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Other muscles connect the clavicle purchase digoxin once a day prehypertension eyes, the humerus and provide support for the glenohumeral scapula discount 0.25mg digoxin fast delivery hypertension thyroid, and body wall to the proximalend of the humerus purchase on line digoxin prehypertension lisinopril. These include the pectoralis major, pectoralis minor, Trapezius Levator scapulae Rhomboid minor Latissimus dorsi A B Fig. The compartment by the humerus and by medial and lateral thenar muscles allow the thumb to move freely relative to intermuscular septa. Lying on each Muscles in the arm act mainly to move the forearm at side of the superior thoracic aperture at the base of the the elbow joint, while those in the forearm function pre­ neck is an axillary inlet, which is formed by: dominantly to move the hand at the wrist joint and the fngers and thumb. The major artery and vein of the upper limb pass between the thorax and the limb by passing over rib I and Back and thoracic wall through the axillary inlet. Nerves, predominantly derived Muscles that attach the bones ofthe shoulder tothe trunk from the cervical portion of the spinal cord, also pass are associated with the back and the thoracic wall and Nerves to upper limb Axillary inlet Lateral margin of rib I Superior margin of scapula Axillary vein Axillary artery Medial margin of coracoid process Fig. Ofen, part of the breast Innervation by cervical and upper known as the axillary process extends around the lateral thoracic nerves margin of the pectoralis major into the axilla. Lymphatic drainage from lateral and superior parts Innervation of the upper limb is by the brachial plexus, of the breast is predominantly into lymph nodes in the which is formed by the anterior rami of cervical spinal Levator scapulae Trapezius Pectoralis major Axillary process Blood vessels and lymphatics Latissimus dorsi Latissimus dorsi from back Fig. This plexus is initially Selected joint movements are used to test myotomes formed in the neck and then continues through the axil­ (Fig. Major nerves that ultimately innervate the arm, forearm, and hand originate from the • Abduction ofthe arm atthe glenohumeral joint iscon­ brachial plexus in the axilla. As a consequence of this innervation pattern, clinical • Flexion of the forearm at the elbow joint is controlled testing of lower cervical and Tl nerves is carried out by primarily by C6. Musculocutaneous nerve • All muscles in anterior compartment of arm Median nerve • Most flexors in forearm • Thenar muscles in Radial nerve • All muscles in posterior compartment of arm Ulnar nerve and forearm • Most intrinsic muscles in hand • Flexor carpi ulnaris and medial half of flexor digitorum profundus in forearm Anterior Posterior Axillary nerve • Superior lateral cutaneous nerve of arm Radial nerve Radial nerve • Inferior lateral T2 • Inferior lateral cutaneous cutaneous nerve of arm nere of arm • Posterior cutaneous nerve of arm • Posterior cutaneous nerve of forearm Musculocutaneous nerve • Lateral cutaneous nerve of forearm Musculocutaneous nerve Median nerve B Median nerve Fig. Radial groove of humerus • Most intrinsic muscles of the hand are innervated by the ulnar nerve, except for the thenar muscles and two lateral lumbrical muscles, which are innervated by the median nerve. In addition to innervating major muscle groups, each of the major peripheral nerves originating from the brachial plexus carries somatic sensory information from patches of skin quite different from dermatomes (Fig. Sensation in these areas can be used to test for peripheral nerve lesions: • The musculocutaneous nerve innervates skin on the anterolateral side of the forearm. Nerves related to bone Three important nerves are directly related to parts of the posterior surface of the middle of the humerus in the humerus (Fig. The most signifcant of these The basilic vein originates from the medial side of the veins are the cephalic, basilic, and median cubital veins dorsal venous network of the hand and passes proximally (Fig. It passes onto The cephalic and basilic veins originate from the the anterior surface of the limb just inferior to the elbow dorsal venous network on the back of the hand. This opposition of the a result, movements of the thumb occur at right angles to thumb is essential for normal hand function. For example, flexion brings the thumb across the palm, whereas abduction moves it away from the fngers at right angles to the palm. The bone framework of the shoulder consists of: Surface for • the clavicle and scapula, which form the pectoral articulation girdle (shoulder girdle), and with acromion Surface for articulation with manubrium of sternum and • the proximal end of