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A case is reported of a sixty-two-year-old male who had pulmonary tuberculosis twenty-five years before admission to the hospital; a left nephrotomy for the removal of multiple renal calculi twenty-one years ago; and who subsequently developed a bladder calculus with all the signs and symptoms of hyperparathyroidism. The first operation at which only the right side of the neck was explored, resulted in the removal of a parathyroid adenoma. However, the symptoms persisted as did the hypercalcemia and the elevated serum phosphatase. A second operation seven weeks later failed to reveal a second parathyroid adenoma. Further studies were continued, the patient meanwhile showing no improvement, and it was decided to reoperate a third time. A large parathyroid tumor containing remnants of thymus tissue was found on the left side. The patient died shortly afterward with evidence of cardiac failure. The question of what influence, if any, the treatment for pulmonary tuberculosis with its high caloric diet and increased milk intake, and subsequent load on the parathyroids, is properly raised. Also the long-standing interval between the appearance of the renal calculi twenty-one years before, and the subsequent development of the typical signs and symptoms of hyperparathyroidism is discussed. Attention is called to the fact that an exhaustive exploration must be done thoroughly on both sides even though a large tumor may be readily found on one side. Cope's admonition that the problems of parathyroid surgery are not those of the regional anatomy of the neck, but are peculiar to the anatomy and physiology of the parathyroid glands, should be emphasized. Likewise special training is required for this type of surgery.

Normal urinary bladder function and micturition are the result of well integrated somatic and visceral nervous activity. Micturition requires complex reciprocal actions between detrusor force and outflow resistance, and abnormalities in this reciprocal activity can be demonstrated by percutaneous stimulation of the sacral roots while simultaneously measuring changes in intravesical pressure. When an abnormal sacral innervation is demonstrated by electrocystometry, selective root blockade with phenol may restore normal bladder function and micturition in some patients. Because of his knowledge of regional anatomy and neurophysiology the anaesthesiologist, acting as a member of a team, can contribute greatly to the overall care of patients with neurovesical dysfunction.

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T HE DIAGNOSIS of thoraco-abdomina1 injuries requires menta1 projection of considerable knowIedge and more mental gymnastics and more finesse in management than aImost any other type of injury. The diagnosis of these injuries requires, as a minimum, a knowIedge of regiona anatomy and proper and compIete physica examinations. Certain anciIIary information is heIpfu1, but not essential to successfu1 diagnosis. This information covers such points as position of patient and assaiIant at the time of injury, type of instrument and manner of manipuIation or method of impact, and so forth. A detaiIed knowIedge of regiona anatomy is without question absolutely essentia1. One must practice drawing straight Iines through the body, using any point as the entrance of a buIIet, projecting the Iine in many different angIes and trying to visualize the various organs involved. To make this exercise a bit Iess arduous, the reader shouId know that in 90 per cent of buIIet wounds the course of the missiIe is straight from entrance to exit or to point of Iodging. The stories of buIIets or missiIes ricocheting around in circIes are oId wives’ taIes and can be readiIy expIained by knowing the position of the patient at the moment of wounding. For exampIe, a case was that of a soIdier hit by a single buIIet traveling in a straight line. (Fig. I.) This missiIe involved the Ieft Iower Iobe of the lung, diaphragm, stomach, Iarge bowel, spIeen and Ieft kidney. (Fig. 2.) This soIdier was Iying down with Ieft side up, facing up a hi& and was shot as the enemy came over the hilltop. A gIance at Figure z shows how straight was the buIIet’s course, but this is regional anatomy which was never taught in the past in medica schoo1 cross sectiona anatomy. Practice in projection of straight Iines traversing the body in many different directions is exceIIent preparation for proper diagnosis of organ invoIvement. KnowIedge of the mobiIity of organs and extremes of their dispIacement in the norma human being is vital. As an exampIe, a buIIet wound with entrance just media1 to the midcIavicuIar Iine anteriorly, entering the Ieft portion of chest through the third intercosta1 space (nicking the superior border of the fourth rib) and exiting posteroIateraIIy on a Iine paraIIe1 with the ground, resuIted in invoIving the stomach and spIeen. The answer simpIy is that the man was squatting and was in deep expiration at the time of wounding. The extremes of diaphragmatic excursion in deep inspiration and expiration are depicted in Figure 3. OccasionaIIy, one sees instances of wounding in which, at first gIance, ricocheting of the missiIe is seriousIy considered; for exampIe, a wound of entrance high in the chest anteriorIy with a missiIe found posteriorIy in the chest at the IeveI of the eIeventh rib posteriorIy. CIose examination of the roentgenogram reveaIed that the rib posteriorly, at the same IeveI of the anterior wound of entrance, had been fractured. Thus, the expIanation is simply that the missile traveling in a straight Iine hit a rib posteriorIy and (either having a Iow veIocity or near a high veIocity end point) was stopped by the posterior portion of the rib, dropped free in the pIeura1 cavity and came to rest deep in the posterior costophrenic angIe. KnowIedge of buIIet veIocity and the distance of air trave1 gives vaIuabIe information as to organ damage [I]. There is a direct proportion between the degree of organ damage and muzzIe veIocity. A missiIe of high velocity does far more damage by its “shock wave” than by the simpIe hoIe it makes. This is, of course, more evident in solid organs and is even more important in hemorrhage from late or delayed necrosis. In the use of knives, information as to the

