. Name the chief functions of the alimentary system. 65. Name the organs related to the alimentary system. 66. Name the parts of the oral cavity. 67. What structures form the walls of the oral vestibule? 68. What the oral cavity proper is bounded with? 69. Name the parts of the palate. 70. What structures can be distinguished in the hard palate? 71. The parts of the soft palate and its exterior. 72. Name the muscles of soft palate and describe their actions. 73. What the bottom of oral cavity is formed of and what structures can be found on its mucosa? 74. What is fauces and what is it bounded with? 75. Description of the teeth: a. parts of a tooth; b. interior of a tooth; c. types of teeth and their characteristics. 76. How many dentitions do humans develop? 77. Describe the dental formula for deciduous teeth. Name beginning and end terms of eruption. 78. Dental formula of the permanent teeth and their eruption terms. 79. Describe exterior of the tongue. 80. Name the structures on the mucosa of the dorsum of tongue and the inferior surface of tongue. 81. How are the muscles of tongue subdivided? 82. Describe the proper muscles of tongue. 83. Name the extrinsic muscles of tongue. Describe their structure and actions. 84. Name the major salivary glands that open into the oral cavity. 85. Describe structure and relations of the parotid gland. Where the opening of its duct is situated? 86. Describe structure and relations of the submandibular gland. Where the opening of its duct is situated? 87. Location of the sublingual gland and its ducts. 88. Topography of the pharynx. 89. The parts of the pharynx and their limits. 90. Name the structures on the nasopharynx walls. 91. Describe the oropharynx and the laryngopharynx. 92. What structures form the pharyngeal lymphoid ring? What is the function of the ring? 93. What layers can be distinguished in the pharyngeal wall? 94. Describe the features of the submucosa and fibrous layer of the pharynx. 95. How the muscles of pharynx are subdivided? 96. Topography of the oesophagus. 97. Describe the oesophageal wall structure. 98. Name the oesophageal constrictions and dilations. 99. What forms the abdominal walls? 100. Name the types of peritoneal relations. 101. Describe the shape of the stomach and its exterior. 102. Topography of the stomach. 103. Parts of the duodenum. Skeletotopy of the intestine. 104. Describe the wall structure of the duodenum. 105. Functional significance of the small intestine. 106. What is the length of large intestine and what parts are distinguished in it? 107. What are the exterior differences between the large and the small intestines? 108. Topography of the large intestine. 109. What are the differences between structure of the rectum wall and wall structure of other segments of large intestine? 110. Peritoneal relations of the large intestine. 111. Functional significance of the small intestine. 112. Role of the liver as a GIT organ. 113. The exterior of liver and its lobes. 114. Hepatic segmentation. 115. Topography of the liver. 116. Peritoneal relations and ligaments of the liver. 117. The interior of the liver, its lobules and features of the internal circulation. 118. Bile ducts, their formation and topography. 119. The gallbladder — its structure, topography, peritoneal relations and functions. 120. Topography of the pancreas. 121. Functional significance of the pancreas. 122. Peritoneum, its structure, plates and peritoneal cavity. 123. The parietal peritoneum and its features on the anterior abdominal wall. 124. The retroperitoneal space and its practical significance. 125. The visceral peritoneum and the structures formed. 126. The definition of the peritoneal cavity. The levels of the peritoneal cavity and their limits. 127. What structures bound the hepatic bursa? 128. Name the limits of pregastric bursa. 129. The omental bursa, its walls and parts. Tne omental foramen and its limits. 130. The parts of the middle level of peritoneal cavity. 131. The limits of the right and the left paracolic gutters. 132. What organs belong to the respiratory system? Name the organs related to upper and lower respiratory tracts. 133. Describe structure of the nose. 134. Describe divisions of the nasal cavity. 135. What is the common nasal meatus? Where the olfactory region of nasal mucosa is situated? 136. Name the paranasal sinuses and discuss their significance. 137. The larynx, its significance and structure. 138. What cartilages form the laryngeal skeleton? Describe their morphology. 