颈部、腋窝的动脉变异
     阑尾的临床解剖
     良性十二指肠淤滞症的临床与解剖
     手足的分化与人类的进化
     腕部离断再植术的临床解剖
     膝关节半月板的临床解剖
     痔的临床解剖
     Situs inversus and its importance in clinical practice
     The history of Artificial pacemaker With a case of double superior vena cava

颈部、腋窝的动脉变异

04临床1班 陈鹏举、陈晓鹏、胡向欣、黄慧雅、方艳
04临床4班 李加宁、张守强、张浚鹏、李萌、程微子

    动脉变异的情况可谓多种多样。很多时候书上所写的是统计出的最多情况，但是即便是最多，有时也仅有50-60%或是不到半数的人是“最常见”的。所以关注动脉变异便就成为极有意义的事情。
    其实我们通常关注的动脉变异是针对中动脉或是比较重要的小动脉进行的，也就是说当他们更加深入，分支更加细微的时候，不确定性就更为显著，甚至于无法总结出何为“最常见类型”。不过中动脉和小动脉的变异也是最值得关注、最有意义的——因为可以明确地分辨出供血范围、脉管走向，对采用何种切口，在何处结扎，在何方断离，用何种办法手术都是有指导意义的。比如在进行冠心病的手术或是内科的介入疗法，比如普外的胆囊切除，就应弄清楚冠状动脉和胆囊动脉的不同变异类型，不论是动脉造影还是直接的肉眼观察，都是不可或缺的。
    这样我们就能根据个体的不同而施与不同的处理——这是必然需要的。在“个体”的重要性越来越突出的时代，分支细微地关注每一个个体的不同也体现了对其的尊重。
    颈区的几种动脉变异情况。
    首先是最常见的颈总动脉分为颈外、颈内两支，而后颈外动脉又分为五个分支。颞浅动脉、上颌动脉、面动脉、舌动脉、甲状腺上动脉。一般而言，后三支的变异情况比较突出，常出现共干的状况。如面动脉和舌动脉的共干状况以及五个分支从基本上同一个地方发出，而后面动脉与舌动脉共干。
    面动脉和舌动脉的共干是比较常见的一种变异情况，但是在本次局解中出现的是舌动脉与甲状腺上动脉的共干。与其说是共干，不如说是从融合了的一个点共同发出来的合适。即颈外动脉、甲状腺上动脉、舌动脉以及甲状腺上动脉分出的一支叫做喉动脉的分支。由此也证明我们所见的舌动脉并非膨大的喉动脉。
    此外，可以根据周边组织发现，甲状腺上动脉和舌动脉共起点发出后发出点位于正常的甲状腺上动脉和舌动脉之间。舌动脉的走行由向下变为向上。 此区域的静脉网较密集，拍照时为了清楚断了其中的一部分。迷走神经、壁从的穿出处也可以作为判断方位的根据。
    腋窝区的动脉变异状况
    涉及的动脉有旋肱后动脉与腋动脉（或是肱动脉）、肩胛下动脉、肱深动脉之间的关系。图表显示了这几个动脉的几种变异状况。其中旋肱后动脉是诸类型变异的焦点，可以由肩胛下动脉发出也可以和肱深动脉共干。和肱深动脉的共干也有开口于肱深动脉的开口处及原旋肱后动脉的开口处两种情况。而其中又可以产生各种状况的交通支。
    事实证明旋肱后动脉比较容易“两边倒”。而且有的时候偏离比较大就不一定从四边隙走了。
    这是我们的标本状况。很明显，脉管和神经走的不是同一个孔洞。旋肱后动脉并未伴随腋神经穿四边隙而过，而是从背阔肌下缘直接翻向背面。这两张基本相同，都是从背面的相同角度拍摄的。中间仍然是背阔肌的肌腱，而此次能看到的是旋肱后动脉从共干分出之后上行的状况。而肱深动脉直接穿向肱骨下段，向桡神经沟走行。镊子夹起的是从四边隙穿出的腋神经，可以清楚的见到腋神经之后的走向，发往三角肌和小圆肌。在另外一幅施力较小的图片上显示的是共干的状况和明显的四边隙。
    由此可见，本组的动脉变异状况是上边所罗列的四种状况中的第三种，仅有14%左右的人是这样的情况。

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阑尾的临床解剖

闫琦 谢敏 李照青 贺静 周健 贺致宾 刘凯 康海利 张博超

    阑尾是一个多变异的器官。阑尾变异以阑尾异位最多见，占76.8％，阑尾发育异常次之，阑尾畸形较少，阑尾内异位组织最少。异位阑尾的存在常给临床诊断造成一定的困难，因此对异位阑尾所致的阑尾炎及其他疾病引起足够重视，以减少误诊漏诊的发生。

阑尾解剖学基础

阑尾变异

阑尾炎病因

阑尾炎诊断要点

临床表现

阑尾炎手术处理

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良性十二指肠淤滞症的临床与解剖

04级临床四班：朱怡 柏露 陈识 李冉 陈幸 潘凌霄 金星星 顾航宇 陈云超

一．病例讨论： 患者40岁，女，体重30KG因为腹痛伴呕吐入院，来诊时休克及严重电介质紊乱合并严重营养不良。术中患者胃扩张几乎占据整个腹腔，减压后才拖出胃，吸出胃液约3000ML,十二指肠全程扩张，选择行TREITZ韧带松解，结肠后胃空肠吻合，术后恢复良好出院。
二．十二指肠的解剖：
    1位于幽门和空肠之间，呈C形，环抱胰头，全长约25CM。
    2分为四部分：
     1-球部
     2-降部
    3-水平部：自降部转向左侧横行，长约10CM，位于腹膜后，上方临胰头，后方为腹主动脉，前方有肠系膜上动静脉纵行越过——相当于腹主动脉和肠系膜上动脉之间形成一个夹角，将十二指肠水平部夹持在内。
     4-升部

