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The posterior cervical triangle arthritis guitar quality voltaren 50 mg, 9 arthritis in the knee cap symptoms buy voltaren 50mg on-line, 8 rheumatoid arthritis mri purchase voltaren 100mg, 7, Plate 4, in which the subclavian artery is situated, is again subdivided by the muscle omo-hyoid into two lesser regions, each of which assumes somewhat of a triangular shape. The lower one of these embraces the vessel, A, and those nerves of the brachial plexus, I, which are in contact with it. The posterior belly of the omo-hyoid muscle, K, and the anterior scalenus muscle, N, form the sides and apex of this lesser triangular space, while the horizontal clavicle forms its base. This region of the subclavian artery is well defined in the necks of most subjects, especially when the muscles are put in action. In lean but muscular bodies, it is possible to feel the projection of the anterior scalenus muscle under the skin, external to the sterno-mastoid. But in all subjects may be readily recognised that hollow which occurs above the clavicle, and between the trapezius, 8, and the sterno cleido-mastoid, 7 B, in the centre of which hollow the artery lies. The contents of the larger posterior cervical triangle, formed by B, the sternomastoid before; 9, the splenius; and 8, the trapezius behind, and by the clavicle below, are the following mentioned structures-viz. All these structures, except some of the lymphatic glands, are concealed by the platysma myoides A, as seen in Plate 3, and beneath this by the cervical fascia, which latter shall be hereafter more clearly represented. In somewhat the same mode as the posterior half of the omo-hyoid subdivides the larger posterior triangle into two of lesser dimensions, the anterior half of the same muscle divides the anterior triangle into two of smaller capacity. The great anterior triangle, which is marked as that space inclosed within the points, 6, the top of the sternum, the mental symphysis and the angle of the maxilla; and whose sides are marked by the median line of the neck before, the sterno-mastoid behind, and the ramus of the jaw above, contains C, the common carotid artery, becoming superficial from beneath the sterno-mastoid muscle, and dividing into E, the internal carotid, and D, the external carotid. The anterior jugular vein, 3, also occupies this region below; while some venous branches, which join the external and internal jugular veins, traverse it in all directions, and present obstacles to the operator from their meshy plexiform arrangement yielding, when divided, a profuse haemorrhage. The precise locality at which the common carotid appears from under the sternomastoid muscle is, in almost all instances, opposite to the thyroid cartilage. At this place, if an incision, dividing the skin, platysma and some superficial branches of nerves, be made along the anterior border of the sterno-mastoid muscle, and this latter be turned a little aside, a process of cervical fascia, and beneath it the sheath of the carotid artery, will successionally disclose themselves. In many bodies, however, some degree of careful search requires to be made prior to the full exposure of the vessel in its sheath, in consequence of a considerable quantity of adipose tissue, some lymphatic glands, and many small veins lying in the immediate vicinity of the carotid artery and internal jugular vein. This latter vessel, though usually lying completely concealed by the sternomastoid muscle, is frequently to be seen projecting from under its fore part. In emaciated bodies, where the sterno-mastoid presents wasted proportions, it will, in consequence, leave both the main blood-vessels uncovered at this locality in the neck. For the greater part of this extent it is covered by the sterno-mastoid muscle; but as this latter takes an oblique course backwards to its insertion into the mastoid process, while the main blood-vessel dividing into branches still ascends in its original direction, so is it that the artery becomes uncovered by the muscle. Even the root of the internal carotid, E, may be readily reached at this place, where it lies on the same plane as the external carotid, but concealed in great part by the internal jugular vein. It would be possible, while relaxing the sterno-mastoid muscle, to compress either the common carotid artery or its main branches against the cervical vertebral column, if pressure were made in a direction backwards and inwards. The facial artery V, which springs from the external carotid, D, may be compressed against the horizontal ramus of the lower jaw-bone at the anterior border of the masseter muscle. The temporal artery, as it ascends over the root of the zygoma, may be compressed effectually against this bony point. The external jugular vein, H, Plate 4, as it descends the neck from the angle of the jaw obliquely backwards over the sterno-mastoid muscle, may be easily compressed and opened in any part of its course. This vein courses downwards upon the neck in relation to that branch of the superficial cervical plexus, named auricularis magnus nerve, Q, Plate 4, G, Plate 3. The nerve is generally situated behind the vein, to which it lies sometimes in close proximity, and is liable, therefore, to be accidentally injured in the performance of phlebotomy upon the external jugular vein. The coats of the external jugular vein, E, Plate 3, are said to hold connexion with some of the fibres of the platysma-myoides muscle, A A, Plate 3, and that therefore, if the vessel be divided transversely, the two orifices will remain patent for a time. The position of the carotid artery protects the vessel, in some degree, against the suicidal act, as generally attempted. The depth of the incision necessary to reach the main blood-vessels from the fore part of the neck is so considerable that the wound seldom effects more than the opening of some part of the larynx. The ossified condition of the thyroid and cricoid parts of the laryngeal apparatus affords a protection to the vessels. The more oblique the incision happens to be, the greater probability is there that the wound is comparatively superficial, owing to the circumstance of the instrument having encountered one or more parts of the hyo-laryngeal range; but woeful chance sometimes directs the weapon horizontally through that membranous interval between the thyroid and hyoid pieces, in which case, as also in that where the laryngeal pieces persist permanently cartilaginous, the resistance to the cutting instrument is much less. The anatomical position of the parotid, H, Plate 3, and submaxillary glands, W, Plate 4, is so important, that their extirpation, while in a state of disease, will almost unavoidably concern other principal structures. Whether the diseased parotid gland itself or a lymphatic body lying in connexion with it, be the subject of operation, it seldom happens that the temporo-maxillary branch of the external carotid, F, escapes the knife. But an accident, much more liable to occur, and one which produces a great inconvenience afterwards to the subject, is that of dividing the portio-dura nerve, S, Plate 4, at its exit from the stylo-mastoid foramen, the consequence being that almost all the muscles of facial expression become paralyzed.