139. What joints do the laryngeal cartilages form? Describe possible movements in these joints. 140. Describe the laryngeal ligaments. What structures form the elastic framework of larynx? 141. Discuss classification of the laryngeal muscles. What muscles widen the rima glottidis and laryngeal cavity? 142. Describe the muscles that narrow the rima g:ottidis and laryngeal cavity. 143. What muscles alter tension of the vocal folds? 144. What structures bound the laryngeal inlet? 145. Name the divisions of laryngeal cavity. 146. Describe topography of the larynx (holotopy, skeletotopy and syntopy). 147. Describe the external morphology and topography of the trachea. 148. Describe the structure of trachea. 149. How do the main bronchi form? Discuss structural differences between the right and left main bronchi. 150. Describe exterior of the lungs. 151. Discuss exterior differences between the right and left lungs. 152. Give definition of the pulmonary segment. 153. List the segments of the right lung. 154. Give description of bronchi branching. 155. What bronchial divisions belong to the bronchial tree? Discuss its significance. 156. What elements form the alveolar tree? Discuss its significance. 157. Name the main differences in wall structure of bronchial and alveolar tree elements. 158. Give definition of the acinus. 159. What is pleura and what layers are distinguishable in it? Discuss its significance. 160. Give definition of the pleural cavity. 161. Give definition of the pleural recess. Name the recesses you know. Discuss their functional significance. 162. Describe the boundaries of lungs. 163. Do boundaries of lungs and pleural cavity have the same surface relations? Give definition of the mediastinum. 164. What compartments are distinguishable in the mediastinum? 165. What organs reside in the superior mediastinum? 166. What organs reside in the compartments of the inferior mediastinum, namely in the anterior, middle and posterior? 167. Discuss features of respiratory organs in invertebrates. 168. What respiratory organs do the inferior vertebrates feature? 169. What animals first develop the lungs? Describe appearance of these organs. 170. What organs belong to urinary system? 171. Describe the exterior of kidney. 172. Describe relations of both kidneys (holotopy, syntopy and skeletotopy). 173. Describe peritoneal relations of kidneys. 174. Name the structures responsible for kidney support. 175. Discuss features of intrarenal arterial branching. What is arterial rete mirabile? 176. Give definition of renal lobes and lobules. Give definition of nephron and describe its structure. 177. What groups of nephrons are distinguishable in renal cortex? 178. What is the length of ureters and what parts are distinguishable in them. 179. Name constrictions of ureters and discuss their practical significance. 180. Name the wall layers of ureter. 181. Describe relations of bladder in males and females. 182. What developmental anomalies occur in humans? 183. What organs belong to external and internal male genitalia? 184. Describe the exterior of male gonad (testis). 185. Where does the epididymis reside and what parts are distinguishable in it? 186. Describe the interior of testis and epididymis. 187. Where are the male gametes formed? 188. List the testicular tunics and explain what they are formed of. 189. List the constituents of spermatic cord. 190. Describe relations of the ductus deferens and name its parts. 191. What structures form the ejaculatory duct and where does it open? 192. Describe structure and relations of the seminal vesicles. Explain their physiological significance. 193. Describe structure of the prostate. 194. Where do the bulbo-urethral glands reside and where do their ducts open? 195. Describe structure of the penis. 196. Describe the scrotum structure. 197. Name the parts of male urethra. Describe the prostatic part of male urethra. 198. Describe the interior of ovary. 199. What types of follicles are distinguishable in the ovary? Where do they reside? 200. What changes occur in the follicle during oocyte development? 201. Give definition of the corpus luteum. Explain its functional significance. 202. Describe exterior of the uterine tube. Explain its function. 203. List the uterine wall layers and describe each layer. 204. What is the shape of uterine cavity? What orifices open into the uterine cavity? 205. What is the shape of cervical canal? Where does it open? 206. What are the internal and external os of uterus? 207. What terms describe normal position of the uterus? 