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手足的分化与人类的进化

陈骏良，范宇，林杰荣，米悦，南少奎，齐越，汤睿，王天昱，王玺

    手是我们身体最重要的器官之一，手足的分化标志着人类的产生，人类直立行走之后手就被解放了出来，来参与人的劳动过程，制造工具，使用工具。我们的手可以为我们做很多事情：我们可以用手来互相交流，这就是我们创造的手语；我们可以用手来创造美丽，美丽的艺术和音乐都是我们用手展现出来的；我们还可以用手来抗击生命中的苦难；我们还可以用手来拯救珍贵的生命，这也就是我们将来要做的伟大的医学事业；虽然脚有时候也可以代替手来完成一些手的工作，但是大部分时间脚还是驮着我们的身体奔波。
    我们知道手和脚有很大的相似性，但是它们可以完成的动作何以有这么大的区别呢？这个需要我们从它们的解剖结构入手来探讨。臧微观老师经常对我们讲：一个器官的功能是什么源自于它的解剖结构是怎样的。所以让我们先来看一下运动手的一些肌肉。
    这里是支配手的运动的全部肌肉，包括前臂的一些肌肉和手部的一些肌肉。这些肌肉都是我们手可以做如此多的精细动作的基础。大家在这里可以有一个初步的印象，就是支配手的肌肉是如此之多，幸好手肌不是我们考试要求的重点啊。这些内容在我们课堂上都有所提及，在这里我就不再详细介绍了，只给大家说一下这个拇指。人的拇指有一个区别于其他所有动物的特殊的运动，那就是人拇指可以弯曲作对掌运动，这个运动是由拇指鱼际肌支配的。对掌运动是指拇指尖的掌面和其他各指的掌面向接触的运动 对掌运动是人手所特有的运动,是人手作为劳动器官所特有的功能 这个动作可以保证人类可以更加牢固的持握工具，早期的人类就是依靠这个动作持握木棒和弓箭等。从某种意义上讲，这引导了人类科技的进步。大家知道我们经常使用这个对掌运动做什么么？发短信玩手机啊。最近就出现了一种新的疾病，就叫手机病，就是由于青少年玩手机过多，导致手臂麻木、腕关节肿胀、手部动作不灵活、视力下降以及表现为紧张性头痛、焦虑、忧郁等症状。这些是我们平时要注意的。还有就是由于支配大鱼际肌的主要是正中神经的返支，在正中神经受侵的情况下大鱼际肌萎缩、瘫痪、拇指不能作掌侧外展及对掌运动。检查方法很简单，就是将患者的手平放于桌面，掌心向上，然后告诉患者竖起拇指而与手掌呈直角。如不能的话，就是猿手。
    这里是支配足部运动的全部肌肉。在这里可以看出足部和手部肌肉有很大的相似性，很多都是对称存在的。但是通过对比我们可以看出这些要比支配手的肌肉少了很多。比如手部有专门支配伸小指的小指伸肌，而足部就没有，这也和我们的基本观点相一致，那就是在人类进化过程中，由于直立行走，手足分化，使得手被专门用来进行劳动，功能的分化导致了解剖学上的一些分化。
    我们还发现，人类在一些进化的过程中要更加符合拉马克的“用进废退”理论。人类拥有一定的对抗环境改变的能力，例如医学的长足的进步，可以打破优胜劣汰的自然法则，使得“劣”的个体可以生存下来。所以我们有一个结论，那就是今后人类进化可能是常用器官的功能适应型进化与无用器官的退化消失的过程。这个过程还会继续下去，因为人类直立行走至今才百万年而已，相对于已经在地上爬了几亿年的动物们来说进化的还相当不完善，人类的很多结构都不太适合直立行走。比如柔弱的脊柱，却要支撑整个上半身的重量。这些都会随着时间儿慢慢改变。这里是一张美国科学家预想的未来人类身体结构的一张图，就设想人类脊柱将会变得更加粗大，身体结构将更趋合理。

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腕部离断再植术的临床解剖

04级临床专业：陈曦 季娟 牛硕 潘峰 宋曼 王琼 肖飞 徐轶 余其多

[摘要] 断肢再植术是指将断肢重新接回原处的手术。因外伤或手术致使大部分或全部组织离断的肢体称为断肢。断肢再植采用的手术方法以缝接动静脉为主，也包括骨关节的整复或内固定，神经、肌肉、肌腱、皮肤等修复，在临床上有较高难度。 本文完整记录了腕部离断的手术处理方法，报告了和局部解剖学学习相关的腕部离断再植术内容。
[关键词] 腕部离断 再植 手腕部局解
    再植手术大概涵盖以下内容：①对骨折断端作必要的短缩后行坚固的内固定；若为经关节的断肢，应视具体情况进行关节功能位融合或关节成形术。②缝合断裂的肌肉、肌腱。③修复断裂的神经，这是再植肢体后期功能恢复的基础。④吻合断裂的血管，这是肢体存活的关键。凡是有条件吻合的血管，都应争取吻合。吻合静脉的数量应尽量多于动脉数量，以使再植肢体既有充足的血供，又有足够的血液回流。根据血管的口径、长短的设备及技术条件可以做端对端的间断缝合（较大口径的血管也可做连续缝合），可做套接式缝合，也可做激光焊接。⑤闭合伤口，这是预防伤口感染，减少疤痕并为后期一些修复手术创造良好条件的重要措施。⑥断肢筋膜间隙内和血管吻合口附近必要的引流。适度的包扎伤口和妥善外固定。
    1963年陈中伟、钱允庆等在世界医学史上首先报告一例右腕上2.5cm完全离断肢体再植成功，该患者康复治疗后右手功能恢复良好。Malt和Mckhann1964年也报告了他们在1962年5月对一例12岁男孩上臂部再植成活。1967年，陈中伟、Komatsa、Tamai等相继报告断指再植成功。断肢再植成功的经验表明，人体部分组织和器官离断后，在一定条件下利用显微外科技术重建其血供从而使它回归机体，这是一个重要的医学概念突破。自从1963年我国第一例断肢再植成功以来已近40年，我国在断肢(指)再植领域始终保持着世界先进水平。
    ——手腕肌肉及肌腱的局部解剖
    手掌面的结构主要包括来自前臂的屈指肌腱和它们的腱滑液鞘、手肌以及他们的血管和神经。屈指肌腱有指浅、深屈肌腱和拇长屈肌腱，他们经腕管入掌止于指骨。手背主要含有从前臂延续来得伸指和伸、展拇指肌的肌腱。前臂伸肌腱经伸肌支持带深方走向手指时，都被包绕在腱滑膜鞘内。来自前臂的3块伸腕肌、3块伸指肌和3块伸、展拇指肌，共12条肌腱，分别为6个键滑膜鞘所包裹，通过6个骨纤维管。腱滑膜鞘都略超出伸肌支持带的近侧缘和远侧缘。
图1: 左腕关节横断面

