Atlas of Medical Anatomy 0030596564, 9780030596568

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Atlas of Medical Anatomy JAN LANGMAN, M.D., Ph.D. Professor and Chairman, Department of Anatomy, University of Virginia

M. W. WOERDEMAN, M.D., Ph.D., D.Sc.h. Professor of Anatomy and Embryology Emeritus; Formerly Director of the Department of Anatomy, The University of Amsterdam

A Saunders Paperback

THE SAUNDERS PRESS W. B. Saunders Company Philadelphia London Toronto

THE SAUNDERS PRESS/SAUNDERS PAPERBACKS W. B. Saunders Company West Washington Square Philadelphia, PA 19105

IN THE UNITED STATES DISTRIBUTED TO THE TRADE BY

HOLT, RINEHART AND WINSTON 383 Madison Avenue New York, New York 10017

IN CANADA DISTRIBUTED BY

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© 1982, 1978 by W. B. Saunders Company Copyright under the Uniform Copyright Convention. Simultaneously published in Canada. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Made in the United States of America. Library of Congress catalog card number 81-51356 W. B. Saunders Company ISBN: 0-7216-5622-6 Holt, Rinehart and Winston ISBN: 0-03-059656-4 Print number

98765432

1

PREFACE

Portrait painters and sculptors study anatomy to create an accurate surface impression of the underlying structures; sport trainers examine the muscles, bones and joints to analyze and prescribe the most efficient movements. Students of medicine and dentistry study anatomy to better understand and evaluate the symptoms of disease. Every human being interested in body form and function studies anatomy to know where the various organs and structures are located and how they are related to each other. We have composed this atlas with all these groups of interested people in mind. We hope particularly that they will obtain a thorough, three-dimensional knowledge of the normal human body and that the text will help them understand the clinical applications of anatomical knowledge. Certain areas of gross anatomy are difficult to understand even when represented in three-dimensional illustrations. For this reason we have added schematic drawings that either simplify the anatomical relation or explain them by making use of the simple re¬ lations seen in the embryo. The simplicity of the structures found during development helps us understand the complicated topography in the adult. In many chapters we have presented photographs of the surface features in an attempt to bridge the gap between the dissected specimen and the live human being. Similarly, a number of radiographs have been presented. Both the surface photographs and the radio¬ graphs try to correlate anatomical observations with data obtained from normal and diseased human beings. This book was illustrated and written originally with the training of medical students in mind. This is reflected in the selection of illustrations, most of which were prepared from adult specimens, but some from newborn infants. Throughout the writing and illustration of this book, however, we have kept in mind that it is not only medical and dental students who must learn the anatomy of the human body; rather, many if not most human beings are interested in the structure of their bodies. Hence, we expect that while the medical student will benefit from the clinical application of his anatomical knowledge, our other readers will be fascinated by the structure of the human body.

Martin W. Woerdeman, M.D., Ph.D., D.Sc.h.c. Jan Langman, M.D., Ph.D.

ACKNOWLEDGMENTS

The publication of an anatomical atlas is a monumental task involving the dissection of numerous specimens, the preparation of several thousand illustrations and the logical arrangement of the material. The greatest collaborative effort over a prolonged period of time is required to bring such a large work to its final form. We are therefore deeply indebted to our many co-workers, varying from artists to secretaries and from colleagues in anatomy to a host of medical students. This work could not have been accomplished without the dedication of the late Mrs. H. L. Blumenthal-Rothschild, the principal artist, who prepared the majority of the illustrations. She made her artistic and scientific talents available for this work with the greatest enthusiasm

and

attracted

a number of excellent co-workers. These artists, Mmes.

L. M. Binger, W. van Slooten and A. van Hamersveld and Messrs. J. Tinkelenberg and Chr. van Huizen, each contributed a substantial number of illustrations to this book. To them we offer our most sincere thanks. Some of the drawings that were in the collection of the Anatomy Department of the University of Amsterdam were generously made available to us by its Chairman, Dr. J. van Limborgh. We are also greatly indebted to Mr. W. Fairweather, who directed the color work on the illustrations for this atlas and prepared several additional drawings. For this arduous work our thanks go particularly to Mrs. Judy Fairweather, who prepared the thousands of color overlays with endless patience, great enthusiasm and skill. We also wish to express our great appreciation to the W. B. Saunders Company, who undertook the task of publishing this book. In particular, our thanks go to Mr. John Hanley, who encouraged us continuously in the preparation of this work. We are also indebted to Miss Ruth Goddard, who edited the text and checked the labels in the illustrations. Finally, we especially wish to thank Mrs. Hanna Woerdeman and Mrs. Ina Langman for their wonderful encouragement and devotion during the preparation of this book.