208. What pathological positions of uterus may occur? 209. Describe peritoneal relations of uterus. 210. What structures belong to supporting apparatus of uterus? 211. Name the walls of vagina. Describe relations of vagina. 212. Where does the superior portion of vagina attach? Where does its ostium open? 213. How does the vaginal fornix form? What is the practical significance of the posterior part of fornix? 214. What layers are distinguishable in the vagina? 215. Discuss features of vaginal mucosa structure. 216. Describe the structure of female external genitalia: a. the mons pubis; b. the labia majores; c. the labia minores; d. the clitoris; 217. Name the spaces bounded by:  the labia majores;  the labia minores. 218. Describe the bulb of vestibule. 219. Where does the greater vestibular gland reside? Where does its duct open? 220. Describe the structure of female urethra. Where does its external orifice open? 221. Give definition of the perineum. 222. Describe divisions of perineum and explain how the dividing line runs. 223. What organs form the pelvic diaphragm? 224. Name the muscles, which form the pelvic diaphragm. 225. Name the pelvic diaphragm fascia. 226. What muscles form the perineal diaphragm? Describe their structure and functions. 227. Name the perineal diaphragm fascia. 228. Where does the ischio-anal fossa reside? Describe its boundaries. 229. What tissue fills the ischio-anal fossa? Discuss practical significance of the fossa. 230. Which duct undergoes reduction in developing male fetus? 231. What structure gives rise to the ductus deferens? 232. What structures give rise to the uterine tubes, uterus and vagina? 233. Where do the gonads primordia appear? 234. What processes assist the testes descent? 235. Describe development and fate of the processus vaginalis. 236. Give definition of terms ‘monorchism’, ‘anorchism’ and ‘cryptorchidism’. 237. Name the developmental anomalies of female internal genitalia. 238. What changes occur in indifferent primordia during development of external genitalia:  in male embryo;  in female embryo. 239. Give definition of hermaphroditism. What major types of hermaphroditism do you know? 240. Name the anatomical and physiological distinctions between endocrine and exocrine glands. 241. Discuss classification of endocrine glands according to their origin. 242. Describe relations, structure and functions of pineal gland. 243. Where does the pituitary reside and what parts are distinguishable in it? 244. Describe connections between hypothalamus and pituitary. 245. Name the hormones produced by anterior lobe of pituitary and discuss their effects on an organism. 246. What part of the brain produces hormones of posterior lobe of pituitary? Discuss their effects on an organism. 247. Describe gross structure of the thyroid gland and its relations. 248. What the thyroid gland is covered with? Describe its histological structure. 249. Name the hormones produced by thyroid gland and discuss their effects on an organism. 250. Where do the parathyroid glands reside? What hormones do they produce? 251. Describe gross structure and relations of the thymus. 252. Name functions of the thymus. 253. What structures belong to endocrine part of the pancreas? What hormones does it produce? 254. Describe gross structure and relations of the suprarenal glands. 255. What parts are distinguishable in the suprarenal glands? 256. Name hormones produced by the cortex of suprarenal glands and discuss their effects on an organism. 257. Name hormones produced by the medulla of suprarenal glands and discuss their effects on an organism. 258. Give definition of paraganglia and describe their origin and functions. 259. Name structures belonging to endocrine part of ovaries and testes and list the hormones produced. 260. Name three compartments of analyzer. 261. Name types of receptors featured by sense organs. 262. Describe main stages of evolution of sense organs. 263. Describe the parts and topography of the eye. 264. Describe development, develop-mental anomalies and external features of eyeball. 265. Name and recognize the layers of eyeball. 266. Describe the fibrous layer of eyeball 267. Describe the vascular layer if eyeball. 268. Describe the retina. 269. Describe the refractive media of eyeball 270. Describe the chambers of eyeball. 271. Describe production and circulation of the aqueous humor. 272. Name the accessory visual structures. 273. Describe the conjunctiva. 274. Describe the extrinsic muscles of eyeball. 275. Describe lacrimal apparatus and circulation of lacrimal fluid. 