    ——手腕部血管的局部解剖
    1）桡动脉：有两条伴行静脉，行于肱桡肌尺侧缘，此缘是暴露桡动脉的标志。该动脉上1/3位于肱桡肌与旋前圆肌之间，下2/3位于肱桡肌与桡侧腕屈肌之间，其 远侧1/3位置表浅，为触摸脉搏处。
    2）尺动脉：经旋前圆肌深面，穿指浅屈肌腱弓至前臂前区尺侧；在前臂近侧1/3，位于指浅屈肌深面，在远侧2/3，位于尺侧腕屈肌与指浅屈肌之间，经屈肌支持带 的浅面、豌豆骨桡侧入手掌。尺动脉上端发出骨间总动脉，该动脉分为骨间前、活动脉，分别行于前臂骨间膜前、后方。
    ——手腕部神经的局部解剖
    通过手腕部的神经有：正中神经、尺神经、桡神经。
    1）正中神经：在屈肌支持带附近，正中神经发出小的掌支，分布到掌心和鱼际肌表面的皮肤。
    腕部正中神经损伤后的主要表现是：运动：三个鱼际肌即拇对掌肌，拇短展肌及
    拇短屈肌浅头瘫痪，因此拇指不能对掌，不能向前与手掌平面形成90°，不能用指肚接触其它指尖，大鱼际萎缩、拇指内收形成猿手畸形，拇短屈肌有时为异常的尺神经供给。
    感觉：手部感觉丧失以正中神经伤影响为最大。伤后拇、食、中指、环指桡侧半掌面及相应指远节背面失去感觉，严重影响手的功能，持物易掉落，无实物感，并易受外伤及烫伤。
    营养改变：手指皮肤、指甲有显著营养改变，指骨萎缩，指端变小变尖。
    2）尺神经：在屈肌支持带的前面，伴尺动脉进入手掌。
    损伤后的主要表现是：
    运动：手指平放时，小指不能爬桌面。手内肌广泛瘫痪，小鱼际、骨间肌及第3、4蚓状肌、拇内收肌及屈拇短肌内侧头均瘫痪。小鱼际及掌骨间有明显凹陷。环指、小指有爪状畸形。在指屈深肌神经供给远侧损伤，因指深屈肌失去手内肌的对抗作用，爪状畸形明显，即环小指掌指关节过伸、指间关节屈曲。不能在屈曲掌指关节的同时伸直指间关节。由于桡侧二蚓状肌的对抗作用，食中指无爪状畸形或仅有轻微畸形。各手指不能内收外展。夹纸试验阳性。拇指和食指不能对掌成完好的“O”形，此两指对捏试验显示无力，是由于内收拇肌瘫痪、不能稳定拇指掌指关节所致。小指与拇指对捏障碍。因手内肌瘫痪，手的握力减少约50%，并失去手的灵活性。
    感觉：手的尺侧、小指全部、环指尺侧感觉均消失。
    3）桡神经：
    损伤后的主要表现是：
    运动：上臂桡神经损伤时，各伸肌属广泛瘫痪，肱三头肌、肱桡肌、桡侧腕长短伸肌、旋后肌、伸指总肌、尺侧腕伸肌及食指、小指固有伸肌均瘫痪。故出现腕下垂，拇指及各手指下垂，不能伸掌指关节，前臂有旋前畸形，不能旋后，拇指内收畸形。拇指失去外展作用，不能稳定掌指关节，拇指功能严重障碍。因尺侧腕伸肌与桡侧伸腕长短肌瘫痪，腕部向两侧活动困难。前臂背侧肌肉萎缩明显。在前臂背侧桡神经伤多为骨间背神经损伤，感觉及肱三头肌，肘后肌不受影响，桡侧腕长伸肌良好。其他伸肌均瘫痪。
    感觉：桡神经损伤后，手背桡侧半、桡侧两个半指、上臂及前臂后部感觉障碍。 断肢再植的手术步骤及术后护理（略）

[参考文献]
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4．断肢再植术30例报告 赵国红 实用手外科杂志 2006/01
5．断腕再植的体会 张国如 实用手外科杂志 2003/04
6．对断肢(指)功能再植问题的探讨 陆锡平 实用骨科杂志 2006/01
7．上臂毁损性离断的再植与功能重建 牛志勇 中华显微外科杂志 2006/06
8．断指再植病人的护理 赵燕 护理实践与研究 2007/02

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膝关节半月板的临床解剖

宋一帆，孟昭婷，王小艺，吴小静，刘文清，刘沛，刘军广，孟令超，肖犇，马 栋

1、膝关节半月板的结构与功能
1.1 膝关节结构总述
    膝关节是人体最易损伤的关节之一，它由股骨远端，胫骨近端和髌骨组成。同时附着在它们上的韧带，关节囊和半月板组成了关节的稳定结构。前交叉韧带起于股骨外髁的内侧面，止于胫骨内侧隆突的前外侧，限制胫骨的前移与旋转。后十字韧带起于股骨内髁的外侧面，止于胫骨平台后缘，位于关节水平的下方，限制胫骨的后移。它们是维持膝关节稳定的关节内的重要结构。半月板，或称半月形软骨，是膝关节内C型纤维软骨盘，它可以吸收撞击，增加关节面适应性，增加关节稳定性，有助于关节液均匀分布。
1.2半月板
    在关节内，生有由纤维软骨构成的半月板,这使得呈球面凸隆的股骨内、外侧髁的关节面和较浅的胫骨髁的关节窝彼此更加适应。半月板的外缘较厚，与关节囊紧密愈着，内缘薄而游离；上面略凹陷，朝向股骨髁，下面平坦，朝向胫骨髁。 内侧半月板大而较薄，呈“C”形，前端狭窄而后份较宽。前端起于胫骨髁间前窝的前份，位于前交叉韧带的前方，后端附着于髁间后窝，位于外侧半月板与后交叉韧带附着点之间，边缘与关节囊纤维层及胫侧副韧带紧密愈着。
    外侧半月板较小，呈环形，中部宽阔，前、后部均较狭窄。前端附着于髁间前窝，位于前交叉韧带的后外侧，后端止于髁间后窝，位于内侧半月板后端的前方，外缘附着于关节囊，但不与腓侧副韧带相连。
    半月板具有一定的弹性，能缓冲重力，起着保护关节面的作用。由于半月板的存在，将膝关节腔分为不完全分隔的上、下两腔，除使关节头和关节窝更加适应外，也增加了运动的灵活性，如屈伸运动主要在上关节腔进行，而屈膝时的轻度的回旋运动则主要在下腔完成。此外，半月板还具有一定的活动性，屈膝时，半月板向后移，伸膝时则向前移。
2、 常见半月板损伤
    半月板损伤主要分为慢性退变性撕裂和急性外伤性撕裂。
2.1慢性退变性撕裂：
    慢性退变性撕裂与老龄化和反复慢性损伤有关，组织学表现为粘液样变性，包括糖胺聚糖基质增加、软骨细胞坏死、原纤维分离和微小囊肿形成等。随着病程进展，纤维软骨分离断裂，沿胶原纤维的方向形成水平状的离断层，当其延伸到关节面时即形成半月板撕裂。 退变的发生顺序是：内侧半月板的后角和体部、外侧半月板的前角、体部和后角、内侧半月板的前角。内侧半月板后角的下关节面比其他部位更容易发生退变和退变性撕裂。
2.2急性外伤性撕裂 ：
    在强力骤然运动时，半月板易造成损伤，甚至撕裂。当膝关节处于曲屈而胫骨固定时，股骨下端由于外力骤然过度旋内、伸直，可导致内侧半月板撕裂；同理，如该时股骨下端骤然外旋、伸直，外侧半月板也可发生破裂。
    后文主要讨论急性外伤性撕裂的诊断与治疗。

