Front matter
m m
THE EMBRYOLOGY, DEVELOPMENT, AND ANATOMY
OF THE
Preface
The object of this monograph is to present a study of the embryology, development and anatomy, both microscopic and macroscopic, of the human nose, the paranasal sinuses, the olfactory organ and certain other ancillary structures. The study had its inception in work done on the maxillary sinus in 1907 at Cornell University. The field of investigation was gradually extended so as to include ultimately the entire nasal region and its immediate environs. The study was continued at intervals at Cornell University (1907-11), at Yale University (1911-14), and at the Jefferson Medical College since 1914.
A number of papers on various phases of the study were published from time to time as the work progressed, and the author now takes the liberty of drawing upon them in this connection; this being alike true for text, diagrams, tables and illustrations. Most of the matter, however, appears in new form and for the first time.
All work must needs be based in part on the labors of the past and the author is not unmindful of the help derived from the recorded observations of other workers in the field. No attempt, however, is here made to review the literature on the subject: had this been done, the size of the book would have been increased far beyond the limits set for it. The aim has been to present a more or less comprehensive account of personal studies and observations on the genesis, development, and anatomy of the nose and its related parts rather than to compile a fairly voluminous literature with its not infrequent diverse conclusions. In large measure, therefore, the descriptions and discussions as set forth in subsequent chapters and paragraphs are based upon researches by the author, extending over a period of years. Likewise most of the illustrations are based upon preparations, reconstructions, and dissections by the author and reproduced either by him or under his directions. Of course, where vital points are at issue or where the author feels that his own observations are inadequate, due reference is made of the work and conclusions of other investigators. Moreover, a certain number of illustrations are after other writers for which proper credit is given in the respective legends.
vii viii PREFACE
Seldom, indeed, is it that all phases of a study reach a state of finality. Unfortunately, this is true in the present connection, for in some instances it has become necessary to assume certain conclusions tentatively from established and related facts and the clinical evidence at hand. This, however, seems warranted, for unless we exercise some scientific judgment and imagination no progress can be made. Further study and analyses may affirm or deny the assumptions. It is no easy task, for example, to establish with certainty all the fiber tracts in some neuron circuits. Moreover, when a few hours markedly alter a structure during its developmental stages, it is obviously difficult to have at hand and in serial sections human embryos closely enough graded to demonstrate every possible point that arises in a study such as this. Fortunately, experience has shown that mammalian embryos are of great value in filling in our gaps of knowledge of human embryology and until human embryos of the proper ages fall into the hands of competent observers, it is altogether proper to assume certain hypotheses based upon the study of other and related forms.
In order to consider all portions of the nose and the cognate regions and structures and bring the results of the observations and studies within the limits of an average-sized volume, it was necessary in many instances to omit the records of many detailed observations and to record the essentials only. This is more or less true throughout the work, but especially so in connection with the central olfactory organ and the individual bones that comprise the nasal framework. Important and essential points are, of course, treated in greater detail. Moreover, where brevity of description and discussion would have befogged clearness some otherwise unessential details are recorded. It is, of course, obvious that any one of the chapters and, indeed, in some cases parts of chapters could be profitably amplified into individual monographs. The purpose and plan of the book, however, did not require such amplification.
Despite the large amount of materials studied over a period of years, the author recognizes that this work is incomplete, but hopes the descriptions, discussions and suggestions will be found helpful by physicians and surgeons and undergraduates in medicine.
The author is not unmindful of the many opportunities afforded for the furtherance of this work at the Cornell University Medical College, the Yale University Medical School, and the Jefferson Medical College. Nor of his indebtedness to the Mutter Museum of the College of Physicians of Philadelphia for the privilege of studying certain materials, and to its curator, Dr. Clarence Hoffman, for many courtesies. Moreover,
PREFACE ix
thanks are due Dr. H. E. Radasch for the preparation of tissues from the author's collection for Figs. 181 and 182, Miss Bremerman for valued help in the preparation of the manuscript and proof-reading, and Miss Neely and Mrs. Schaeffer for certain translations.