Amsterdam, Holland Charlottesville, Virginia

Martin W. Woerdeman Jan Langman

v

CONTENTS

THORAX T1-T3

Surface view of the thorax

T4

The superficial fascia of the thorax

T5, T6

The breast and its lymph drainage

T7-T10

Bones and joints of the thorax

Til

Respiratory movements

T12-T16

The large thoracic muscles

T17-T21

Intercostal musculature, nerves and vessels

T22

Contents of the thorax in the newborn

T23, T24

The anterior thoracic wall

T25-T29

Lungs and pleura in sections through the thorax

T30

Auscultation of the heart

T31

Contents of the thorax in the adult

T32-T37

Right lung —surface aspects and bronchial tree

T38-T42

Left lung —surface aspects and bronchial tree

T43, T44

Trachea and tracheobronchial lymph nodes

T45

Surface views of the heart

T46

The pericardium and its sinuses

T47-T50

The coronary vessels

T51-T55

Interior aspect of the heart

T56

Conducting system of the heart

T57, T58

The pericardial cavity

T59-T61

The great vessels in relation to the trachea and esophagus

T62, T63

Structures in the posterior mediastinum

T64

Azygos veins

T65

Sympathetic chain

T66

The diaphragm and diaphragmatic hernia

ABDOMEN A1-A3

Surface views of the abdomen

A4

The bony pelvis

A5, A6

The superficial fascia, nerves and vessels VI

CONTENTS A7- 412

Muscles of the abdominal wall

A13-A17

The inguinal region and spermatic cord

A18

Inguinal hernias

A19-A21

The peritoneum and its development

A22-A24

The abdominal contents

A25

The lesser omentum

A26-A34

The stomach—position, vascularization and lymph drainage

A35-A45

Small and large intestines —position, vascularization and lymph drainage

A46

Attachment of the mesenteries

A47-A50

The pancreas, duodenum and spleen

A51-A57

The liver

A58-A60

The gallbladder

A61-A69

The kidneys and suprarenal glands

A70, A71

The autonomic nervous system

A72-A74

The diaphragm and posterior abdominal wall

PELVIS P1-P8

The bones and joints of the pelvis

P9, P10

External genital organs in the male

P11-P13

The testis and epididymis

P14-P19

The penis —position, vascularization and lymph drainage

P20, P21

Anal and urogenital triangles in the male

P22-P24

The urogenital diaphragm in the male

P25-P27

Vascularization and lymph drainage of the male pelvis

P28-P31

The bladder, prostate and seminal vesicles

P32-P34

The rectum and ischiorectal fossa

P35

The internal iliac artery and its branches

P36-P40

External genital organs in the female —vascularization and lymph drainage

P41-P43

Sections through the female pelvis

P44, P45

Vascularization of the female pelvis

P46-P50

Uterus, ovary and vagina

P51, P52

Ligaments of the uterus

P53

Lymph drainage of the female pelvis

P54-P56

The pelvic diaphragm

P57

The lumbosacral plexus

P58

The autonomic nervous system in the pelvis

UPPER LIMB

viii

UL1-UL3

Brachial plexus and segmental innervation

UL4-UL7

The bones of the shoulder girdle

UL8-U112

The pectoral muscles

UL13-UL16

Vessels and nerves

UL17-UL21

The scapular muscles

UL22

Humerus, radius and ulna

UL23-UL29

Muscles, vessels and nerves of the arm

CONTENTS UL30-UL34

The shoulder joint

UL35-UL40

Muscles, vessels and nerves of the anterior side of the forearm

UL41

The bones of the hand

UL42-UL45

Arteries and nerves of the palm of the hand

UL46, UL4J7

The thenar and hypothenar musculature

UL48, UL49

The lumbrical and interosseous muscles

UL50, UL51

The median and ulnar nerves

UL52-UL56

Muscles, vessels and nerves of the posterior side of the forearm

UL57, UL58

Nerves and arteries of the dorsum of the hand

UL59

The radial nerve

UL60-UL63

The elbow joint

UL64

The carpal bones

UL65-UL67

Joints and ligaments of the wrist and hand