276. Describe formation and topography of the optic nerve. 277. Describe the visual pathway. 278. Name and recognize the principal pars of ear. Discuss embryonic development of the ear and its developmental anomalies. 279. Describe the external ear. 280. Describe the auricle. 281. Describe the external acoustic meatus. 282. Describe the tympanic membrane. 283. Describe the middle ear. 284. Describe the tympanic cavity with related canals. 285. Describe the auditory ossicles with related joints and muscles. 286. Describe the auditory tube. 287. Name the parts of internal ear. 288. Describe the bony labyrinth. 289. Describe the semicircular canals. 290. Describe the vestibule. 291. Describe the cochlea. 292. Describe membranous labyrinth. 293. Describe the perilymphatic space. 294. Describe the endolymphatic space. 295. Describe the vestibular part of membranous labyrinth. 296. Describe the semicircular ducts. 297. Describe the cochlear duct. 298. Describe the route of sound waves. 299. Describe the auditory pathway. 300. Describe the vestibular pathway. 301. Describe the olfactory organ. 302. Describe the gustatory organ. 303. Name the parts of integument. 304. Describe the breast. 305. Name the principal parts of heart. 306. Name the surfaces of heart. 307. What cardiac chambers feature the auricles? 308. Name the borders of the heart. 309. Name the layers of cardiac wall. a. How many muscular layers are distinguishable in the atrial myocardium? b. How many muscular layers are distinguishable in the ventricular myocardium? c. Name the insertion point of all myocardial fibers. d. Name the cardiac chambers that comprise the papillary muscles and the musculi pectinati. 310. What cardiac chamber contains the fossa ovalis, the opening of coronary sinus and the valve of inferior vena cava? a. Name the cardiac opening that features the tricuspid valve. b. Name the cardiac opening that features the mitral valve. c. Name the cusps of the right atrio-ventricular valve. d. Name the cusps of the left atrio-ventricular valve. e. Where do the semilunar cusps reside? f. What valves have their cusps attached to the chordae tendineae? 311. What area contains the opening of right coronary artery? 312. What area contains the opening of left coronary artery? 313. Name the areas supplied by the left coronary artery. 314. Name the main branch given by the right coronary artery. 315. Name the areas supplied by the right coronary artery. 316. Name the cardiac veins that open into the right atrium directly. Name the cardiac veins drained by the coronary sinus. 317. Where does the sinu-atrial node reside? 318. Where does the atrioventricular node reside? 319. Where does the atrioventricular bundle reside? 320. Name the layers of pericardium. Name the limits of pericardial cavity. Name the pericardial sinuses. What is the average heart weight in males and females? 321. Describe surface relations of the left boundary of heart. 322. Describe surface relations of the right boundary of heart. 323. Describe surface relations of the superior boundary of heart. Describe surface relations of the inferior boundary of heart. Describe surface relations of the apex of heart. 324. Name the auscultatory point for the left atrioventricular valve. Name the auscultatory point for the right atrioventricular valve. Name the auscultatory point for the aortic valve. Name the auscultatory point for the pulmonary valve. 325. Describe surface relations of the aortic and pulmonary valves. 326. Describe surface relations of the mitral and tricuspid valves. 327. Name three main positions of heart with respect to constitutional type of body. 328. Name the organs that receive the most oxygenated blood during embryo’s development. 329. What vessels are connected by the ductus arteriosus in fetus? 330. Name the area, where the umbilical vein enters the fetus’ body. 331. Describe the pulmonary trunk and its topography. 332. Describe topography of pulmonary arteries 333. Describe intrinsic divisions of the pulmonary arteries. 334. Describe formation and topography of the pulmonary veins. 335. Give general description of the aorta. Describe the aortic arch and name its branches. 336. Describe the common carotid artery (both left and right). 337. Describe the external carotid artery. 338. Describe the anterior branches of the external carotid artery. 339. Describe the facial artery. 340. Describe the posterior branches of the external carotid artery. 341. Describe the medial branches of the external carotid artery. 