the humerus. Conoid tubercle Bones Clavicle Theclavicle is theonly bony attachment between thetrunk Inferior view and the upper limb. It is palpable along its entire length and has a gentle 5-shaped contour, with the forward-facing convex part medial and the forward-facing concave part lateral. The acromial (lateral) end of the clavicle is flat, whereas the sternal (medial) end is more robust and some­ what quadrangular in shape (Fig. The sternal end has a much largerfacetfor articulation mainly with the manubrium of the sternum, and to a lesser extent, with the frst costal cartilage. The inferior surface of the lateral third of the clavicle possesses a distinct tuberosity consisting of a tubercle • three processes (acromion, spine, and coracoid process) (the conoid tubercle) and lateral roughening (the trap­ (Fig. The lateral angleofthe scapula ismarked by a shallow, In addition, the surfaces and margins of the clavicle are somewhat comma-shaped glenoid cavity, which articu­ roughened by the attachment of muscles that connect the lates with the head of the humerus to form the glenohu­ clavicle to the thorax, neck, and upper limb. A large triangular-shaped roughening (the infragle­ noid tubercle) inferior to the glenoid cavity is the site of Scapula attachment for the long head of the tricepsbrachii muscle. The scapula is a large, flat triangular bone with: A less distinct supraglenoid tubercle is located supe­ rior to the glenoid cavity and is the site of attachment for • three angles (lateral, superior, and inferior), the long head of the biceps brachii muscle. The costal surface and margins provide for major, respectively) muscle attachment, and the costal surface, together with its related muscle (subscapularis), moves freely over the Deltoid underlying thoracic wall. The superior border is marked on its lateral end by: Greater • the coracoid process, a hook-like structure that pro­ tubercle jects anterolaterally and is positioned directly inferior to Superior facet the lateral part of the clavicle; and (supraspinatus) • the small but distinct suprascapular notch, which Anatomical Middle facet lies immediately medial to the root of the coracoid neck (infraspinatus) Surgical process.

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Splenectomy involves: ligature of the splenic pancreatic juice into the pancreatic ducts and order 0.25 mg digoxin prehypertension blood pressure treatment, from there purchase discount digoxin on line heart attack alley, ultimately vessels approaching the hilum (taking care not to injure the tail of the into the duodenum order line digoxin arteria buccalis. The secretion is essential for the digestion and pancreas or colon); and dissection of the splenic pediclesbthe gastro- absorption of proteins, fats and carbohydrates. The mechanism by all patients are routinely vaccinated against the capsulated bacteria, which these aetiological factors result in pancreatic injury is unknown; and children, who are the group most at risk of sepsis, are maintained however, they both appear to result in activation of pancreatic exocrine on long-term antibiotic prophylaxis. The pancreas and spleen 47 20 The posterior abdominal wall Inferior phrenic artery Oesophagus Coeliac artery Superior mesenteric artery Transversus Iliohypogastric nerve Quadratus Ilioinguinal nerve lumborum Psoas major Gonadal artery Inferior mesenteric artery Genitofemoral nerve Femoral nerve Lateral cutaneous nerve of thigh Median sacral artery Fig. The small diagram shows how the renal columns represent the cortices of adjacent fused lobes Suprarenal Diaphragm Spleen Outline of pleura Duodenum Stomach 12th rib Pancreas Liver Transversus abdominis Colon Subcostal nerve Colon Ilio-inguinal nerve Small intestine Quadratus lumborum Small Psoas major intestine Fig. At the ischial spine the ureter passes forwards and medially to enter The adrenal (suprarenal) glands. The intravesical portion of the ureter is The lumbar sympathetic trunks and plexuses and the lumbar plexus approximately 2 cm long and its passage through the bladder wall (see p. Each kid- Blood supply: as the ureter is an abdominal and pelvic structure it ney is approximately 10–12 cm long and consists of an outer cortex, an receives a blood supply from multiple sources: inner medulla and a pelvis. The upper ureterareceives direct branches from the aorta, renal The hilum of the kidney is situated medially and transmits from front and gonadal arteries. The renal pelvis divides into two or three major calices and these, in turn, divide into minor calices which receive urine from the medullary Ureteric stones pyramids by way of the papillae. Most ureteric calculi arise for unknown reasons, although inadequate Position: the kidneys lie in the