Part 84

The nerves arising from the sacral plexus are the following:

1. =N. gluteus superior= (Fig. 162, i; Fig. 163, j).--The superior gluteal nerve arises from the lumbosacral cord and the first sacral nerve; it passes dorsad in the notch between sacrum and ilium, caudolaterad of the first anterior sacral foramen, curves over the dorsal border of the ilium between the gluteus medius and pyriformis muscles (Fig. 163, 7), passes between the gemellus superior (6) and gluteus minimus (5) and ventrad of the latter, and reaches the medial surface of the tensor fasciæ latæ, which it innervates. In its course it sends branches to the gluteus medius, gluteus minimus (5), and gemellus superior.

2. =N. gluteus inferior= (Fig. 162, j; Fig. 163, i).--A small nerve from the lumbosacral cord and the first sacral nerve. It passes dorsocaudad, lying on the dorsal surface of the great sciatic nerve (Fig. 162, h). After leaving the pelvis by the great sciatic notch it divides beneath the pyriformis (Fig. 163, 7) into two branches; one goes to M. caudofemoralis (4), the other to M. gluteus maximus (3).

3. =N. ischiadicus= (Fig. 162, h; Fig. 163, a).--The =great sciatic= nerve, the largest nerve in the body, arises from the lumbosacral cord (formed chiefly by the sixth and seventh lumbar nerves), the first sacral nerve and a small branch from the second sacral. It passes caudodorsad and leaves the pelvis by passing across the great sciatic notch, between M. pyriformis and M. gemellus superior. It passes across the tendon of M. obturator internus (Fig. 163, 9) near the insertion, and here sends caudad a large muscular branch (b) beneath the biceps. This branch innervates the biceps, semitendinosus (17) and semimembranosus (16). Other twigs in this region pass to the quadratus femoris (10) and tenuissimus. The great sciatic nerve (a) now passes across the quadratus femoris (10), adductor femoris (15), and semimembranosus (16), lying beneath the biceps femoris. It thus enters the popliteal space and approaches the popliteal artery and vein. Here it gives off one or two small muscular branches to the distal part of the biceps, and sends a slender branch, =N. suralis= (c), along the medial surface of the biceps to the lateral surface of the lateral head of M. gastrocnemius (20). The sural nerve (c) becomes cutaneous at the distal (ventral) border of the biceps, and divides three or four centimeters proximad of the ankle into two branches. One passes over the tendon of Achilles (27) to the proximal end of the calcaneus and ramifies in this region. The other passes onto the lateral surface of the foot, and supplies the integument in this region over the tarsus and part of the metatarsus.

The great sciatic nerve now divides in the popliteal space into the =peroneus communis= (d) and the =tibialis= (e).

The biceps, caudofemoralis, gluteus maximus, gluteus medius, tensor vaginæ femoris, and part of the peroneus longus have been removed. a, N. ischiadicus or great sciatic nerve; b, muscular branch; c, N. suralis; d, N. peroneus communis; e, N. tibialis; f, N. peroneus profundus; g, N. peroneus superficialis and its terminal branches; h, branches of N. cutaneus femoris posterior; i, N. gluteus inferior; j, N. gluteus superior; k, vena saphena parva; k′, communicating branch to V. glutea inferior. 1, M. sartorius; 2, cut origin of M. gluteus medius; 3, cut origin of M. gluteus maximus; 4, cut origin of M. caudofemoralis; 5, M. gluteus minimus; 6, M. gemellus superior; 7, M. pyriformis; 8, M. flexor caudæ longus; 9, M. obturator internus; 10, M. quadratus femoris; 11, tuberosity of the ischium; 12, great trochanter of femur; 13, M. rectus femoris; 14, M. vastus lateralis; 15, M. adductor femoris; 16, M. semimembranosus; 17, M. semitendinosus (the slender ribbon-like muscle crossing this is M. tenuissimus); 18, M. vastus intermedius; 19, M. plantaris; 20, M. gastrocnemius; 21, M. peroneus longus (cut); 22, M. tibialis anterior; 23, M. extensor longus digitorum; 24, transverse ligament; 25, M. peroneus brevis; 26, M. soleus; 27, tendon of Achilles; 28, M. extensor brevis digitorum; 29, tendon of M. peroneus tertius.]

a. =N. peroneus communis= (d).--This is the more lateral of the two divisions of the great sciatic nerve. It passes along the medial surface of the biceps to the lateral surface of the lateral head of M. gastrocnemius (20), where it extends to a point just distad of the head of the fibula. Here it passes beneath that part of the gastrocnemius which has origin on the fascia of the shank, passes between the soleus and peroneus longus (21), then between the peroneus longus and peroneus tertius. It gives off a number of small muscular branches, then divides two or three centimeters distad of the head of the fibula into two main branches, =N. peroneus superficialis= (g) and =N. peroneus profundus= (f).