LOWER LIMB LL1-LL3

Lumbosacral plexus and segmental innervation

LL4-LL6

Major nerves and vessels

LL7

The bones

LL8, LL9

Lymph drainage and cutaneous innervation of the anterior aspect of the thigh

LL10-LL12

The saphenous opening, femoral sheath and femoral hernia

LL13-LL19

Muscles, vessels and nerves on the anterior and medial sides of the thigh

LL20

The femoral nerve

LL21-LL24

Muscles, vessels and nerves in the gluteal region

LL25-LL28

Muscles, vessels and nerves in the posterior region of the thigh

LL29

The common peroneal and superior gluteal nerves

LL30-LL37

The femur, hip bone and hip joint

LL38-LL44

Muscles, vessels and nerves on the interior side of the leg and dorsal aspect of the foot

LL45-LL51

Muscles, vessels and nerves on the posterior side of the leg

LL52

Tendon sheaths on the medial side of the foot

LL53

The tibiofibular joints

LL54-LL60

The knee joint

LL61-LL65

Muscles, vessels and nerves of the sole of the foot

LL66

The sciatic nerve

LL67-LL76

Joints and ligaments of the ankle and foot

HEAD AND NECK HN1-HN4

The newborn and adult skull

HN5, HN6

Major vessels of the head and neck

HN7

The trigeminal nerve

HN8-HN10

The facial nerve and musculature

HN11-HN13

The parotid gland and its relations

HN14, HN15

Bones and cartilages of the ear and nose

HN16-HN18

The eye and lacrimal apparatus

HN19-HN22

The scalp and its relation to the brain IX

CONTENTS HN23, HN24

Extracranial and intracranial veins and sinuses

HN25-HN28

The cranial cavity and the dura

HN29, HN30

The cranial nerves and the base of the skull

HN31, HN32

The middle cranial fossa and hypophysis

HN33, HN34

The bony orbit

HN35-HN40

The muscles of the eye and their nerves

HN41-HN45

The eyeball

HN46, HN47

Median sections through the head

HN48-HN54

The nose and paranasal sinuses

HN55

The temporal bone

HN56-HN67

The external, middle and internal ear

HN68-HN72

The posterior triangle of the neck with its nerves and vessels

HN73-HN76

The infrahyoid musculature and vessels of the neck

HN77-HN80

The sympathetic trunk and vessels in the neck

HN81

Fascial layers in the neck

HN82-HN86

The salivary gland and muscles of mastication

HN87, HN88

The mandible and temporomandibular joint

HN89-HN91

The parasympathetic ganglia

HN92-HN97

The oral cavity and tongue and their innervation

HN98-HN103

The teeth and their innervation

HN104

The base of the skull and foramina

HN105-HN109

The pharyngeal musculature and nerves

HN110

The prevertebral musculature

HN111-HN115

The oropharynx, nasopharynx and palate

HN116-HN121

The larynx and its cartilages and muscles

HN122, HN123

The thyroid gland

BACK

x

B1-B6

The vertebrae and vertebral column

B7

The spinal nerve

B8

Nerves and vessels in the occipital region

B9-B16

Superficial and deep muscles of the back

B17

Suboccipital muscles, vessels and nerves

B18-B20

Atlanto-occipital and atlantoaxial joints and ligaments

B21

Ligaments of the vertebral column

B22-B28

The spinal cord and the meninges

THORAX

THORAX -T1 clavicle

suprasternal notch

sternal angle

xiphisternal joint

costal margin-

The following landmarks are important in

A.

Anterior surface of the thorax in a male.

the physical examination of the thorax. They can all be easily palpated and are helpful as reference points in determining the position of the heart and lungs.

sternal angle

*f Suprasternal notch: the midline depression bordered by the superior margin of the sternum and the medial ends of the clavi¬ cles. Deep to the depression the tracheal cartilages can be felt. By moving the finger xiphisternal joint

slightly upwards the cricoid cartilage of the larynx can be palpated.