3、诊断与治疗
    临床上对半月板损伤的诊断主要有体检检查、X片检查和关节镜检查等。
    3.1体检检查：
    3.1.1内侧半月板损伤症状与诊断
    1）运动过程中及运动后膝关节内侧疼痛。
    2）膝关节绞索感，这是由于半月板的撕脱部分遗留于关节内限制了关节的运动，使关节不能完全屈伸，在某个位置出现关节绞索感。
    3）膝关节过伸过屈或膝关节屈伴随小腿和足外旋使关节内侧有触痛。
    4）运动后，有时关节内有积液。
    如果以下检查出现三个或更多，则可考虑内侧半月板损伤。
    (1) 关节内侧某一点有触痛。
    (2) 膝关节过伸时，关节内侧线处疼痛。
    (3) 膝关节过屈时，关节内侧线处疼痛。
    (4) 膝关节90度范围，足和小腿外旋时出现疼痛。
    (5) 股四头肌变弱或萎缩。
3.1.2外侧半月板损伤，症状与诊断
    1）关节运动时，膝关节外侧疼痛。
    2）绞索症状。
    3）关节过屈或过伸，膝外侧疼痛。当关节屈90度时，足和小腿和对干股骨内旋，膝线外侧疼痛。
    4）关节内有时出现积液。
    在关节检查中，如果出现三个或更多的如下症状，则应考虑外侧半月板损伤。
    （1） 外侧膝线上某一点触痛。
    （2） 关节过伸时，外侧膝线疼痛。
    （3） 关节过屈时，外侧膝线疼痛。
    （4） 膝在不同角度屈时，伴随足和小腿的内旋，出现膝痛。股四头肌变弱或萎缩。
3.2 X片检查：
    X片见患侧间隙增宽，胫骨平台和股骨髁边缘骨质增生，腓骨小头位置比正常稍高。
3.3关节镜检查与治疗
    关节镜下诊断半月板损伤的优点: 镜下可直视关节内部结构, 全面了解膝关节内情况, 准确判断半月板是否有损伤, 明确损伤部位、区域、类型及半月板性状, 以及是否合并有软骨、滑膜及交叉韧带的病变, 镜下诊断准确, 全面。
    具体方法为，在髌韧带外、内侧关节间隙处分别用尖刀作长约7 mm 切口, 穿刺鞘进入关节后安装关节镜头,注水后按顺序进行关节镜检查, 特别注意检查术前体检和MRI提示有损伤的半月板, 用探针确定半月板的损伤部位和类型及活动度, 根据半月板损伤类型, 决定半月板切除的多少和手术方法, 用蓝钳以及各种手术器械, 切除破损的半月板, 用刨削器修整保留的半月板游离缘使其光滑。保护好半月板关节囊连接部的纤维环, 维持半月板周围关节囊的稳定性。在处理半月板的同时或前后, 处理关节内的其他病变, 如先行摘除游离体, 刨除增生的滑膜更有利于半月板的处理, 修整软化的关节面, 切除滑膜皱襞等。最后作关节腔彻底灌洗, 以清除所有的残余碎片, 尽量抽出关节腔的盐水后缝合皮肤切口, 关节腔内注射透明质酸钠, 以改善术后早期关节活动度, 行棉垫裹膝, 弹力绷带加压包扎。
    术后第2 d 开始行股四头肌收缩、直腿抬高训练和膝、踝关节伸屈活动, 术后3～ 7 d 下地行走, 5～ 7 d 拆线, 2～ 3周行下肢悬空负重股四头肌收缩锻炼, 术后活动应根据不同的患者制定不同的恢复锻炼计划。
    术中检查半月板一定要仔细, 由探针检查半月板的松弛度及半月板破裂的类型,不可遗漏水平样撕裂,尤其要注意探查半月板底面不完全撕裂的存在,如允许可将关节镜镜头置于半月板与胫骨关节面之间进行观察。由于内侧半月板后角在术中暴露常不满意,可使膝关节外翻、纵向牵引的同时作小腿外旋,以充分显露内侧半月板全部。这样,就能够检查彻底,全面,不会遗漏任何一处损伤,达到准确诊断的目的。
    膝关节半月板是膝关节发挥正常功能的重要组成部分, 其对保持关节稳定、传导负荷及分散应力的功能已为人们所共识。半月板全切除可导致膝关节过早发生退行性改变, 远期引发骨性关节炎, 现很少采用。关节镜治疗半月板损伤的优势在于关节镜检查的准确性和手术的微创性( 切口小、创伤轻、恢复快) , 特别是双侧半月板损伤或合并关节软骨、韧带损伤以及膝关节韧带、滑膜和关节内游离体等疾病得已及时发现和治疗, 故采用关节镜治疗是半月板损伤治疗的金标准, 根据损伤的不同, 采用半月板成形术、修补缝合术、部分切除术、大部切除术、全部切除术、表面清理术和其它病变清扫术。由于半月板切除术对膝关节功能带来的损害已愈来愈受到重视, 保留半月板一直是临床医师的努力方向。半月板损伤的外科治疗中, 应该遵循(1) 争取关节镜下手术; (2) 争取缝合或部分切除, 术中尽量保留半月板, 进行半月板修复, 以最大限度地保留其功能,不要对正常的半月板组织作不必要的切除(特别是周围缘) , 不要在中央游离缘遗留不自然的弧度, 尽量切除任何不稳定的半月板组织。半月板术后要系统、正规的康复训练, 术后正规的康复训练对于提高手术疗效有重要帮助。康复训练包括肌力锻炼和关节活动练习, 早期适度活动可以预防关节粘连、松解挛缩、改善静脉回流、消除肿胀, 同时可增加肌力, 使患者尽早恢复肢体和关节功能。
    总之, 对于膝关节半月板损伤, 有很多诊断和治疗方法, 每一种方法各有其优缺点, 综合而言, 关节镜诊断有全面、准确的特点, 治疗有手术创伤小、并发症少、恢复快、疗效确切的优点,是半月板损伤诊治的一种好方法。

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痔的临床解剖

04级临床四班第3实习组

一 直肠的解剖学结构：
    肛门直肠为消化道的末端，是通于体外的出口。直肠起源于内胚层，而肛管则起源于外胚层形成的原肛，由于两者起源不同，所以在血液供应、神经支配、内衬上皮上也各不相同，故齿线作为其分界，是临床上重要的标志。

1 直肠的肌肉：
    直肠上端在第二骶椎平面与乙状结肠相接，向下沿骶尾骨前面下行，终于齿线与肛管连接，全长约0.8cm。直肠上部与骶骨曲度一致形成骶曲，同时由于直肠腔大小在上端与乙状结肠同，下端则扩大为直肠壶腹，而壶腹前壁向前膨出，与肛管几成直角形成会阴曲。此二曲为乙状结肠镜检查时必须注意的解剖特点。肠管上1/3前面与两侧为腹膜所遮盖，中1/3前面腹膜向前反折成为直肠膀胱或直肠子宫陷凹，直肠下1/3完全在腹腔之外。肠壁肌层与结肠相同，在下部肥厚成为肛门内括约肌。直肠黏膜较厚，有3个半月形的皱襞，内有环肌纤维，称为直肠瓣。