(1) =N. peroneus superficialis= (g).--The superficial peroneal nerve passes distad between the peroneus longus and peroneus tertius. Near the ankle it becomes superficial, passing along the concavity of the ankle across the transverse ligament which binds down the tendons of the extensor longus (23) and tibialis anterior (22), and thus reaches the dorsal side of the foot. Two or three minute twigs are given off to the ankle, then the nerve divides into four divisions. These pass distad to the toes, subdividing so as to send a nerve to each side of each toe.

(2) =N. peroneus profundus= (f).--The deep peroneal nerve passes between the tibialis anterior and extensor longus digitorum muscles, gives branches to these muscles, and passes distad with the tibialis anterior artery, lying on the inner surface of the tibialis anterior muscle. It passes onto the dorsum of the foot, lying on the inner surface of the tendon of the muscle. On the tarsus it divides into two branches. The lateral branch passes into the extensor brevis digitorum, while the medial one extends in the dorsal groove between metatarsals four and five to the toes; here it divides into two nerves which supply the contiguous sides of digits four and five.

b. =N. tibialis= (e).--The tibial nerve passes distad parallel with the peroneal nerve, but mediad of it. It passes between the lateral and medial heads of the gastrocnemius, giving off muscular branches to these, and to the plantaris and soleus. It then passes between the plantaris and the medial head of the gastrocnemius, and reaches the space between the plantaris and flexor longus hallucis, where it passes distad. It gives off, in the region just described, muscular branches to the flexor longus digitorum, flexor longus hallucis, and tibialis posterior. Below the middle of the lower leg the nerve becomes superficial (Fig. 127, i, page 310), lying on the ventral surface of the flexor longus hallucis. It passes in the depression between the heel and the medial malleolus onto the plantar surface of the tarsus, sends a small branch to the plantar surface of the heel, and divides into two branches, the =medial= and the =lateral plantar= nerves.

(1) =N. plantaris medialis.=--The medial plantar nerve passes along the medial border of the flexor brevis digitorum and divides into two branches. One passes to the medial (second) digit, supplying both sides; the other supplies the third digit in the same way. Both send branches to the fibrous pad on the sole of the foot.

(2) =N. plantaris lateralis.=--The lateral plantar nerve passes laterad across the tendon of the flexor longus digitorum to its lateral edge. At about the proximal end of the metatarsi it divides into two branches. The lateral branch passes distad to the ventral surface of the fifth digit. The medial branch passes beneath the tendon of the flexor longus digitorum and transversely across the interossei; it divides into numerous tendons which innervate the interossei and other short muscles of the sole of the foot.

4. =N. pudendus= (Fig. 162, l; Fig. 112, 8, page 265).--This arises (Fig. 162, l) from the sacral plexus caudad of the great sciatic nerve. It has two roots, one from the second sacral, one from the third, and it may also receive a small accession from the great sciatic nerve (h) three or four centimeters caudad of the origin of the latter. It passes at first dorsolaterad, laterad of the coccygeus muscle, then curves mediad toward the anus. It divides into two branches: one passes to the base of the penis, sends twigs into the compressor urethræ muscle, and passes onto the dorsal surface of the penis. This branch is =N. dorsalis penis=; it extends with the artery of the same name to the glans. The second branch of N. pudendus (=N. hemorrhoidalis medius=) passes to the anus and innervates the muscles and other structures about the caudal end of the rectum. In the female, branches of N. pudendus supply the urogenital sinus and adjacent structures (Fig. 112, 8).

5. =N. cutaneus femoris posterior= (Fig. 162, k; Fig. 163, h).--This arises from the sacral plexus, its roots coming chiefly from the second and third sacral nerves, and passes caudodorsad, at first in close connection with N. pudendus. It then accompanies the posterior gluteal artery and vein, sends branches (perineal nerves) into the fat at the sides of the anus, and branches onto the lateral surface of the biceps muscle. One of the latter follows the communicating vein (Fig. 163, k′) from V. saphena parva, and may be traced as far distad as the popliteal space.