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There is a danger rheumatoid arthritis knee images discount 100mg voltaren otc, too arthritis in back of head and neck discount voltaren 50 mg otc, of injuring the middle branch of the sciatic nerve arthritis and joint pain in dogs buy generic voltaren 100mg on line, in the incisions required to reach the artery; and, lastly, there is a possibility of this vessel dividing higher up than usual. Considering these facts in reference to those cases in which it might be supposed necessary to tie the popliteal artery-such cases, for example, as aneurism of either of the crural arteries, or secondary haemorrhages occurring after amputations of the leg at a time when the healing process was far advanced and the bleeding vessels inaccessible, -it becomes a question whether it would not be preferable to tie the femoral, rather than the popliteal artery. But when the popliteal artery itself becomes affected with aneurism, and when, in addition to the anatomical circumstances which forbid the application of a ligature to this vessel, we consider those which are pathological, -such as the coats of the artery being here diseased, the relative position of the neighbouring parts being disturbed by the tumour, and the large irregular wound which would be required to isolate the disease, at the risk of danger to the health from profuse suppuration, to the limb from destruction of the collateral branches, or to the joint from cicatrization, rendering it permanently bent, -we must acknowledge at once the necessity for tying the femoral part of the main vessel. When the popliteal artery happens to be divided in a wound, it will be required to expose its bleeding orifices, and tie both these in the wound. For this purpose, the following operation usually recommended for reaching the vessel may be necessary. The skin and fascia lata are to be incised in a direction corresponding to that of the vessel. The extent of the incision must be considerable, (about three inches, ) so as the more conveniently to expose the artery in its deep situation. On laying bare the outer margin of the semi-membranosus muscle, while the knee is straight, it now becomes necessary to flex the joint, in order that this muscle may admit of being pressed inwards from over the vessel. The external margin of the wound, including the middle branch of the sciatic nerve, should be retracted outwards, so as to ensure the safety of that nerve, while room is gained for making the deeper incisions. The adipose substance, which is here generally abundant, should now be divided, between the mesial line and the semimembranosus, till the sheath of the vessels be exposed. The sheath should be incised at its inner side, to avoid wounding the popliteal vein. As the vein adheres firmly to the coats of the artery, some care is required to separate the two vessels, so as to pass the ligature around each end of the artery from without inwards, while excluding the vein. While this operation is being performed in a case of wound of the popliteal artery, the haemorrhage may be arrested by compressing the femoral vessel, either against the femur or the os pubis. In the operation for tying the posterior tibial artery near its middle, an incision of three or four inches in extent is to be made through the skin and fascia, in a line corresponding with the inner posterior margin of the tibia and the great muscles of the calf. The origins of the gastrocnemius and soleus muscles require to be detached from the tibia, and then the knee is to be flexed and the foot extended, so as to allow these muscles to be retracted from the plane of the vessels. This being done, the deep fascia which covers the artery and its accompanying nerve is next to be divided. The artery will now appear pulsating at a situation an inch from the edge of the tibia. While the ligature is being passed around the artery, due care should be taken to exclude the venae comites and the nerve. The posterior tibial nerve continued from the middle branch of the sciatic, and extending to K, behind the inner ankle. The short (posterior) saphena nerve, formed by the union of branches from the peronaeal and posterior tibial nerves. The posterior tibial artery appearing from beneath the soleus muscle in the lower part of the leg. The internal annular ligament binding down the vessels, nerves, and tendons in the hollow behind the inner ankle. Beneath the integuments and subcutaneous adipose tissue on the fore part of the leg and foot, the fascia H H, Plate 67, Figure 2, is to be seen stretched over the muscles and sending processes between them, thus encasing each of these in a special sheath. It is attached on the inner side of the leg to the spine of the tibia, D, Plate 67, Figure 2, and on the outer side it passes over the peronaeal muscles to those forming the calf. Between the extensor communis digitorum, B b, and the peronaeus longus, F, it sends in a strong process to be attached to the fibula, E. In front of the ankle joint, the fascia is increased in density, constituting a band (anterior annular ligament) which extends between the malleoli, forms sheaths for the several extensor tendons, and binds these down in front of the joint. From the lower border of the annular ligament, the fascia is continued over the dorsum of the foot, forming sheaths for the tendons and muscles of this part. Behind the inner malleolus, d, Plate 67, Figure 1, the fascia attached to this process and to the inner side of the os calcis appears as the internal annular ligament, which being broad and strong, forms a kind of arch, beneath which in special sheaths the flexor tendons, and the posterior tibial vessel and nerve, pass to the sole of the foot. On tracing the fascia from the front to the back of the leg, it will be seen to divide into two layers-superficial and deep; the former passes over the muscles of the calf and their common tendon (tendo Achillis) to which it adheres, while the latter passes between these muscles and the deep flexors. The deep layer is that which immediately overlies the posterior tibial and peronaeal vessels and nerves.

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