    肛管长约5cm，其外端为肛门，上端与直肠相连接,周围有内、外括约肌环绕。肛管的表层覆以肛管皮肤，在直肠黏膜与肛管皮肤交界处黏膜呈6～10个纵行皱折，称为直肠柱或肛柱。两个直肠柱下端之间有半月形黏膜皱襞，称为肛门瓣；肛门瓣与直肠柱之间的肠壁黏膜形成向上开口的袋状间隙，称为隐窝或窦。隐窝底部有肛腺体的导管开口。肛腺较集中于肛管的后壁，呈分支状，一般在黏膜下，但部分分支可穿通肛管周围组织，因此肛门直肠周围脓肿的发生与肛腺的感染化脓有关。上述结构使直肠黏膜与肛管皮肤之间形成一条不整齐的界线，称为齿线。齿线上有2～6个三角形乳头状突起，称为肛乳突。 　　
    肛门括约肌分为外括约肌与内括约肌。外括约肌有三部分：皮下部、浅部和深部。皮下部是环状肌束，不附着于尾骨，围绕肛管下端，位于内括约肌的外下方，两括约肌之间有一沟，称为括约肌间沟，恰与肛门白线相当。皮下部外括约肌常在手术时被切断，不致引起大便失禁。 　　
    浅部位于皮下层的外上方，后部与尾骨连结构成肛尾韧带，在内括约肌水平面分为两束，围绕肛管再合而为一止于会阴。深部外括约肌位于浅部的上外侧，也是环状肌束，不附着于尾骨。内括约肌为不随意肌，是直肠的环状肌在肛管上部的肥大部分，围绕肛管的上2/3。外括约肌深、浅两部围绕直肠纵肌及肛门内括约肌，并联合肛提肌的耻骨直肠肌，环绕肛管直肠连接处，组成一肌环，称为肛管直肠环。此环如手术时被切断，即可引起肛门失禁。

2 肛门直肠的血供： 　
    肛门直肠的血液来自直肠上动脉、直肠下动脉、肛门动脉及骶中动脉四支动脉供应。直肠上动脉是肠系膜下动脉的末段，在直肠上端后面分为两支，沿直肠两侧下行，在齿线以上分出许多小支与直肠下动脉、肛门动脉吻合。直肠下动脉为髂内动脉的分支，其大小与分布没有一定的规律。肛门动脉由阴部内动脉分出，在肛管分为数小支。骶中动脉是腹主动脉的连接分支，一般很小，与直肠上动脉、直肠下动脉吻合。 　　 　
    静脉的排列与动脉相似，主要来自两个静脉丛，以齿线为界，齿线上为痔内静脉丛(直肠上静脉丛)，分布在右前、右后、左侧者最为显著，是内痔的好发部位。直肠上静脉丛向上，经直肠上静脉、肠系膜下静脉，纳入脾静脉、门静脉。齿线下为痔外静脉丛(直肠下静脉丛)，汇集于直肠下静脉、肛门静脉，流入髂内静脉。直肠上静脉无瓣膜，血液可逆向回流，且直肠上静脉丛和直肠下静脉丛在肛门白线附近互相交通，使门静脉系统与体静脉系统相通，在门静脉高压患者，此处是一侧支循环，故门静脉高压者“痔出血”不宜手术结扎。 　
    肛门直肠的血液来自直肠上动脉、直肠下动脉、肛门动脉及骶中动脉四支动脉供应。直肠上动脉是肠系膜下动脉的末段，在直肠上端后面分为两支，沿直肠两侧下行，在齿线以上分出许多小支与直肠下动脉、肛门动脉吻合。直肠下动脉为髂内动脉的分支，其大小与分布没有一定的规律。肛门动脉由阴部内动脉分出，在肛管分为数小支。骶中动脉是腹主动脉的连接分支，一般很小，与直肠上动脉、直肠下动脉吻合。 　　 　
    静脉的排列与动脉相似，主要来自两个静脉丛，以齿线为界，齿线上为痔内静脉丛(直肠上静脉丛)，分布在右前、右后、左侧者最为显著，是内痔的好发部位。直肠上静脉丛向上，经直肠上静脉、肠系膜下静脉，纳入脾静脉、门静脉。齿线下为痔外静脉丛(直肠下静脉丛)，汇集于直肠下静脉、肛门静脉，流入髂内静脉。直肠上静脉无瓣膜，血液可逆向回流，且直肠上静脉丛和直肠下静脉丛在肛门白线附近互相交通，使门静脉系统与体静脉系统相通，在门静脉高压患者，此处是一侧支循环，故门静脉高压者“痔出血”不宜手术结扎。
3 直肠的神经支配： 　
    直肠受交感、副交感神经支配，属于植物神经系统。肛门的神经支配为体神经系统的阴部内神经的分支，分布至肛 提肌、外括约肌、肛管及肛门周围皮肤。所以齿线以上黏膜对痛感迟钝，而肛管和肛门周围皮肤感觉异常敏锐，肛门部刺激可以引起反射性肛提肌和外括约肌痉挛。另外，膀胱颈部的肌肉也受阴部神经支配，因此肛门部疾病或手术可引起小便困难、尿潴留等。 　　 　
    肛管与直肠的主要生理功能是排便，吸收水分和部分药物。在正常情况下，粪便储存于乙状结肠内，直肠无粪便。排便是由于结肠出现蠕动，粪便下行至直肠内，使直肠下端膨胀而引起便意，同时外括约肌因反射性抑制而松弛，肛提肌松弛使粪便排出。
二 痔的定义： 　
    由于各种因素导致的肛管、直肠下段血管性衬垫组织的病理性增生或扩张。
三 痔的形成原因 　
    四种学说：静脉曲张学说，肛垫下移学说，血管增生学说、痔疝形成学说。 　
    1 静脉曲张学说： 静脉曲张的形成是由于静脉壁脆弱，或者是当血液从腿部流回心脏时，阻止血液流错方向的小阀衰弱。静脉曲张因为长时间的站或坐而加剧，造成血液在某个部位上积聚。严重的情形，静脉会从皮肤鼓起而且变得相当地痛。痔是直肠下端粘膜下肛管皮肤下的静脉丛扩大、曲张而形成的静脉团。是常见的肛门疾病之一，其形成的主要原因是痔上静脉无瓣膜、壁薄、周围又缺乏支持组织，因此任何增高腹内压力的因素，如习惯性便秘、排尿困难、肝硬化腹水、盆腔肿瘤、妊娠等，都能使静脉回流受到影响，以致直肠静脉丛充血而扩张，从而引起痔。 　
    2 衬垫下移学说： 肛管和直肠交界处黏膜下存在一种比较肥厚的组织垫,它在胎儿期形成,主要位于肛管的左侧、右前、右后区域，有丰富的由血管、平滑肌( Treitz 肌) 、弹力纤维和结缔组织构成的直肠海绵体,后被Thomson 称之为“肛管血管垫”,简称“肛垫”,是人人皆有的正常结构。该结构类似于人体的勃起组织,可以根据需要收缩和扩张,协助肛门括约肌控便,与人体的精细控便有密切的关系。肛垫由于腹泻、便秘、腹压增高等原因,发生病理性肥大、下移称之为痔,因此痔是一个病理性的概念,当痔合并出血、脱垂、疼痛时,称为“痔病”。。肛垫存在于肛管上口,具有进一步密闭肛管、避免肠液溢出的作用。肛垫内存在众多的感受器,具有精细的辨别觉。在肛门自制中的作用越来越受到人们的重视,保留肛垫的痔手术成为临床的一个热点话题。 　
    肛垫与痔的区别 　
    凡言“肛垫”即指“是粘膜上皮+血管十平滑肌+纤维组织共同构成的复合体，是正常解剖 结构，属生理性组织一不是病，而且没有任何病症和痛苦。 　
    凡言“痔”即指“肛垫”已发生病理性变化:以肛门部静、动脉血管的扩大，曲张和直肠粘膜组织及结缔组织不断增生，变性形成的痔核—是病，而且可以有不同的临床症状和体征等。 　
    其组成主要包括静脉(或称静脉窦)、结缔组织、Treitz肌,称为肛管血管垫,简称为肛垫。Treitz肌是指介于肛垫和肛门内括约肌之的平滑肌,具有固定肛垫的作用。当Treitz肌肥厚或断裂时肛垫则脱垂,临床表现为内痔脱出
四 痔的分类： 　
    以肛门齿状线为界限，痔可分为内痔、外痔和混合痔３种。 　
    1 内痔：内痔是指发生于肛管齿线以上，直肠粘膜下的血管性衬垫扩张或增生形成的隆起性组织，又称“里痔”。按症状轻重分为4 期Ⅰ期内痔:便血，色鲜红或无症状。肛门镜检查见齿线上直肠粘膜隆起，直径超过两个钟点位置，粘膜表面色淡红;Ⅱ期内痔:便血，色鲜红，大便时伴有肿物脱出肛外，便后可自行还纳复位。肛门镜检查见齿线上直肠粘膜隆起，粘膜表面色暗红;Ⅲ期内痔:排便或其他原因增加腹压时，肛内肿物脱出，需休息或手推方能还纳复位，粘膜表面暗红;Ⅳ期内痔:肛内肿物脱出，无论休息或手推均不能复位，粘膜表面糜烂。 　
    2外痔:外痔是指发生于肛管齿线以下，肛管部隆起性组织。根据组织的病理特点，又分为结缔组织性外痔、血栓性外痔、静脉曲张性外痔、炎性外痔四类。 结缔组织性外痔：齿线以下有柔软的隆起性组织，表面覆盖皮肤，无疼痛，无红肿，又称皮赘;血栓性外痔：齿线以下突发性红肿包块，疼痛明显，皮下可触及硬结;静脉曲张性外痔:增加腹压时齿线以下形成隆起性包块，质地柔软，无压痛，皮下可见扩张的血管团;炎性外痔:齿线以下发生的红肿包块，起病较急，包块皮肤水肿潮红，压痛明显。 　
    3 混合痔：混合痔是指齿线上下互相融合的隆起性组织，它具有内痔和外痔的临床特征。在诊断混合痔时，应注明内痔的分期和外痔的分类。
五 痔的预防、诊断和治疗（略）