The index is the work of Dr. Benjamin Lipshutz.
The author wishes to express his obligations to the publishers for their hearty cooperation and generosity.
J. PARSONS SCHAEFFER.
Contents
INTRODUCTION xix
CHAPTER I The Proton and Rudiment 3
The Nasal Pits 3
Frontonasal Process 4
Nasal Processes 4
Maxillary Process 4
The Primitive (Primary) Nasal Fossae 7
The Bucconasal Membranes 9
The Primitive Choanae 9
The Nares ' 10
The Primitive Palate u
The Definitive Palate 12
The Definitive Choanae 14
The Primary Nasal Septum 16
The Secondary Nasal Septum . . . 16
The Definitive (Secondary) Nasal Fossae 17
The Lateral Nasal Wall 18
The Major Nasal Conchae and Meatuses 18
The Inferior Nasal Concha 20
The Inferior and Middle Nasal Meatuses 20
The Ethmoidal Conchae and Meatuses 21
The Nasoturbinal (agger nasi) 26
The Nasal Atrium 26
The Olfactory Sulcus 26
The Sphenoethmoidal Recess 26
Nomenclature 27
The Minor Nasal Conchae and Meatuses 27
The Descending Ramus of the Meatus Nasi Medius 28
The Suprabullar Furrow or Recess 30
The Bullar Furrow 31
The Infrabullar Furrow 31
The Infundibulum Ethmoidale 31
The Superior Bullar Fold or Concha 32
The Inferior Bullar Fold or Concha .- • • 32
The Infundibular Fold or Concha 33
The Processus Uncinatus 33
xi xii CONTENTS
The Ascending Ramus of the Meatus Nasi Medius 33
Recessus Frontalis 33
The Frontal Folds or Conchae 33
The Frontal Furrows or Pits 33
The Descending Ramus of the Meatus Nasi Superior 35
The Rudiments of the Paranasal Sinuses 36
The Maxillary 36
The Ethmoidal 36
The Frontal 36
The Sphenoidal 36
The Definitive Nasal Septum 37
The Development of the Nasal Skeleton 38
The Cartilaginous Nasal Capsule 38
^Ossification of Elements 40
The Ethmoid Bone 40
The Vomer 41
The Maxilloturbinal 42
The Palate Bone 42
The Nasal Bone 42
The Lacrimal Bone 42
The Sphenoid Bone 43
The Sphenoturbinal 43
The Maxilla 44
The Frontal Bone 45
Skeleton Changes Incident to Growth 45
The Epithelium of the Primitive Nasal Fossae 47
The Olfactory Nerves 47
The Nasal Glands 47
The Vomeronasal Organ 47
The Embryonic External Nose 48
Congenital Defects of the Nose .Si
CHAPTER II The External Nose 61
The Bones of the External Nose 63
The Cartilages of the External Nose 66
The Greater Alar Cartilage 68
The Lateral Nasal Cartilage 69
The Lesser Alar Cartilages 70
The Sesamoid Nasal Cartilages 70
The Muscles of the External Nose 70
The Internal Nose 7I
The Nares 72
The Vestibule 73
CONTENTS xiii
The Choanae (Posterior Nares) 73
The Floor of the Nasal Cavity 75
The Roof of the Nasal Fossa 77
The Median Wall of the Nasal Fossa 77
The Osseous Portion of the Nasal Septum 78
The Vomer 79
The Mesethmoid 80
Other Osseous Elements 81
The Cartilaginous Portion of the Nasal Septum 81
The Cartilage of the Septum 81
The Vomeronasal Cartilages 82
The Greater Alar Cartilage 82
The Membranous Portion of the Nasal Septum 82
Asymmetry of the Nasal Septum 83
Perforation of the Nasal Septum 86
X The Lateral Wall of the Nasal Fossa 86
The Osseous Framework 87
The Inferior Nasal Concha 88
The Inferior Nasal Meatus 89
The Ostium of the Nasolacrimal Duct 89
The Middle Nasal Concha 90
The Middle Nasal Meatus 91
The Ethmoidal Infundibulum 92
The Uncinate Process 93
The Ethmoidal Bulla 94
The Suprabullar Furrow or Recess 95
The Frontal Recess 95
The Superior Nasal Concha 95
The Superior Nasal Meatus 95
The First Supreme Nasal Concha 96
The First Supreme Nasal Meatus 96
The Sphenoethmoidal Recess 96
The Second and Third Supreme Nasal Conchae 97
The Agger Nasi 97
The Nasal Atrium 97