✓ The posterior fossa surgical approach to aneurysms arising from the vertebral and basilar arteries and their branches is presented. The importance of detailed preoperative angiography is stressed, particularly as related to regional anatomy.

According to observations carried out on 50 subjects (24 men and 26 women), the arteria profunda femoralis, which is on an average 38,3 mms. distant from the ligamentum inguinalis, considered as a fixed point of reference, gives rise in 73% of cases to the arteria circumflexa femoris medialis, with uniform distribution between the two sexes, and in 83% of cases to the arteria circumflexa femoris lateralis, with prevalence in the female sex, while in the remainder of the cases the two aa. circumflexae derive directly from the arteria femoralis. In relation to the different modes of origin of the aa. circumflexae femoris, the cases examined were subdivided into four groups: in the first group (5%) the two aa. circumflexae originate from the arteria femoralis; in the second group (22%) only the arteria circumflexa medialis arises from the arteria femoralis; in the third group (12%) it is the arteria circumflexa lateralis which originates from the arteria frofunda femoralis. While in the second group there is a prevalence of the female sex and in the 3rd group of the male, in the 4th group the two sexes are uniformly distributed. In as many as 29 cases a symmetrical arrangement of the arteries, on the two sides, was observed with prevalence in the female sex. Nach den an 50 Individuen (24 Mannern und 26 Frauen) durchgefuhrten Untersuchungen gehen von der Arteria profunda femoris, die vom Ligamentum inguinalis, das hier als fester Bezugspunkt angenommen wird, einen Abstand von durchschnittlich 38,3 mm hat, in 73% der Falle die Arteria circumflexa femoris medialis aus, bei gleicher Verteilung auf beide Geschlechter, und in 83% der Falle die Arteria circumflexa femoris lateralis, mit groserer Haufigkeit beim weiblichen Geschlecht; in den ubrigen Fallen dagegen haben die beiden Aa. circumflexae direkt bei der Arteria femoralis ihren Ursprung. Auf Grund des verschiedenen Ursprungs der beiden Aa. circumflexae femoris sind die untersuchten Falle in vier Gruppen eingeteilt worden: bei der ersten Gruppe (5%) gehen die beiden Aa. circumflexae von der Arteria femoralis aus, bei der zweiten Gruppe (22%) geht nur die Arteria circumflexa femoris medialis von der Arteria femoralis aus, bei der dritten Gruppe (12%) geht die Arteria circumflexa femoris lateralis von der Arteria femoralis aus und bei der vierten Gruppe (61%) haben beide Aa. circumflexae ihren Ursprung bei der Arteria profunda femoris. Wahrend bei der zweiten Gruppe das weibliche und bei der dritten Gruppe das mannliche Geschlecht bevorzugt ist, ist bei der vierten Gruppe die Haufigkeit bei beiden Geschlechtern gleich. In 29 von 50 Fallen konnte eine symmetrische Anordnung der betreffenden Arterien auf beiden Seiten festgestellt werden, wobei das weibliche Geschlecht bevorzugt war.