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Situs inversus and its importance in clinical practice

04级临床1班：李丹、孔迅、李葚煦、李渊、常冬元、王燕磊、孙丽丽、司偲、万璐、刘洋

Preface
    After these weeks of regional anatomy practice , we have got a specific view on human body construction. Knoweledge of this field is esscential and basic for us medical students to learn and to practice clinical medicine in the future. However, there are a certain few people whose viscera are different to normal people——their organs are inversus inside! We become very interested in this aspect, and also we think it is very important for doctors, especially surgeons to be aware of this. So we decided to choose situs inversus(SI) to be our topic. To know what it is; why it is important.

Introduction——what is situs inversus
    Situs inversus refers to the mirror image of the viscera,while situs solitus is defined as the normal anatomical situation. Situs inversus is a rare anomaly that was first described in humans almost 400 years ago by Fabricius. Interestingly, Aristotle is the first to discover SI in animals. SI’s frequency is reported to be between 1/4000 and 1/20 000 live births. Situs inversus totalis including the heart, lungs, liver, kidneys, spleen, the whole digestive tract, and also the blood vessels and nerves associated with them.
    Figure 1. this is an overview of a situs inversus cadaver. (A) The thoraco-abdominal viscera after partial removal of the diaphragm (D). Note the heart shifted to the right side of the body. (B) The greater omentum was removed from the stomach and the transverse colon (TC) is reflected upward by forceps. L, large left anatomical lobe of the liver. (C) The configuration of the superior mesenteric artery (SMA) and vein (SMV). The cecum is reflected to show the appendix (AP).
    Usually, people with SI lead a normal life just like everyone of us. All the viscera, though not in the proper place, have normal functions. There is a vetnan woman who lived 102 years old without being identified as with SI until she was sent to the hospital because of pneumonia.
    Figure 2.show the left and right recurrent and laryngeall nerves. The left-sided vagus nerve (ltX) is found in the inferior margin of the left-sided subclavian artery (LSA), whereas the right-sided vagus nerve(rtX) is seen between the aortic arch (AO) and right-sided pulmonary artery (RPA).
    Figure 3.show the lungs which are inverted. The right lung has2 lobes and 心包切迹while the right lung has 3 lobes.
    Figure 4. show the Retroperitonel organs and vessels. The venous cava is on the right side while descending aorta left. The left-sided kidney (LK) is located higher than the right-sided kidney(RK).
    Figure 5. The apex of the heart was in the dextracardia position. the left-sided right ventricle, connects the pulmonary arterial trunk.

How does SI happen?
     Til now the reasons for situs inversus is not quite clear. However, there are some supposals. Chromosome aberrations such as balanced translocation appear to have a significant influence. Some say that it may be concerned with wrong nucleotide sequence in DNA. Others think it may have something to do with kindred gene factor. During the embryonic development if cardiac tube bends to left instead of right,then the heart will become mirror imaging. And similarly,during10th-12th week of embryo,when ansa interstinalis retraces to the abdominal cavity but without transposition or transposition being insufficient,then the intestinal canal situs inversus will happen.

Why is SI important?
     Since patients with situs inversus whose organs are not in the normal place, it brings pitfalls for doctors for diagnosing. For example, a left upper abdominal pain often leads to the suspision of diseases associated with stomach. However, if the patient is so special with SI, then the pain may due to problem on liver. Hence , if the doctor has not thought about this aspect, and doesn’t rely on other physical examinations, it will leads to false diagnosis.
    On the other hand , it is even more important to identify patients with SI before performing any surgery procesure. If not, the displacement of viscera which is out of expect，will cause confusion and serious problems, even patient’s death on the operation table.
    With many physical examinations, patients with SI can be easily identified. For example, CT, X-ray, MRI, ultrasonography and so on. Even the electrocardialgram can show some abnormalities if the heart is dextrogyrous.
    But detection before surgery alone is not enough. Surgeons must be very aware of the body anatomy of the SI patient, which is inverted compared with normal people. They have to be very meticulous not to cause lesions. And also some of the operations on SI patients needs to exchange the work between left and right hands.which requires the surgeon’s skills and experience.