6. =N. hemorrhoidalis inferior= (or =posterior=) (Fig. 162, m).--This arises by two roots, from the second and third sacral nerves, and passes with the inferior hemorrhoidal artery ventrad across the lateral surface of the rectum to the urethra. Here it divides into two parts: one passes craniad to the bladder, the other caudad onto the ventrolateral surface of the rectum.

A small nerve passes from the sacral plexus, especially from the third sacral nerve, into M. levator ani (Fig. 162, 11). Another small nerve from the same region passes to M. coccygeus, and a third to the proximal end of M. tenuissimus.

E. NERVES OF THE TAIL. COCCYGEAL NERVES.--From the intervertebral foramina of the first seven or eight caudal vertebræ spinal nerves of the usual type are given off. The dorsal rami innervate the dorsal muscles of the tail. The ventral rami are interconnected with each other and with the last sacral nerve by a longitudinal cord; they innervate the muscles and integument of the ventral side of the tail.

3. The Sympathetic Nervous System. Systema nervorum sympathicum.

The sympathetic system consists essentially of a chain of ganglia on each side of the ventral surface of the vertebral column, interconnected by longitudinal nerve-cords, and stretching from the base of the skull to the tail. The ganglia are connected to the spinal nerves by communicating branches, and numerous branches pass from them to the abdominal and thoracic viscera, and to the walls of the lymph- and blood-vessels, forming complicated plexuses.

=Cervical portion= (Fig. 156, page 379).--The sympathetic system begins just caudad of the tympanic bulla as the =superior cervical ganglion= (=G. cervicale superius=) (Fig. 156, e). This is a large ganglion closely applied to the ganglion nodosum (d) of the vagus, and lying on its ventrocranial side. From the superior cervical ganglion the sympathetic trunk passes caudad usually closely bound up with the vagus (d′), so that the two can scarcely be distinguished. They lie (i) at the side of the trachea (6), close against the lateral surface of the carotid artery. A few centimeters before reaching the first rib the two separate (Fig. 157, page 381); the sympathetic (c) is here the smaller and more dorsal of the two. Just craniad of the first rib the sympathetic usually forms a small swelling, the =middle cervical ganglion= (Fig. 157, d), beyond which it divides into two portions. The larger dorsal division passes dorsocaudad and joins a large ganglion, the =inferior cervical= (e), which lies at the head of the first rib, on the lateral surface of the longus colli muscle. The ventral branch (g′) passes caudad, turns laterad about the medial and caudal surface of the subclavian artery, and likewise reaches the inferior cervical ganglion.

In some cases the middle cervical ganglion (d) is lacking.

=Branches of the Sympathetic in the Cervical Region.=--From the cranial end of the superior cervical ganglion several nerves pass craniad. Some of these become connected immediately with the cranial nerves emerging from the jugular foramen, forming a plexus in this region. Others pass with the internal carotid artery craniad, forming a plexus about that artery; from the plexus twigs arise which pass to the fifth and sixth cranial nerves; doubtless also to the seventh and eighth. A specially large branch, the =deep petrosal nerve= (see page 373), passes from the superior cervical ganglion along with the internal carotid artery to the pterygoid canal, thence through this to the =sphenopalatine= ganglion. Before separating from the vagus the sympathetic gives off one or two =cardiac= nerves (Fig. 157, i). These are closely bound up with the vagus (b), so that they appear usually to have origin from the vagus at about the level of the first rib. These pass with the vagus to the heart and take part in the formation of the =cardiac plexus= (k).

At the middle cervical ganglion (d) usually a communicating branch is given to the vagus. The branches of the inferior cervical ganglion (e) fall in the thoracic region, and are described in that connection.

=Thoracic Portion of the Sympathetic= (Fig. 157, page 381).--The inferior cervical ganglion (e) lies entirely within the thoracic cavity. It has the following branches:

1. One or two small =cardiac= branches (h), which pass to the heart (r).

2. A =large communicating branch= (e′), which passes craniad from the cranial end of the ganglion (e) along the lateral surface of the longus colli muscle, and gives communicating branches to the sixth, seventh, and eighth cervical nerves (VI, VII, and VIII).

3. One or two small communicating branches to the first thoracic nerve (I′).

4. A communicating branch to the second thoracic nerve.