The Olfactory Sulcus 97
CHAPTER III General Considerations 109
The Relations of the Sinus Floor to the Nasal Floor in
The Relations of the Maxillary Sinus to the Teeth 112
Ridges, Crescentic Projections and Septa 116
Duplication of the Maxillary Sinus 113
The Size of the Maxillary Sinus .122 xiv CONTENTS
The Maxillary Ostium . . . 127
Duplication of the Maxillary Ostium 129
The Accessory Maxillary Ostium .13°
CHAPTER IV General Considerations 146
Size of the Adult Frontal Sinus 147
Extensive Pneumatizations 147
Supernumerary Frontal Sinuses 1 50
The Frontal Bulla 152
Frontal Sinus Diverticula 154
Agenesis of the Frontal Sinus 157
The Nasof rental Connections 160
The Nasofrontal Duct 166
Chapter V The Sphenoidal Sinus 175
General Considerations 178
The Topography of the Adult Sphenoidal Sinus 180
Osseous Septa and Recesses of the Sphenoidal Sinus 183
Diverticula of the Sphenoidal Sinus 184
The Sphenoidal Septum 187
The Sphenoidal Ostium 187
The Size of the Sphenoidal Sinus 188
The Hypophysis Cerebri as Related to the Sphenoidal Sinus 188
The Optic Nerve and Commissure as Related to the Paranasal Sinuses 190
The Cavernous Sinus and Contained Structures as Related to the Sphenoidal
Diminutive Sphenoidal Sinuses 197
Agenesis of Sphenoidal Sinuses 198
CHAPTER VI General Considerations 211
Classification . 212
CONTENTS xv
Dehiscences 212
Size of the Ethmoidal Labyrinth : 214
The Anterior Ethmoidal Cells 215
The Frontal Group 216
The Infundibular Group -216
The Bullar Group 218
The Frontal Bulla 218
The Posterior Ethmoidal Cells 219
The Conchal Cells 221
The Middle Conchal Sinus 226
CHAPTER VII Genetic and Developmental Anatomy 237
Variations and Anomalies 242
The Lacrimal Fossa and the Nasolacrimal Canal 244
The Lacrimal Ducts 247
The Lacrimal Sac 248
The Nasolacrimal Duct 248
The Nasolacrimal-duct Diverticula and Valves 250
The Nasal and Paranasal Relations of the Membranous Nasolacrimal Passageways . 252
The Nasolacrimal Ostium 253
Concluding Remarks 255
CHAPTER VIII The Nasal Vestibule 261
The Nasal Fossa 261
The Respiratory Portion 262
The Olfactory Portion 266
The Vomeronasal Organ 270
The Genital Spots (so-called) 271
Chapter IX
THE BLOOD- AND LYMPH-VASCULAR SYSTEMS OF THE NOSE AND THE PARANASAL SINUSES 275
The Arterial Supply 275
The Sphenopalatine Artery 275
The Anterior and Posterior Ethmoidal Arteries 277
The Descending Palatine Artery 278
The Pharyngeal Artery 278
The Infraorbital Artery 278
The External Maxillary (Facial) Artery 278
The Venous Supply 278 xvi CONTENTS
The Lymphatic Supply 279
The Nasal Cavity . . . .• 280
The External Nose 282
Chapter X
THE COMMON SENSORY AND THE SYMPATHETIC NERVES OF THE NOSE AND PARANASAL
SINUSES 285
The Nerves of Common Sensation 285
The Ophthalmic Nerve 285
The Maxillary Nerve 285
The Central Connections 285
The Sympathetic Nerves 286
Sympathetic Efferent Neurons 288
Sympathetic Afferent Neurons 289
The Vasoconstrictor Center 290
The Vasodilator Center 290
Reflex Circuits 291
Reflex Nasal Manifestations 293
Naso-sexual Relations 296
The Transference and Reference of Afferent Impulses 302
The Peripheral Nerves and the Sphenopalatine Ganglion 306
The Maxillary Division of the Trigeminal Nerve in its Nasal Distribution .... 306 The Ophthalmic Division of the Trigeminal Nerve in its Nasal Distribution . . .313
The Sphenopalatine Ganglion 314
The Motor Root 314
The Sympathetic Root 316
The Sensory Root 317
The Anatomic Relations of the Sphenopalatine Ganglion 318
The Anatomic Relations of the Nerve of the Pterygoid Canal (Vidian Nerve) . 320