342. Describe the superficial temporal artery. 343. Describe the maxillary artery. 344. Describe the internal carotid artery. 345. Describe the subclavian artery. 346. Describe the basilar artery. 347. Describe the cerebral arterial circle. 348. Describe the axillary artery. 349. Describe the brachial artery. 350. Describe the radial artery. 351. Describe ulnar artery. 352. Describe the cubital anastomosis. 353. Describe the superficial palmar arch 354. Describe the deep palmar arch. 355. Describe the dorsal carpal arch. 356. Describe the palmar carpal arch. 357. Describe the palmar arterial anastomoses. 358. Describe the thoracic aorta. 359. Give general description of the abdominal aorta. 360. Describe the parietal branches of the abdominal aorta. 361. Describe the paired and unpaired visceral branches of the abdominal aorta. 362. Describe the intersystem and in-trinsic anastomoses of the branches of abdominal aorta. 363. Describe the common iliac artery. 364. Describe the parietal branches of the internal iliac artery. 365. Describe the visceral branches of the internal iliac artery. 366. Describe the external iliac artery. 367. Describe the femoral artery. 368. Describe the deep artery of thigh. 369. Describe the popliteal artery. 370. Describe the anterior tibial artery. 371. Describe the posterior tibial artery. 372. Describe the genicular anastomosis. 373. Describe the medial plantar artery. 374. Describe the lateral plantar artery. 375. Describe the dorsal artery of foot. 376. Describe the arterial anastomoses of foot. 377. Discuss arrangement regularities of the veins. Give definition of the root veins and tributary veins. 378. Describe the superior vena cava. 379. Describe the internal jugular vein. 380. Describe the intracranial tributaries of the internal jugular vein. 381. Describe the extracranial tributaries of the internal jugular vein. 382. Describe anastomoses between the intracranial and extracranial tributaries of the internal jugular vein. 383. Describe the venous angle. 384. Describe the external jugular vein. 385. Describe the anterior jugular vein and the jugular venous arch. 386. Describe the brachiocephalic vein. 387. Give general description and classification of the veins of upper limb. Describe the superficial veins. 388. Describe the deep veins of upper limb. Discuss their features. 389. Describe the axillary vein. 390. Describe the azygos vein. 391. Describe the hemiazygos vein. 392. Describe the accessory hemiazygos vein. 393. Describe the intercostal veins. 394. Describe the veins of vertebral column. 395. Describe the inferior vena cava. 396. Describe the visceral tributaries of the inferior vena cava. 397. Describe the parietal branches of the inferior vena cava. 398. Describe the hepatic portal vein. 399. Describe the internal iliac vein. 400. Describe the parietal tributaries of the internal iliac vein. 401. Describe the external iliac vein. 402. Give general description of the veins of lower limb. Describe the superficial veins of the lower limbs. 403. Describe the great saphenous vein. 404. Describe the deep veins of lower limb. 405. Describe the femoral vein. 406. Describe the venous plexuses of lesser pelvis. 407. Give definition of intrinsic and intersystem venous anastomoses. 408. Describe the porto-caval anastomoses at the esophagus. 409. Describe porto-caval anastomoses at the rectum. 410. Describe the portocaval anastomoses by the posterior abdominal wall. 411. Describe the cava-caval anastomoses by the anterior abdominal wall. 412. Describe the porto-cava-caval anastomosis by the anterior abdominal wall. 413. Describe the cava-caval anasto-mosis by the posterior abdominal wall. 414. Describe the cava-caval anastomosis along the vertebral column. 415. What structural features allow differentiation of blood and lymphatic capillaries? 416. What parts are distinguishable in the thoracic duct? 417. Describe formation of the right lymphatic duct. 418. Name the lymphatic ducts. 419. Where do the lymphatic trunks and ducts open? Name the body regions drained by each trunk and duct. 420. Name the groups of lymph nodes situated on the border of head and neck. 421. What groups of lymph nodes reside within the cervical region? 422. Name the groups of parietal tho-racic lymph nodes. Name the regions drained by these nodes. 423. Name the groups of visceral thoracic lymph nodes. Name the viscera drained by these nodes. 424. Name the groups of parietal abdominal lymph nodes. 425. Name the groups of visceral abdominal lymph nodes. Name the viscera drained by these nodes. 