Sternal angle: the angle between the manu¬ brium and the body of the sternum. At this level the second costal cartilage joins the lateral border of the sternum. The sternal angle

is

an

important landmark when

counting the ribs and intercostal spaces.

Xiphisternal joint: the joint between the body of the sternum and the xiphoid proc¬ ess. The cartilage of the seventh rib attaches

B.

Anterior view of the thorax. The bony skeleton is superimposed.

to the sternum just above the joint; occa¬ sionally it is attached to the xiphoid proc¬ ess. Palpation of the inferior tip of the xiphoid process may be painful. ♦f Costal margin: the lower boundary of the thorax, formed by the cartilages of the seventh, eighth, ninth and tenth ribs. «f Clavicle: one of the few bones whose entire length lies immediately under the skin.

Ribs: The ribs can best be palpated and counted by first determining the position of the second rib, which is easily identifiable because it attaches to the sternum at the sternal angle. Counting of the ribs is easiest in the midclavicular line. The first rib cannot be felt since it lies deep to the clavicle. Similarly, the eleventh and twelfth ribs are difficult to palpate. The number of each intercostal space corresponds to the number of the rib forming its upper boundary. (For bony components of the thorax see T9 and T10.) 2

THORAX-T2

mammillary line

A.

parasternal line

Anterior view of the thorax in a female. Orientation lines are indicated.

Subcutaneous fat tissue and the mam¬ mary glands make palpation of the bony landmarks and auscultation and per¬ cussion of the heart and lungs more dif¬ ficult in the female than in the male. The following orientation lines may be helpful in physical diagnosis:

1. Midsternal line: lies in the median plane of the sternum. 2. Parasternal line: is drawn about half an inch from the lateral border of the sternum. 3. Midclavicular

line:

runs

vertically

down from the midpoint of the clavi¬ cle. 4. Anterior axillary line: runs vertically down from the anterior axillary fold. 5. Mammillary or nipple line: is not of much value considering individual

B.

Schematic drawing of the anterior aspect of the thorax. The outline of the heart and lungs is superimposed.

variations and the changes in the position of the nipple that occur with age.

Note also the following important points: The top or apex of the lung extends above the first rib and clavicle into the neck, where it forms a dome. Deep wounds above the clavicle may penetrate into the apex of the lung. «J

On the right side of the sternum the heart is covered anteriorly by the right lung; on the left side, it is covered anteriorly by the lung except in parts of the fourth and fifth inteicostal spaces and behind the fourth and fifth ribs (see B).

«j

The apex of the heart, formed by the left ventricle, lies behind the fifth intercostal space. The beat of the heart (apex beat) can be felt in this space 3% inches from the midsternal line. When the heart is enlarged, the apex beat may be felt in the midclavicular or even in the anterior axillary line.

THORAX-T3

spine of scapula

root of spine

A.

Posterior view of the thorax in a male.

In

examining the posterior aspect of the

thorax only a few bony landmarks and orien¬ tation lines are used as reference points.

The vertebra prominens. This is the seventh cervical

vertebra.

Its

spinous

process,

contrary to that of the other cervical verte¬ brae, can be palpated easily by moving the fingers downward along the midline of the posterior aspect of the neck. The first spinous process that is easily distin¬ guishable is that of the seventh cervical vertebra (C7).

The spinous processes of the thoracic verte¬ brae. Once the spinous process of C7 has been determined, it is easy to palpate the The bony points, lungs and pleura are superimposed.

spines of the thoracic vertebrae by moving the fingers downward along the vertebral column.

«J

The spine of the scapula. This is an easily palpable subcutaneous part of the scapula. The root of the spine lies at the level of the spinous process of the third thoracic vertebra (T3). This landmark is of little value since the scapula can move considerable distances along the posterior body wall. Its relationship to the spine is valid only if the arms are hanging at the sides.

The scapular line, which runs vertically downward from the inferior angle of the scapula when the arms are hanging at the sides.

^

The posterior axillary line, which runs vertically downward from the posterior axillary fold (see T12 A).