Followed are 2 examples
    First one is a laparoscopic cholecystectomy for cholecystitis in patient with Situs viscerum inversus. A 51-year-old female with known dextrocardia and diabetes mellitus presented with left upper abdominal pain. The pain began 3 days prior admission after fatty meal and wasassociated with nausea and vomiting. The patient had atemperature of 38.81C. Abdominal ultrasonography demonstrated SVI and distended gallbladder, located in the left upper quadrant, with thickened wall containing multiple stones and cystic duct obstruction. On the third day of admission patient underwent llaparoscopic cholecystectomy and had an uneventful postoperative period and was discharged on the second postoperative day.
     laparoscopic cholecystectomy on patients with SI is challenging and potentially hazardous due to the altered biliary anatomy might made the identification of common duct difficult and increase the risk of common bile duct injury. Careful dissection beginning at Hartmann’s pouch with clear identification of structures before division will decrease the likelihood of catastrophic biliary injuries. The use of intraoperative cholangiography may help to define the anatomy or identify bile duct injury that should be treated.
    Another example is mediastinoscopy in SI patients. when advancing the mediastinoscope to the lower paratracheal area, the mirror-image changes should be aware. Very important is that the esophagus and recurrent laryngeal nerve which are easy to get injured now are on the right side of trachea. And also during normal mediastinoscopy azygos-caval junction from which major hemorrhage may occur is now on the left side rather than right side.
    In a word, the normal surgery on SI patients is challenging but definitely not a contraindication of mediastinal exploration. With clear attention to anatomy disposition pattern and experienced skills, operations can be safe in this rare group of patients.
    However, when it comes to transplantation, things may become a lot more complicated. Here we use liver transplantation for specific explanation.
    Liver transplantation was previously considered to be a contraindication for liver transplantation(LT) because of technical difficulties considering the special vascular anatomy.
    The first LT in a patient with SI was described in 1988 by Raynor et al. Until today, only a few cases have been reported. Most cases were performed in children with SI suffering from biliary atresia because of polysplenia syndrome, as biliary atresia is mostly associated with SI in children. Til 2006, there are 4 successful liver transplantation cases in adult patients been reported.
    The main difficulty of liver tranplatations in patients with situs inversus include (1) the potential difficulties associated with a left-sided suprahepatic vena cava; (2) the difficulty in accommodating a large right lobe in the right upper quadrant, which is already occupied by the stomach and spleen (or multiple spleens); and (3) the potential for kinking of the suprahepatic vena caval anastomosis by the anterior and leftward displacement of the large right hepatic lobe.
    For the second difficulty, Raynor et al. have suggested, but not attempted, rotation of the donor liver 180 degrees on the vertical axis, allowing the anterior aspect of the bulky right hepatic lobe to lie posteriorly in the left upper quadrant, which has the theoretical advantage of orienting the hilar structures toward, rather than away from, the native porta hepatic. Another suggestion is the selection of smaller donor liver. Furthermore, the partial liver transplant, which has evolved into a clinically useful procedure, alleviates the shortage of donors for those smaller patients and, by using only the left lobe, solves the space problems as well.
    As to the anastomosis of the recipient’s inferior vena cava and the donor’s infrahepatic vena cava, til now there are 2 ways practiced. heterotopic and orthotopic technique Herrera and colleagues described the use of a modified technique including preservation of the venacava and anastomosis of the donor superior vena cava to the recipient right suprahepatic vein. They recommend, that liver transplantation always be performed with preservation of the inferior cava. In contrast to Herrera, Asfar et al. favor a counterclockwise 90 °rotation of the graft in order to bring the donor portal structure into alignment with the portal structure of the recipient for end-to-end anastomosis. The technique, including a 90°rotation of the liver graft with end-toside anastomosis of the donor inferior vena cava with the recipient infrahepatic vena cava, might cause kinking and obstruction.
     In conclusion, liver transplantation in recipients with SI is feasible, even when the graft is from anormal donor.

References
1. Human situs inversus of the thoracoabdominal structures.Yui Mano et al. Anatomical Science International (2006) 81, 7–20
2. Laparoscopic Cholecystectomy for Acute Cholecystitis in Patient With Situs Viscerum Inversus.Boris Kirshtein et al. Surg Laparosc Endosc Percutan Tech 2006;16:169–171
3. Safety of Mediastinoscopy in Anatomical Variations of the Mediastinum: The Situs inversus syndrome.Ahmed Mahmoud; Hien Pham; Nathaniel Matolo; Deepak Shrivastava.The American Surgeon; Jan 2006; 72, 1; Health & Medical Complete pg. 64
4.A routine liver transplantation in a patient with situs inversus: a case report and an overview of the literature Wente MN, et al. Clin Transplant 2006: 20: 151–155. r Blackwell Munksgaard, 2006
5. Liver transplantation in patients with situs inversus Keith Colomb et al. Transpl Int (1993) 6:158-160
6. Situs inversus of donor or recipient in liver transplantation. Felix Braun et al. Transpl Int (1998) 11: 212±215
7.“不在其位，仍谋其政”的“镜面人”；李定国；维普数据库

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The history of Artificial pacemaker With a case of double superior vena cava

范爽 90401311，邓瑞芬 90401316，王鉴顺 90401312，冯学会 90401318 吴茜 90401313，杨勇 90401319，许钥 90401314，李玲玲 90401320 刘琪 90401315，于杰 90405110

A case of double superior vena cava
    During the operation in topographic anatomy, we found from the corpse that there’re double superior vena cava in the thoracic cavity. As shown by the following pictures.

    There’re another picture from the internet to show the double superior vena cava clearly.

    1 thyroid gland、 2 diaphragmatic nerve、 3 trach、 4 diaphragmatic nerve、 5 right superior vena cava;RSVC、 6 cranial nerve、 7 aortic arch、 8 right lung、 9 auticle of left atrium、 10 arcula cordis、 11 arteria thyreoidea superior、12 arteria carotis communis、13 internal jugular vein、14 external jugular vein、15 subclavian vein、 16 left superior vena cava、17 cavitas pericardialis、18 aorta ascendens、 19 left lung、 20 costodiaphragmatic recess， 21 diaphragmatic pleura、 22 auricle of right atrium、 23 apex cordis、 24 costal pleura。
    We can see from the two pictures that there’re double superior vena cava. And so there may be some problems with the heart when the old man was alive. We can not find more information about the old man. But when we dissected the pectoral region we found the special medical equipment on the pectoralis major (shown by picture3).
    

    After we took the equipment down and watched it carefully we found it was a Artificial pacemaker which greatly interested all of us. So here we make a summarize of the artificial pacemaker.

Artificial pacemaker

    A pacemaker (or artificial pacemaker, so as not to be confused with the heart's natural pacemaker) is a medical device designed to regulate the beating of the heart. The purpose of an artificial pacemaker is to stimulate the heart when either the heart's native pacemaker is not fast enough or if there are blocks in the heart's electrical conduction system preventing the propagation of electrical impulses from the native pacemaker to the lower chambers of the heart, known as the ventricles.
    There shows a picture to show the pacemaker in the body with the x ray.