426. What lymph nodes receive lymph from the lesser pelvis viscera in part from the rectum? 427. What groups of lymph vessels are distinguishable in the upper limb? Name the destination point of these vessels. 428. What groups of lymph vessels are distinguishable in the lower limb? Name the destination point of these vessels. 429. What lymph nodes receive lymph from the breast? 430. Name the structures related to the primary and secondary organs. Explain your choice. 431. What populations of lymphocytes form the lymphoid tissue? 432. Discuss developmental and structural regularities of the lymphoid system. 433. Name the common morphological features of all secondary lymphoid organs. 434. What organs contain the lymphoid nodules? 435. Discuss structural features of the tonsils that from the pharyngeal lymphoid ring. 436. Name the principal components of the peripheral nervous system and give their general characteristics. 437. Describe formation, topography and branches of the spinal nerves. Explain relations of the spinal nerves to the spinal segments. 438. Describe contents, topography and responsibility areas of the posterior branches of spinal nerves. 439. Describe the posterior branch of the first cervical nerve including contents, topography and responsibility areas. 440. Describe the posterior branch of the second cervical nerve including contents, topography and responsibility areas. 441. Describe the anterior branches of spinal nerves with featured structural and topographical regularities. 442. Describe formation, branches, topography and responsibility areas of the thoracic nerves. 443. Describe formation, branches, topography and responsibility areas of the intercostal nerves. 444. Describe structural features of the nervous plexuses. 445. Describe formation, branches, topography and responsibility areas of the cervical plexus. 446. Describe formation, branches, topography and responsibility areas of the phrenic nerve. 447. Describe formation, topography, parts and classification of branches of the brachial plexus. 448. Describe the trunks and the cords of the brachial plexus. 449. Describe the supraclavicular part of the brachial plexus. 450. Describe the short branches of the brachial plexus with featured topography and responsibility areas. 451. Describe the axillary nerve. 452. Describe the infraclavicular part of the brachial plexus. 453. Describe the long branches of the brachial plexus with featured topography and responsibility areas. 454. Describe the musculocutaneous nerve. 455. Describe the median nerve. 456. Describe the ulnar nerve. 457. Describe the radial nerve. 458. Describe the long cutaneous branches of the brachial plexus. 459. Describe the lumbar plexus. 460. Describe the femoral nerve. 461. Describe the obturator nerve. 462. Describe the sacral and the coccygeal plexuses. 463. Describe the short branches of the sacral plexus. 464. Describe the pudendal nerve. 465. Describe the long branches of the sacral plexus. 466. Describe the sciatic nerve. 467. Describe the tibial nerve. 468. Describe the common fibular nerve. 469. Describe the coccygeal plexus. 470. Name all pairs of the cranial nerves. 471. Discuss classification of the cranial nerves by fibers contents. 472. Discuss classification of the cranial nerves by origin. 473. Describe the III cranial nerves including their origination, the general features, the featured nuclei, the point of arise, the escape point, the related branches and the responsibility areas. 474. Describe the IV cranial nerves including their origination, the general features, the nucleus, the point of arise, the escape point and the responsibility areas. 475. Describe the V pair of cranial nerve including origination, the general features and intracranial part of the nerve. 476. Describe the sensory ganglion of the V cranial nerve with related topography and fibers. 477. Describe the first branch of the V cranial nerve including formation, escape point, the related branches and responsibility areas. 478. Describe the second branch of the V cranial nerve including formation, escape point, the related branches and responsibility areas. 479. Describe the third branch of the V cranial nerve including formation, escape point, the related branches and responsibility areas. 480. Describe the VI cranial nerves including their origination, the general features, the nucleus, the point of arise, the escape point and the responsibility areas. 