retroperitoneum against the posterior urinary drainage, the presence of infected urine, and hypercalcaemia abdominal wall. Large Blood supply: the renal arteries arise from the aorta at the level of impacted stones can lead to hydronephrosis and/or infection of the L2. Together, the renal arteries direct 25% of the cardiac output affected kidney and consequently need to be broken up or removed by towards the kidneys. The differential pressures cortex is derived from mesoderm and is responsible for the production between afferent and efferent arterioles lead to the production of an of steroid hormones (glucocorticoids, mineralocorticoids and sex ultrafiltrate which then passes through, and is modified by, the nephron steroids). The right gland lies behind the right The ureter is considered in abdominal, pelvic and intravesical portions. The left Structure: the ureter is approximately 20–30 cm long and courses adrenal is anteriorly related to the lesser sac and stomach. It has a muscular wall and Blood supply: the phrenic, renal arteries and aorta all contribute is lined by transitional epithelium. The posterior abdominal wall 49 21 The nerves of the abdomen T12 (subcostal) L1 Nerves L2 Subcostal Iliohypogastric L3 Ilioinguinal L4 Genitofemoral Lateral L5 cutaneous of thigh Femoral Obturator Fig. Sympathetic supply: the lumbar sympathetic chain is a continuation The trunks of the plexus lie within the substance of psoas major and, of the thoracic sympathetic chain as it passes under the medial arcuate with the exceptions of the obturator and genitofemoral nerves, emerge ligament of the diaphragm. The upper two ganglia no intercostal space but, instead, runs below the rib in the neurovascu- receive white rami from L1 and L2. The lumbar sympathetic chain, the splanchnic nerves and the vagus The iliohypogastric nerve is the main trunk of the 1st lumbar nerve. It contribute sympathetic and parasympathetic branches to plexuses supplies the skin of the upper buttock, by way of a lateral cutaneous (coeliac, superior mesenteric, renal and inferior mesenteric) around the branch, and terminates by piercing the external oblique above the abdominal aorta. In addition, other branches continue inferiorly to form superficial inguinal ring where it supplies the overlying skin of the the superior hypogastric plexus (presacral nerves) from where they mons pubis. The ilioinguinal nerve is the collateral branch of the iliohy- branch into right and left inferior hypogastric plexuses. The ilioinguinal runs in the neurovascular plane of the receive a parasympathetic supply from the pelvic splanchnic nerves. The abdominal wall to emerge through the superficial inguinal ring to pro- branches from the inferior hypogastric plexuses are distributed to the vide a cutaneous supply to the skin of the medial thigh, the root of the pelvic viscera along the course and branches of the internal iliac artery. The genitofemoral nerve (L1,2) emerges from the anterior surface of Parasympathetic supply: to the pelvic viscera arises from the anter- psoas major. It courses inferiorly and divides into: a genital component ior primary rami of S2,3,4athe pelvic splanchnic nerves.

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Theopening of themaxillary sinus is nearthetop of the The medial wall ofeach nasal cavity isthe mucosa-covered base generic digoxin 0.25 mg line arrhythmia gatorade, in the center of the semilunar hiatus cheap 0.25 mg digoxin with amex blood pressure zyrtec, which grooves surface of the thin nasal septum cheap digoxin generic heart attack or stroke, which is oriented verti­ the lateral wall of the middle nasal meatus. Nasal spine of frontal bone Sphenoidal sinuses Perpendicular plate of ethmoid bone The sphenoidal sinuses, one on either side within the body of the sphenoid, open into the roof of the nasal cavity via Sphenoidal sinus apertures on the posterior wall of the spheno-ethmoidal recess (Fig. The sphenoidal sinuses are related: • above to the cranial cavity, particularly to the pituitary gland and to the optic chiasm, • laterally, to the cranial cavity, particularly to the cavern­ ous sinuses, and • below and in front, to the nasal cavities. Because only thin shelves of bone separate the sphenoi­ Nasal crest of maxillary and dal sinuses fom the nasal cavities below and hypophyseal palatine bones fossaabove, the pituitary gland can besurgically approached Incisor crest through the roof of the nasal cavities by passing frst Fig. Posteriorly, the roof of each cavity slopes inferiorly to the choana and is formed by: Floor The floor of each nasal cavity (Fig. It consists of: • the ala of the vomer and adjacent sphenoidal process of the palatine bone, and • soft tissues of the external nose, and • the vaginal