    In the body ,we also find the metal-line goes through the cephalic vein and shown by the pictures.

The mechanics of an artificial cardiac pacemaker
    An artificial cardiac pacemaker is a small battery-operated computer, called the pulse generator, which is connected to the heart via one or more pacing leads. These leads are composed of a coiled metal conductor, insulated with plastic and anchored to the inner wall of the heart with either soft plastic hooks or a very short metal screw. The pulse generator sends an electrical signal down the lead to a bare metal electrode, which is fixed against the heart, and the targeted heart chamber is prompted to contract. The system relies on feedback, which means the artificial pacemaker 'listens' to the heart and supplements the heart's natural rate. For example, the heart rate of a person with sick sinus syndrome may not increase during physical exertion. The artificial pacemaker recognises this and boosts the heart rate to an appropriate level. In order to do this, the pulse generator may have sensors to detect physical exertion. Such sensors may detect activity or changes in breathing.
    The two major types of artificial cardiac pacemakers include:
    1Single chamber - only one chamber is regulated, usually the ventricles.
    2Dual chamber - two leads are used. Information from the atria regulates the contractions of the ventricles.
Here comes the History of the artificial pacemaker
    In 1889 J A McWilliam reported in the British Medical Journal of his experiments in which application of an electrical impulse to the human heart in asystole caused a 6ventricular contraction and that a heart rhythm of 60-70 beats per minute could be evoked by impulses applied at spacings equal to 60-70/minute.
    In 1926 Albert Hyman created an electro-mechanical instrument which may have been the first true external artificial pacemaker.
    In 1928 anaesthetist Mark Lidwell [assisted by physicist Edgar Booth] devised a device which "ran on alternating current and required a needle to be inserted into the patient's ventricle". "He used electrical stimulation of the heart to save the life of a child born in cardiac arrest". Lidwell reported his work to the Third Congress of The Australian Medical Society in 1929, but little more is known of his work.
    An external pacemaker was designed and built by the Canadian electrical engineer John Hopps in 1950 based upon observations by cardio-thoracic surgeon Wilfred Bigelow at Toronto General Hospital . A substantial external device using vacuum tube technology to provide transcutaneous pacing, it was somewhat crude and painful to the patient in use and, being powered from an AC wall socket, carried a potential hazard of electrocution of the patient by inducing ventricular fibrillation. A number of innovators, including Paul Zoll, made smaller but still bulky transcutaneous pacing devices in the following years using a large rechargeable battery as the power supply.
    In 1957 Dr. William L. Weirich published the results of research performed at University of Minnesota. These studies demonstrated the restoration of heart rate, cardiac output and mean aortic pressures in animal subjects with complete heart block through the use of a myocardial electrode. This effective control of postsurgical heart block proved to be a significant contribution to decreasing mortality of open heart surgery in this time period. "Weirich W, Gott V, Lillehei C: The treatment of complete heart block by the combined use of a myocardial electrode and an artificial pacemaker. Surg. Forum 1957;8;360-363"
    In 1957 engineer Earl Bakken of Minneapolis, Minnesota, produced the first wearable external pacemaker for a patient of Dr. C. Walton Lillehei. The pacemaker, housed in a small plastic box, had controls to permit adjustment of pacing heart rate and output voltage and was connected to electrode leads which passed through the skin of the patient to terminate in electrodes attached to the surface of the myocardium of the heart.
    The first clinical implantation into a human of a fully implantable pacemaker, was in 1958 at the Karolinska University Hospital in Solna, Sweden, using a pacemaker designed by Rune Elmqvist and ?ke Senning connected to electrodes attached to the myocardium of the heart by thoracotomy . The device failed after three hours. A second device was then implanted which lasted for two days. The world's first implantable pacemaker patient, Arne Larsson, survived the first tests and died in 2001 after having received 22 different pacemakers during his lifetime.
    In 1959 temporary transvenous pacing was first demonstrated by Furman et al in which the catheter electrode was inserted via the patient's basilic vein. "Furman S, Schwedel JB : An intracardiac pacemaker for Stokes-Adams Seizures.(see Stokes-Adams attack). N Eng J Med 1959; 261:943-948"
    In February,1960, an improved version of the Swedish Elmqvist design was implanted in Montevideo, Uruguay in the Casmu Hospital by Doctors Fiandra and Rubio. That device lasted until the patient died of other ailments, 9 months later. The early Swedish-designed devices used rechargeable batteries, which were charged by an induction coil from the outside. Implantable pacemakers constructed by the American Wilson Greatbatch entered use in humans from April 1960 following extensive animal testing. The Greatbatch innovation varied from the earlier Swedish devices in using primary cells (mercury battery) as the energy source. The first patient lived for a further 18 months.
    The first use of transvenous pacing in conjunction with an implanted pacemaker was performed at the Hopital Tenon of Paris, France, in 1963 by Dr Jean-Jacques Welti. The transvenous, or pervenous, procedure involved incision of a vein into which was inserted the catheter electrode lead under fluoroscopic guidance, until it was lodged within the trabeculae of the right ventricle. This method was to become the method of choice by the middle 1960's.
    The preceding implantable devices all suffered from the unreliability and short lifetime of the available primary cell technology which was mainly that of the mercury battery. In the late 1960's several companies, including ARCO in the USA, developed isotope powered pacemakers, but this development was overtaken by the development in 1970 of the lithium-iodide cell by Wilson Greatbatch. Lithium-iodide or lithium anode cells became the standard for future pacemaker designs. A further impediment to reliability of the early devices was the diffusion of water vapour from the body fluids through the epoxy resin encapsulation affecting the electronic circuitry. This phenomenon was overcome by encasing the pacemaker generator in an hermetically sealed metal case, initially by Telectronics of Australia in 1969 followed by Cardiac Pacemakers Inc of Minneapolis in 1972. This technology, using titanium as the encasing metal, became the standard by the mid 1970's.
    Others who contributed significantly to the technological development of the pacemaker in the pioneering years were Bob Anderson of Medtronic Minneapolis, Geoffrey Davies of Devices Ltd in England, Barouh Berkovits and Sheldon Thaler of American Optical, Geoffrey Wickham of Telectronics Australia, Walter Keller of Cordis Corp. of Miami, Hans Thornander who joined previously mentioned Rune Elmquist of Elema-Schonander in Sweden, Janwillem van den Berg of Holland and Manuel A. Villafa?a and Anthony Adducci of Cardiac Pacemakers Inc.(Guidant)

References
1 Electricity and the heart: a historical perspective. Heart Rhythm Foundation
2 Bernstein A, Daubert J, Fletcher R, Hayes D, Lüderitz B, Reynolds D, Schoenfeld M, Sutton R (2002). "The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group". Pacing Clin Electrophysiol 25 (2): 260-4. PMID 11916002.
3王方正. 心脏起搏并发症[M]/ / 陈　新, 孙瑞龙, 王方正主编. 临床心电生理学和心脏起搏. 北京: 人民卫生出版社,1997 :101221013.

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