CHAPTER XI The Peripheral Organ 325
The Olfactory Nerve 326
The Terminal Nerve 326
The Vomeronasal Nerve 327
The Central Organ 328
The Olfactory Brain 328
The Olfactory Bulb 330
The Olfactory Tract 330
The Olfactory Trigone 331
The Anterior Perforated Substance 331
CONTENTS xvii
The Parolfactory Area 331
The Subcallosal Gyrus 333
The Supracallosal Gyrus 333
The Fascia Dentata Hippocampi 333
The Hippocampus 334
The Uncus 334
The Fornix 335
The Septum Pellucidum 335
The Habenular Trigone 336
The Medullary Stria of the Thalamus. . 336
The Mammillary Bodies 337
The Terminal Stria of the Thalamus 338
The Amygdaloid Nucleus 338
The Olfactory Reflex and Cortical Connections 338
The Olfactory Pathways 341
The Relations of the Brain to the Walls of the Nasal Fossae and the Paranasal Sinuses 344
CHAPTER XII ERRATUM xix, 10th line from bottom, for "anatomy" read "embryology."
xv i CONTENTS
The Lymphatic Supply 279
The Nasal Cavity . . . .• 280
The External Nose 282
CHAPTER X
THE COMMON SENSORY AND THE SYMPATHETIC NERVES or THE NOSE AND PARANASAL
SINUSES 285
The Nerves of Common Sensation 285
The Ophthalmic Nerve 285
The Maxillary Nerve 285
The Central Connections 285
The Sympathetic Nerves 286
Sympathetic Efferent Neurons 288
Sympathetic Afferent Neurons 289
The Vasoconstrictor Center 290
The Vasodilator Center 290
Reflex Circuits . .
Reflex Nasal Manifes
Naso-sexual Relation
The Transference am
The Peripheral Nerv<
The Maxillary Div
The Ophthalmic D
The Sphenopalatin
General Stateme
The Motor Root 314
The Sympathetic Root 316
The Sensory Root 317
The Anatomic Relations of the Sphenopalatine Ganglion 318
The Anatomic Relations of the Nerve of the Pterygoid Canal (Vidian Nerve) . 320
CHAPTER XI
The Peripheral Organ 325
The Olfactory Nerve 326
The Terminal Nerve 326
The Vomeronasal Nerve 327
The Central Organ 328
The Olfactory Brain 328
The Olfactory Bulb 33o
The Olfactory Tract 330
The Olfactory Trigone 331
The Anterior Perforated Substance 331
CONTENTS xvii
The Parolfactory Area 331
The Subcallosal Gyrus 333
The Supracallosal Gyrus 333
The Fascia Dentata Hippocampi 333
The Hippocampus - 334
The Uncus 334
The Fornix 335
The Septum Pellucidum 335
The Habenular Trigone 336
The Medullary Stria of the Thalamus. . . 336
The Mammillary Bodies 337
The Terminal Stria of the Thalamus 338
The Amygdaloid Nucleus 338
The Olfactory Reflex and Cortical Connections 338
The Olfactory Pathways 341
The Relations of the Brain to the Walls of the Nasal Fossae and the Paranasal Sinuses 344
CHAPTER XII
The Nose Proper 347
Olfactory Sensation 354
INDEX 360
Introduction
Much productive ground remains unworked in human anatomy and ancillary subjects, despite the unfortunate belief of many graduates in medicine that the study of anatomy has reached a state of finality and that the anatomical field has been fully gleaned of its harvest. When one recalls, however, that modern anatomical teaching and research no longer recognize the unfortunate historic distinction between macroscopic (gross) and microscopic (minute) anatomy; that the human body is now considered from the phyletic, the ontogenetic, the physiologic, the histologic and the gross viewpoints ; that modern anatomy is concerned with evolution, heredity and variation, it is clearly obvious that anatomy is no longer restricted to a purely descriptive study, but that its domain has expanded into its proper spheres and that many problems await solution. Even descriptive or gross anatomy is not without its problems, many of vital and practical importance.