process of the medial plate of the pterygoid • the upper surface of the palatine process of the maxilla process. Underlying the mucosa, the roof is perforated superiorly by openings in the cribriform plate, and anterior to these The naris opens anteriorly into the floor, and the supe­ openings by a separate foramen for the anterior ethmoidal rior aperture of the incisive canal is deep to the mucosa nerve and vessels. Roof The roof of the nasal cavity is narrow and is highest in Lateral wall central regions where it is formed by the cribriform plate The lateral wall of each nasal cavity is complex and is of the ethmoid bone (Fig. Septal Nasal spine offrontal bone Naris Anterior nasal spine Opening of sphenoidal sinus Ala of vomer Palatine process of maxilla Nasal crests Horizontal plate of palatine Sphenoidal rostrum Vomer (articulates in the midline with the vomer) Fig. Inferior to the ethmoidal bulla is a curved gutter • the ethmoidal labyrinth, superior concha, middle (the semilunar hiatus), which is formed by the mucosa concha and uncinate process, covering thelateral wall as it spans a defect in thebonywall • the perpendicular plate of the palatine bone, between the ethmoidal bulla above and the uncinate • the medial pterygoid plate of the sphenoid bone, process below. The conchae do not extend inferior end of the lacrimal sac on the anteromedial wall forward into the external nose. This is formed cases, the frontal sinus drains directly into the anterior concha Lateral process of septal cartilage Medial pterygoid plate of sphenoid bone Minor alar Perpendicular plate of palatine bone Inferior concha A Fig. The nares are oval apertures on the inferior aspect of • The large maxillary sinus opens into the semilunar the external nose and are the anterior openings of the hiatus, usually just inferior to the center of the eth­ nasal cavities (Fig. They are held open by the moidal bulla-this opening is near the roof of the max­ surrounding alar cartilages and septal cartilage, and by illary sinus. The only paranasal sinus that does not drain onto the Although the nares are continuously open, they can be lateral wall of the nasal cavity is the sphenoidal sinus, widened further by the action of the related muscles of Nares Major alar carilage Orbit Attachment to frontal process of maxilla labii superioris alaeque nasi A Naris B Attachment to maxilla Fig. Choanae The roof of the choanae is formed: The choanae are the oval-shaped openings between the nasal cavities and the nasopharynx (Fig. Unlike • anteriorly by the ala of the vomer and the vaginal the nares, which have fexible borders of cartilage and sof process of the medial plate of the pterygoid process, and tissues, the choanae are rigid openings completely sur­ • posteriorly by the body of the sphenoid bone. There are a number of routes by which nerves and The sphenopalatine foramen is a route of communica­ vessels enter and leave the sof tissues lining each nasal tion between the nasal cavity and the pterygopalatine cavity (Fig. Major structures passing through the foramen are: sphenopalatine foramen, incisive canal, and small foram­ ina in the lateral wall, and around the margin of the nares. In addition, small foramina between the cribriform plate and surrounding bone allow the anterior Incisive canal ethmoidal nerve, a branch of the ophthalmic nerve [V1]. Another route by which structures enter and leave the and accompanying vessels to pass from the orbit into the nasal cavities is through the incisive canal in the floor of cranial cavity and then down into the nasal cavity. This canal is immediately lateral to the In addition, there is a connection in some individuals nasal septum and just posterosuperior to the root of the between nasal veins and the superior sagittal sinus of central incisor in the maxilla. The two incisive canals, one the cranial cavity through a prominent foramen (the on each side, both open into the single unpaired incisive foramen cecum) in the midline between the crista galli and fossa in the roof of the oral cavity and transmit: fontal bone. This foramen is just superior to the attach­ ment of the posterior end of the middle nasal concha and Small foramina in the lateral wall Other routes bywhich vessels and nerves get into and out of the nasal cavity include the nares and small foramina in the lateral wall: Foramen cecum Cribriform plate • Internal nasal branches of the infra-orbital nerve of the Sphenopalatine foramen maxillary nerve [V2] and alar branches of the nasal artery from the facial artery loop around the margin of the naris to gain entry to the lateral wall of the nasal cavity from the face. Vessels The nasal cavities have a rich vascular supply for altering the humidity and temperature of respired