The last word in roentgenography of the sinuses has not been said. There is much that is unsatisfactory in the making and in the interpretation of x-ray plates in the diagnosis of sinus conditions. It is in the effort to throw a little added light on this subject and to give a somewhat new angle in its consideration that these studies have been made. 1 It is true that the injection of an opaque material such as bismuth paste or molten metal into the sinuses of dried skulls and their roentgenologic study are old, and much of the knowledge of the inter-relationship of the sinuses and their regional anatomy in the x-ray plate has been obtained by this means. Also there have been sporadic studies of the sinuses of living subjects by the injection of iodized poppy seed oil 40 per cent or similar opaque substances. What

The region of the esophagogastric junction is at the moment an active investigational focus for both clinician and physiologist. An interesting aspect of current study of this area is the lag of anatomic understanding far behind physiologic understanding. There is a need to find out, especially, the relation of the anatomic to the physiologic esophagogastric junction. Proper conclusions can be drawn only from observations made on the living organ. The anatomy of the region is too dynamic to make its features evident in the dead specimen. Achalasia is one of those diseases whose clinical study may permit better understanding of normal regional anatomy and physiology. Here, especially, study of dead organs is not informative. Inspection of the opened esophagus and stomach at the autopsy of a patient with achalasia gives little or no information regarding the anatomic limits of the segment which was narrow during life. Furthermore, study of the anatomy of the cardia in achalasia must be carried out within th...

Summary Perusal of the dental literature has revealed scant reference to the subject of submasseteric abscess and its limitary effect in the spread of dental infection. It is apparent that the astute surgical axiom—‘pus needs drainage’—continues to be defied and reliance placed upon therapeutic measures alone, regardless of the state of infection. From such errors of judgement may arise a refractory case or change in the formal nature of the presentation. Confirmatory evidence of this tendency is shown in the radiographs of bone destruction which occurred beneath mature submasseteric pus formations. A discussion on the controversial matter of the regional anatomy was thought to be apposite, and it does seem that differences in interpretation may be due to inherent difficulties in dissection. Time alone will provide the full answer to the enigma; does an anatomical submasseteric space exist; is it an artefact; or is the pus disposal merely sub-periosteal? One thing cannot be controverted—that is, the reality of the surgical condition.

Clinical problems concerning the distal esophagus are largely anatomic (4). Regional anatomy of the esophagogastric junction is gradually proving to be far more complicated than once believed, and, now that surgical technics permit easy access to the segment, it becomes necessary to submit to critical review the comfortable classical understanding of local structures and relationships. A pressing problem is that of the exact position of the esophagogastric junction. It is of tremendous practical importance to know whether an abnormality observed in this region represents esophageal or gastric disease. In a provocative paper, Barrett (2) pointed out that many reported instances of esophageal ulcer may actually represent gastric ulcer, in stomachs which have been drawn up by unrecognized esophageal shortening. Similarly, it may be that a large proportion of distal “esophageal” adenocarcinomas arise on the gastric side of the esophagogastric junction. As Barrett so convincingly reasons, whatever external app...

This outline was published with the aid of a grant from the Kramer Fund. Part I deals with anatomy, histology, physiology, muscles and optics, while Part III deals with the treatment of some of the more common diseases of the eye. (Part II, which is to appear later, will deal with diagnosis, pathology, bacteriology and perimetry.) The first sixteen pages are concerned with the gross, microscopic and regional anatomy of the eye, orbit and orbital contents. For one who has already studied these subjects in one of the standard textbooks, this section will furnish a comprehensive and condensed resume of the pertinent facts. The three pages devoted to the intra-ocular fluid include a detailed outline of the factors by which the normal intra-ocular tension is maintained as well as the factors by which it may be varied. Three pages are allotted to the pupils ; these are devoted to their

The authors make clear in their introduction that skill in neurological diagnosis rests on meticulous attention to the history and neurological examination and not on diagnostic procedures. This important theme prevails throughout this well-organized, comprehensive textbook of neurology. The initial chapter is devoted to a most lucid presentation of the neurological examination, well worth the reading time of medical students, trainees, and practitioners in any branch of medicine. This is followed by sections on newer concepts of the bases of neurological disorders derived from recent contributions in chemistry, genetics, and studies of developmental defects. There then follows the traditional approach to diagnosis of diseases of the nervous system based on regional anatomy. These sections, comprising a major portion of the text, detail the important anatomical structures, the defects produced when their function is impaired, and the major pathological processes by which they are involved. Separate sections are devoted to the

It is important to the new resident to acquire facility in endotracheal intubation early in his training. In this way he achieves both his own tranquillity of mind and security for the patient. Although residents may know the regional anatomy and the theoretical principles of intubation, the practical application of the knowledge is quite a different matter. Demonstration of the technique is difficult, since the laryngoscope permits clear vision of the larynx to the operator alone. As residents all of us have experienced the frustrations of difficulties with intubation and all the complications it entails.