Tt is very difficult and unsatisfactory to approach an anatomical problem without a basic conception of the underlying genetic and developmental history. In order to properly interpret points in the adult anatomy of a region, it not infrequently is necessary to revert to the embryology of the part or region concerned. Many faulty statements extant in the literature are doubtless the result of drawing conclusions from a study of too few specimens, of studying adult material alone, and of errors in interpretation due to the fact that embryologic and adult studies were not carried on simultaneously. A prominent surgeon recently recommended a study and basic understanding of embryology "as one of the foundation stones of surgical training." Be that as it may, it certainly cannot be gainsaid that a knowledge of human anatomy is of paramount importance in a comprehensive understanding and interpretation of both macroscopic and microscopic anatomy, both for the medical student and the physician and surgeon in the practical field.
Variations in the anatomy of the human body are not uncommon, both ontogenetic and phylogenetic. In the former one has to contend with the very important group of human variants generally spoken of as errors in development — congenital defects. There are also progressive and reversional variants encountered. The phyletic variations have to do with the hereditary reappearance of ancestral characters. When one xx INTRODUCTION
recalls that "each organism in the course of its individual ontogeny repeats the history of its ancestral development" the appearance of remote characters in man is more comprehensible. In order, therefore, to deal intelligently with variations, one needs, indeed, not infrequently to hark back not only to the developmental history of the individual, but to the ancestral history of man as well.
Entirely apart from the variations referred to above there are the ever-recurring variations in what may be termed the gross anatomic type of a structure, organ, or region of the human body. These too, strictly speaking, are ontogenetic variations in that they result from the differentiation of the individual embryo and lead to the development of a certain anatomic type of the adult body. Some of these variations or types occur so infrequently and are so unlike all others that one must assume that they result from atypical differentiation of the embryo, leading to an anomalous or abnormal structure, organ, or region in the adult. On the other hand, certain variations in the anatomy of many parts of the human body occur with sufficient frequence to justify the establishment of normal anatomic types. This, of course, opposes the conception of an unvarying typical or ideal anatomic type and all departures therefrom as anomalies.
In a general sense only do a large series of human bodies conform in their detailed gross anatomy to a so-called typical form. It would appear from some recent studies that not a few of our traditional ideas found in some clinical text-books in explanation of certain physical signs and other conditions encountered in the human body from time to time are at variance with anatomic facts. Conclusions drawn hastily and not sufficiently verified by extensive anatomic studies are not of infrequent occurrence. The idea of an unvarying typical form in the gross anatomy of the human body appears more or less prevalent in the practical field. There is, of course, great need of extensive study of the various regions, organs, and other structures of the body; the conclusions to be based upon a large number of cadavers. This has been done for some regions and splendid monographs and records are extant on such researches. The work, however, must be extended and ulitmately be made to include all of the important regions of the body. Such studies, if based on a arg e amount of material and discriminating work, will establish anatomic types. What is desired is not the average nor the mean but the various gross anatomic types of a region, organ or structure, wherever and whenever it is possible to establish such with a fair degree of certainty. After the normal anatomic types are established, the anomalies of the human body will naturally find their proper place, as will also the average and the
INTRODUCTION xxi
mean. This work should be made to include the several ages of the childhood period, the pubertal stage, and that of the adult. It is obvious that such exhaustive anatomical considerations of special regions and organs are not the province of the general text-books of human anatomy, but clearly the function of anatomic monographs.