481. Describe the VII cranial nerves (with the intermediate nerve) including their origination, the general features, the related nuclei, the point of arise, the escape point and the responsibility areas. 482. Describe the VIII cranial nerves including their origination, the general features, the nuclei, topography of the nerves and the responsibility areas. 483. Describe the IX cranial nerves including their origination, the general features, the featured nuclei, the point of arise, the escape point and the responsibility areas. 484. Describe the X cranial nerves including their origination, the general features, the nucleus, the point of arise, the escape point, the parts and the responsibility areas. 485. Describe the cranial and the cervical parts of the X cranial nerve including topography, the fibers and responsibility areas. 486. Describe the cervical and the tho-racic parts of the X cranial nerve including topography, the fibers and responsibility areas. 487. Describe the XI cranial nerves including their origination, the general features, the nuclei, the point of arise, the escape point and the responsibility areas. 488. Describe the XII cranial nerves including their origination, the general features, the nuclei, the point of arise, the escape point and the responsibility areas. 489. What the autonomic division of CNS is responsible for? 490. What are the evolutional features of the autonomic division of CNS? 491. Name the parts of the autonomic division of CNS. 492. Name the chief function of the parasympathetic part of the autonomic division of CNS. 493. Where do the centers of the parasympathetic part of auto-nomic division of CNS reside? 494. What are they represented with? 495. Where do the superior autonomic centers reside? 496. Give definition of the preganglionic nerve fibers. 497. Give definition of the postganglionic nerve fibers. 498. Name the groups of the autonomic ganglia. 499. Name the autonomic plexuses of the thoracic cavity. 500. Name the autonomic plexuses of the abdominal cavity. 501. What autonomic (sympathetic) ganglia belong to the coeliac plexus? 502. What autonomic plexuses originate from the coeliac plexus? 503. What are the parts of the intestinal plexus? 504. What plexuses arise from the inferior hypogastric plexus? 505. Give definition of the sympathetic trunk. 506. Give definition of the white rami communicantes. 507. Give definition of the grey rami communicantes. 508. What are the compartments of the sympathetic trunk? 509. Where do the superior, the middle and the inferior cervical ganglia reside? 510. What branches arise from the superior cervical ganglion? 511. What branches arise from the middle cervical ganglion? 512. What branches arise from the inferior cervical ganglion? 513. Where do the thoracic ganglia of sympathetic trunk reside? 514. What branches arise from the thoracic ganglia of the sympathetic trunk? 515. Describe the greater splanchnic nerve. 516. Describe the lesser splanchnic nerve. 517. What branches arise from the lumbar and the sacral ganglia of sympathetic trunk? 518. Describe how the preganglionic sympathetic fibers reach the coeliac plexus. 519. Describe the fate of the postganglionic sympathetic fibers. 520. Describe the route of the preganglionic fibers from the accessory nucleus of oculomotor nerve. 521. Describe the route of the postganglionic fibers from the ciliary ganglion. 522. Describe the route of the preganglionic fibers from the superior salivatory nucleus. 523. Describe the route of the preganglionic fibers from the inferior salivatory nucleus. 524. Describe the route of the postganglionic fibers from the ptery-gopalatine ganglion. 525. What branches of the vagus nerve supply the viscera? 526. Describe the route of the preganglionic fibers from the sacral parasympathetic nuclei. 527. Name the autonomic plexuses of the pelvic viscera. References. Basic: 1. Human Anatomy. In three volumes. Volume 3 / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. The additional literature: 1. Langman J. Medical embryology / Langman J. – Baltimore, London, 1981. – 384p. 2. Crouse G.S. Development of the female urogenital system / G.S. Crouse // Semin. Reprod. Endocrinol. – 1986. – V.4, №1. – P. 1-11. 3. Beck F. Human embryology: 2 ed / F. Beck, D. Mossat, D. Davies. - Oxford: Blackwell, 1985. – V. 11. – 372p. 4. Moore Keith L. Clinically oriented anatomy: third ed / Keith L. Moore. – 1992. - 917p. 5. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 6. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 7. https://human.biodigital.com/ 8. http://anatom.ua/nomina-anatomica/