Since the publication of its first edition in three volumes between 1954 and 1958, Anatomy for Surgeons has held a respected and perhaps unique place as a reference work on the shelves of anatomists as well as surgeons. This has been true because of two features: first, it explains superbly the structural basis for function; second, it offers an up-to-date presentation of anatomical variations or of disputed anatomicophysiologic matters. Examples in this volume are a lucid classification of congenital heart disease; the location of ectopic spleen, liver, or suprarenal glands; the reference of pain in situs inversus; the evidence for or against the existence of the several fasciae gynecologists utilize; the evidence for the neural pathways of visceral function. For the surgeon, the work fails in one important aspect: it places little emphasis on regional anatomy or on the detail of surgical operations. Indeed, the illustrations, while helpful, are almost

Audiovisual presentation may have started with cave drawings, progressing to proclamations on stone and papyrus, thence to books. In our day, displays of various sorts enlarge our armamentarium of audiovisual material. Hence it seems reasonable to review in this section ofThe JournalSchlossberg's and Zuidema's transparencies of surgical anatomy of the abdomen and pelvis. Each plate is of a size to fit a panel of the standard X-ray film viewing box. Viewed thus the excellent drawings and vivid colors allow an immediate grasp of the material presented. They can also be adequately seen when laid on a table under ordinary light. The plates are of regional anatomy significant in surgery, executed for the most part in an idealized rather than realistic manner. Several present in diagrammatic form physiological themes pertinent to surgery, such as the control of secretion of gastric acid, or pathways for pain. Explanatory material equivalent to

The recent articles of Brown and Coffee, and of Muller., have given added interest to, as well as a summary of, our present knowledge of the control of the sympathetic over the vascular system. The barrenness of the literature on this subject justifies another case report with some remarks on the technic and regional anatomy of this operation. REPORT OF CASE G. J., a man, aged 78, a cement worker, born in Germany, who had three healthy adult children over 50, whose father died of cancer at 84, and whose mother died of nephritis at 30, had always been robust. He always had chronic bronchitis, which he believed followed an attack of malaria in childhood. He was a moderate drinker and a very hard worker. About three years ago, while climbing a hill, he was suddenly seized with a heavy feeling in the chest, over the precordium, which quickly disappeared

Manual of Surgical Anatomy. By Sir John Bruce, Robert Walmsley, and James A. Ross. 562 pp, 249 illus. $14.50. Williams & Wilkins Co., 428 E Preston St, Baltimore 2, 1964 Two well-written and nicely illustrated manuals of surgical anatomy have recently become available. Both should prove valuable, not only to the senior medical student about to observe for the first time various operative exposures and dissections, but also to interns, residents, and practicing surgeons who, prior to a not entirely familiar surgical exercise, wish to renew their acquaintance with the integrated regional anatomy of the part in question. These two volumes, apparently by pure chance, complement one another to an unusual degree. (One is essentially a fifth revision and the other, a first edition.) Where one is a more detailed and illustrated surgical atlas, the other tends to emphasize the clinical aspects of anatomy in general. In the Atlas of

The teaching of dermatology on a basis of regional anatomy has been developed to a point where an entire book has been devoted to it.1This leads to stereotyped classifications, which may exclude a disease on the basis of the site of involvement. As an example, we wish to present a case of necrobiosis lipoidica diabeticorum of the abdomen, refuted because of the unusual location by several competent dermatologists when the case was presented at a regional dermatological meeting. Report of a Case History.— A 19-year-old white woman first developed a small erythematous lesion on the right leg about 5 months before she was seen by one of us (J.S.S.). The original lesion slowly increased in size, and new lesions gradually appeared over the succeeding months. Most of the new lesions were located on the abdomen near the umbilicus, while a few lesions developed on the right thigh. Past

For many years, almost without exception, my predecessors in the address on surgery have devoted their labors to the exposition of some general or special subject in the domain of operative surgery, and while I would in no measure detract from the value of a thorough technical knowledge, we should not in our attention to the art , fall short of a proper appreciation of the science of surgery. The experienced surgeon soon learns that it requires more than asepsis and the rapid and skilful performance of an operation to achieve the fullest measure of success; that although a thorough practical knowledge of regional anatomy is essential in the highest degree to the conscientious fulfilment of the professional obligation, it is equally important that there be called into requisition the invaluable aid which laboratory research alone can give in determining an accurate diagnosis; in indicating the most rational measures of treatment

This textbook of gross human anatomy is a revision of one of the newer "streamlined" texts, which are organized to present anatomy in a less voluminous form than the standard "unabridged" volumes. The basic concepts of the regional anatomy of the body are presented. Within this format the peripheral nerves are described and a brief discussion of the spinal cord and the meninges given. The anatomy of the brain is omitted.