In studying a given region of the body in an extensive series of cadavers one is profoundly impressed with the ever-recurring departure in the morphology of the part under investigation from the conventional or typal description. This is particularly applicable to the gross anatomy of the paranasal (accessory) sinuses. The primary function of a general text-book of anatomy is doubtless to describe and delineate a "typical" body and to refer to a few variants. It is obviously impossible to do much more within the scope of a single volume. To visualize and understand the anatomy of a typical body is probably also the primary function of a medical student in his initial work in human anatomy.
Unfortunately, however, while there may be a "typical" gross form for regions, organs and structures, it is, strictly speaking, not often encountered in nature. The typical is ideal and the region, organ, etc., as regards shape, size, relations, configuration, etc., very commonly in their actual or real anatomy are variants. It is, therefore, of the greatest importance that the student early recognizes the very common and constant anatomic variations that beset the human body. All that the observant student need do is to witness the dissection of a series of cadavers to have impressed upon him that there is no fixed and unalterable type in very many of the parts of the human body. Unfortunately, however, some students never get beyond the belief and thought that every structure and organ and region conform to an arbitrary and fixed normal, and if there is a slight digression from the conventional text-book description the term "anomaly " is applied. With this erroneous and unfortunate belief they go forth into the practice of medicine: To them the appendix is and must always be in the right iliac fossa; every frontal sinus invades the vertical portion of the frontal bone and if not, there is no frontal sinus present; every liver has the same sized and shaped left lobe and bears a constant topographic relationship to the ventral abdominal wall; all stomachs conform to a single shape; every transverse colon crosses from right to left at a specified plane; the ethmoidal air cells are limited to the ethmoid bone; etc., etc. The far-reaching and direful effects of such faulty conceptions of the anatomy of the human body are so obvious that they need not be discussed here. It, of course, goes without saying that one must primarily have a fundamental understanding of the ground xxii INTRODUCTION
plan of the human body; however, it cannot be gainsaid that one should be equally cognizant of anatomical departures therefrom.
Despite that the actual anatomy of a region or part is not infrequently a variant of the ideal or typal form (if there really be such) it is possible in many instances to establish normal anatomic groups or types. This is of decided advantage over the method of taking, for example, a series of five hundred or a thousand dissections and establishing from them a composite form and accepting it as the typical or ideal anatomy for the region or organ.
In a general way only should physicians and surgeons accept a so-called typal or ideal form in gross anatomy. Initially, of course, in the study of a patient all regions and organs must needs be approached in large measure from the viewpoint of an "average anatomy" despite the fact that relatively few specimens wholly conform to it. Fortunately, rcentgenology has come to the aid of the physician and surgeon in the determination and delineation of anatomic conformations. Admittedly very many variations are insignificant and can be ignored in the practical field despite the fact that they may be of interest and of great value to the student of embryology and morphology. However, it is a matter of grave concern to the physician and surgeon that many important normal variations and anomalies must be dealt with continually. It is, therefore, clearly obvious that the adherence to a single fixed and arbitrary normal is fraught with danger; since with variations come altered size, altered shape, altered anatomical relations. Morphological variation must necessarily have an important bearing on physical diagnosis, pathology, clinical medicine, and surgery. Indeed, the "anatomic type" always looms up before the man in the practical field as an important factor in treatment and prognosis.
I-GENERAL EMBRYOLOGY AND DEVELOPMENT
THE NOSE, PARANASAL SINUSES, NASO LACRIMAL PASSAGEWAYS
AND
OLFACTORY ORGAN IN MAN
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