Note also: The lower border of the pleural cavity extends at least the width of two fingers below the border of the lungs, a fact of great clinical importance. During respiration the lungs move up and down in the pleural cavity (see T26 and T27). 4

THORAX -T4

areolar venous plexusaxillary vein

thoracoepigastric vein-

- thoracoepigastric vein (channel)

umbilical venous plexus

anastomoses with paraumbilical veins

superficial epigastric vein

- superficial circumflex iliac vein femoral vein __ - superficial external pudendal vein superficial dorsal vein of penis great saphenous vein

The veins in the superficial fascia.

The superficial fascia connects the corium of the skin to the underlying deep fascia, which invests the musculature (see T12 A). The superficial fascia consists of loose are¬ olar tissue with collagenous and elastic fibers and usually contains considerable fat. «J

The subcutaneous nerves and the superficial veins are located in the super ficial fascia. Under normal conditions few anastomoses exist between the thoracic veins and the epigastric veins of the abdominal wall. Occasionally, however, if the inferior vtna cava is obstructed, large anastomoses may develop; the most important channel to bypass the vena cava is the thoracoepigastric venous channel.

5

THORAX-T5 nipple /tV'i'ktTC

fatty tissue .lactiferous ducts suspensory ligaments (Cooper)

suspensory ligaments

lobes of mammary gland pectoralis major fascia of pectoralis major

A.

Section through the mammary gland.

The mammary gland is the most important organ in the superficial fascia of the thorax. Note the following clinical¬ ly important points:

Position and attachment. The breast lies in the superfi¬ cial fascia and rests on the deep fascia covering the pectoralis major and serratus anterior muscles. Fibrous bands, called Cooper's suspensory ligaments, fix the breast to the skin and the underlying fascia. These ligaments

B.

Schematic drawing of the milkline and accessory nipples. (From Langman, J.: Medical Embryology, 3rd ed. Baltimore, The Williams & Wilkins Co., 1975.)

are clinically important because the invasion of cancer cells may cause them to retract: on the skin this causes dimpling, and in the nipple area it causes retraction of the nipple. When the tumor invades the fibers inserting into the deep fascia, the breast tissue cannot be moved over the muscles, as in normal women.

Axillary tail (Spence).

This is a tail-like prolongation of the upper-outer quadrant

in an axillary direction. It passes through an opening in the axillary fascia and is thus located deep to the fascia. When the gland is palpated the tail tissue is sometimes con¬ fused with enlarged axillary lymph nodes (see T6 B). ^

Inverted nipple.

Inversion of the nipple is either a congenital condition or the result of

the ingrowth of cancer tissue in the suspensory ligaments in the nipple region.

Ectopic nipple. length

Additional nipples (polythelia) may be found anywhere along the the so-called tnilkHw#, which extends the axillary region to the inguinal

region. Extra nipples are usually not accompanied by breast tissue. Occasionally, how¬ ever, an extra nipple and functional breast tissue are found in the axillary region (poly¬ mastia). 6

interpectoral lymph nodes

THORAX-T6

pectoralis major

apical or infraclavicular lymph nodes I

I

; lymph channels to parasternal nodes

central axillary lymph nodes pectoralis major

'•W

subareolar lymph plexus

(cut and reflected)

lymph channels to epigastric region rectus abdominis

lateral axillary lymph nodes subscapular lymph nodes pectoral (ant. axillary) lymph nodes

latissimus dorsi serratus anterior

A.

Lymph drainage of the female breast. central axillary lymph nodes

infraclavicular (apical) lymph nodes

axillary tail

to parasternal and mediastinal lymph nodes

pectoral (ant. axillary)

B.

Schematic drawing of the lymph drainage of the breast.

lymph nodes

to opposite breast

areolar lymphatics to epigastric and peritoneal lymph nodes

The lymph drainage of the breast is extremely important because of the frequent occurrence of cancer in this region and the spread of malignant cells along the lymph vessels.

«j

Most lymphatics of the glandular tissue course in a superolateral direction and drain into the pec¬ toral (anterior axillary) nodes. Subsequently they drain into the central axillary nodes located in the fat of the axilla under the axillary tuft of hair and along the inner border of the axillary vein. From here they pass toward the apical or infraclavicular group. Finally, they reach the deep cervical or supra¬ clavicular lymph nodes.