air. In fact, the submucosa of the respiratory region, particularly that Small foramina on lateral wall related to the conchae and septum, is often described as Incisive canal "erectile" or "cavernous" because the tissue enlarges or shrinks depending on the amount of blood flowing into Fig. Regional anatomy • Nasal Cavities Posterior septal branches of the sphenopalatine Arteries artery pass over the roof of the cavity and onto the nasal Arteries that supply the nasal cavity include vessels that septum where they contribute to the blood supply of the originate from both the internal and external carotid arter­ medial wall. Sphenopalatine artery Like the sphenopalatine artery, the greater palatine The largest vessel supplying the nasal cavity is the sphe­ artery arises in the pterygopalatine fossa as a branch of the nopalatine artery (Fig. It passes frst onto the roof of the oral branch of the maxillary artery in the pterygopalatine cavity by passing down through the palatine canal and fossa. It leaves the pterygopalatine fossa and enters the greater palatine foramen to the posterior aspect of the nasal cavity by passing medially through the sphenopala­ palate, then passes forward on the undersurface of the tine foramen and onto the lateral wall of the nasal cavity. The greater palatine artery of the lateralwalland anastomose anteriorly withbranches supplies anterior regions of the medial wall and adjacent from the anterior and posterior ethmoidal arteries, and floor of the nasal cavity, and anastomoses with the septal with lateral nasal branches of the facial artery.

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  • A preventive vitamin K shot is not given at birth (if vitamin K is given by mouth instead of as a shot, it must be given more than once and it may not be as effective)
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Macrosomia microphthalmia cleft palate

The nucle- dunculopontine nucleus is found in the lateral teg- us raphes pallidus is found in the ventral medulla mentum purchase cheapest digoxin and digoxin blood pressure 40 over 60, ventral to the inferior colliculus generic 0.25mg digoxin with amex arrhythmia questions and answers. At the oblongata order digoxin 0.25mg mastercard pulse pressure ratio, and the nucleus raphes obscurus is found pontine level, surrounding the medial and lateral more dorsally to the latter at the same level. Histoflu- regions of the superior cerebellar peduncle, are orescence and immunohistochemical techniques found the medial and lateral parabrachial nuclei. The have shown that many cell groups lying in this medi- medial nucleus receives inputs from the gustatory an zone are serotoninergic neurons expressing in- nucleus of the nucleus solitarius, and the lateral nu- dolamine serotonin. Other neurons display immu- cleus receives general visceral afferents from the cau- noreactivity through neuropeptides and amino dal portion of the nucleus solitarius. The fibers originating from serotoninergic project efferents to the hypothalamus and the neurons in the brainstem are extensively distributed amygdaloid body. The lateral reticular nucleus of the me- b The Medial Reticular Zone dulla occupies the anterolateral region of the medul- The medial reticular zone includes: in the midbrain, la, beginning caudal to the inferior olive and the mesencephalic cuneiform and subcuneiform extending to the mid-olivary level. This nucleus is a nuclei, in the pons the nuclei reticulares pontis cau- cerebellar relay nucleus receiving afferents from the dalis and oralis and the reticulotegmental nucleus, spinal cord as the spinoreticular tract, collaterals and in the medulla, at mid-olivary levels, the gigan- from the spinothalamic tracts and projecting fibers tocellular reticular nucleus. The latter is situated via the inferior cerebellar peduncle that end bilater- medial and dorsal to the rostral half of the inferior ally in the anterior lobe as mossy fibers. The lateral olivary nuclear complex, containing characteristical- pontine reticular formation, constituting the en- ly large cells and extending rostrally to the medullary larged rostral portion of the lateral reticular zone, is pontine junction. Descending fibers from the gigan- primarily involved in the regulation of cardiovascu- tocellular reticular nucleus constitute the medullary lar, respiratory and gastrointestinal activities. The reticular nuclei pontis cau- dalis and oralis constitute the major portion of the pontine reticular formation, the nucleus reticularis E Vascular Supply to the Brainstem pontis oralis extending rostrally into the caudal mid- brain. Uncrossed reticulospinal fibers arise from According to Duvernoy (1978), the midbrain, pons cells of the pontine reticular formation. These as- and medulla receive their blood supply from antero- cend in the central tegmental tract, projecting to medial, anterolateral, lateral, and dorsal arteries. The reticu- 1 At the Midbrain Level lotegmental nucleus, located dorsal to the medial lemniscus, constitutes a nuclear relay in the cortico- At the midbrain level, the anteromedial or paramed- cerebellar motor circuits. The midbrain cuneiform ian arteries give rise to medial pedicles which vascu- and subcuneiform nuclei are situated ventral to the larize the red nucleus, the periaqueductal gray mat- tectum, the former extending throughout the rostro- ter, and the oculomotor and trochlear nuclei. The nucleus lateral pedicles supply the medial lemniscus, the subcuneiformis is ventral to the latter. The connec- medial portion of the substantia nigra, and the de- tions of the medial zone, largely confined to the retic- cussation of the superior cerebellar peduncles. The ular formation even though some of the projections anterolateral arteries, also called the short circum- ascend to the diencephalon or descend to the spinal ferential arteries, arise from different vessels and cord, suggest that it is linked to both the motor and vascularize the cerebral peduncle, the substantia ni- sensory pathways. These peduncular branches arise from the posterior cerebral artery, the The Brainstem and Cerebellum 241 posterior communicating artery, the superior cere- us, the middle cerebellar peduncle, the principal sen- bellar artery, and the anterior and posterior choroi- sory nucleus of the trigeminal nerve, the abducens dal arteries (Zeal and Rhoton 1978; Duvernoy 1978). The long pontine arteries supply the tum including the lateral lemniscus, the reticular pontine nuclei, the lateral lemniscus, the central teg- formation, and the central tegmental tract. They are mental tract, and the lateral portion of the pyramidal represented by the superior cerebellar artery, the tract. The terminal segment of the superior cerebel- collicular artery, and the medial posterior choroidal lar artery supplies the superior cerebellar peduncle, artery, all of which perforate the midbrain at the level the locus coeruleus, and the mesencephalic trigemi- of the mesencephalic sulcus. The anteromedial, or paramedian medullary, arter- ies arise from the vertebral artery and the anterior 2 At the Pontine Level spinal artery and supply the pyramid and the medial lemniscus, as well as the medial portion of the infe- The anteromedial or paramedian arteries are rior olive and the central reticular formation. The branches of the basilar artery and the adjacent seg- anterolateral arteries also supply the inferior olive and ment of the vertebral artery which supply the para- the pyramidal tract. The lateral pedicles arise from the median region of the tegmentum, including the py- posterior inferior cerebellar artery, the anterior inferi- ramidal tract, the medial lemniscus, the reticular or cerebellar artery, and the basilar and vertebral ar- formation, the medial longitudinal fasciculus, and teries. The lateral pontine region is inferior olive and lateral medullary fossa, comprising vascularized by arterial perforators originating from the inferior cerebellar peduncle, the spinothalamic the superior cerebellar artery supplying the rostro- and spinocerebellar tracts, the dorsal motor nucleus lateral portion of the pons, mainly the superior cer- of the vagus, the nucleus and tractus solitarius, the ebellar peduncle, the central tegmental tract and spinal trigeminal nucleus, the vestibular nuclei, and pontine reticular formation, the lateral lemniscus, the ambiguous nucleus. The caudal and lateral por- bellar artery vascularizes the posterior medullary re- tion of the pons is supplied by the anterior inferior gion including the cuneate and gracile nuclei and the cerebellar artery, which vascularizes the facial nucle- vagal, vestibular and solitary nuclei (Fig. This expansion is present in most vertebrates and undergoes moderate modifica- In order to better understand cerebellar functioning, tions. The major development of the middle portion, some developmental and comparative data are re- mainly in mammals, including human and nonhu- quired. The cerebellar rudiment develops from the man primates, involves the neocerebellum, corre- cranial portion of the rhombencephalic vesicle as sponding roughly to the cerebellar hemispheres. The rudi- flocculonodular lobe is also named the archicerebel- ment consists of a bilobar mass corresponding to the lum, and the paleocerebellum includes portions of cerebellar hemispheres and separated by a median the vermis located in the anterior lobe as well as the region which will form the vermis.

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