Preclinical Anatomy Review 2023: For USMLE Step 1 and COMLEX-USA Level 1

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PRECLINICAL

ANATOMY

REVIEW

2023

® FOR

USMLE

STEP

1

AND

® COMLEX

USA

LEVEL

USMLE® Medical Kaplan registered affiliated

1

and

United

Examiners and

were trademark

with

States (NBME)

not

Kaplan

Medical

Licensing

and

the

Federation

of State

in the

production

of, and

involved of the and

National

was

Board

not involved

Examination®

is a joint Medical

do

of Osteopathic in the

production

not

program

Boards endorse,

Medical of, and

National

which

product.

Examiners, does

of the

(FSMB), this

Inc.

not endorse,

are

Board not

COMLEX (NBOME), this

of

affiliated USA® which

product

with is a

is not

PRECLINICAL

ANATOMY

REVIEW

2023

FOR

USMLE®

STEP

COMLEX

USA®

USMLE® and of State COMLEX was

United

Medical

States

Boards

Medical

(FSMB),

USA® is a registered

not involved

in the production

Licensing

Examination®

are not affiliated

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of the National does

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LEVEL

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Editors

James

White,

Assistant

Professor

School

of

PhD of

Rowan

Assistant University

Professor of

of

NJ

Cell

Pennsylvania

David

Rutgers–Robert

of

and

Seiden,

Wood

of

Biology

Medicine

PA

Neuroscience

Piscataway,

Developmental

School

Philadelphia,

Professor

Biology

Medicine

University

Stratford,

Adjunct

Cell

Osteopathic

PhD and

Johnson

Cell Medical

N

Biology School

We

want

to

hear

what Please

you email

think. us

What at

do

you

like

[email protected]

or

not

like

about

the

Notes?

Table

PART

PART

PART

I:

EARLY

EMBRYOLOGY

CHAPTER

1:

Gonad

CHAPTER

2:

First

CHAPTER

3:

Histology:

II:

GROSS

AND

8

Weeks

.

of

Contents

HISTOLOGY:

Development

.

.

EPITHELIA

.

.

Development.

Epithelia

.

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3

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7

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. 13

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. 21

ANATOMY

CHAPTER

1:

Back

CHAPTER

2:

Thorax

CHAPTER

3:

Abdomen,

CHAPTER

4:

Upper

Limb.

CHAPTER

5:

Lower

Limb

CHAPTER

6:

Head

III:

of

and

Autonomic

.

.

.

.

.

Pelvis,

.

and

Nervous

.

.

and

.

.

.

System

.

.

Perineum

.

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. 35

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. 85

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179

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195

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207

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225

Neck

NEUROSCIENCE

CHAPTER

1:

Nervous

System

CHAPTER

2:

Histology

CHAPTER

3:

Ventricular

System

CHAPTER

4:

The

Spinal

Cord.

CHAPTER

5:

The

Brain

CHAPTER

6:

The

CHAPTER

7:

Basal

of

Organization

the

and

Nervous

Development

System

.

.

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235

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245

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251

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275

Cerebellum

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309

Ganglia

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317

Stem

CHAPTER

8:

Visual

CHAPTER

9:

Diencephalon

CHAPTER

10:

Cerebral

CHAPTER

11:

Limbic

INDEX

v

. .

. . . .

Pathways

. . .

.

Cortex

System

. . .

.

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325

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335

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343

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361

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. 367

PART

EARLY

I

EMBRYOLOGY

HISTOLOGY:

AND

EPITHELI

Gonad

LEARNING

OBJECTIVES

❏

Explain

❏

Interpret

❏

Answer

❏

Interpret

❏

Solve

GONAD

information

related

scenarios

on

questions

to

testis

about

scenarios

and

gonad

ovary

meiosis

on

problems

indifferent

spermatogenesis

concerning

oogenesis

DEVELOPMENT

Although

sex

indifferent

is determined

stage The

intermediate gonads

are

of

Primary which

•

the

sex

cells

yolk

initially

go

through

specific

ovarian

or

testicular

develop the

in

urogenital

provide in

a

longitudinal

ridge.

an

elevation

The

components

or

ridge

of

the

a at

critical

week

4.

inductive They

influence

arise

from

on

the

gonad

lining

cells

in

sac. are

into

gonads

no

follows:

cords

grow

germ

as

the are

gonads

migrating

wall

there

called

germ

development, the

fertilization,

when

indifferent

Primordial

•

4–7

mesoderm

indifferent

•

at

weeks

characteristics. of

1

Development

the

finger

like

gonad

that

extensions are

of

populated

the by

surface the

epithelium

migrating

primordial

cells.

Mesonephric the

(Wolffian)

indifferent

and

gonad

the

paramesonephric

contribute

to

(Mullerian)

the

male

and

the

testis

or

female

ducts

genital

of

tracts,

respectively.

The

indifferent

gonads

Development

of

develop

the

testis

into

and

either

male

reproductive

ovary.

system

is

directed

by

the

following:

•

Sry

gene

testis •

Testosterone,

•

Müllerian

•

Dihydrotestosterone

Ovarian WNT4

the

short

determining

arm

which

of development

of

factor is

inhibiting

Development

the

on

secreted factor

ovary occurs

Y

chromosome,

which

encodes

for

(TDF)

and

the

Leydig which

external

female in

by (MIF),

(DHT):

the

the

the

cells is

by

the

Sertoli

cells

genitalia

reproductive absence

secreted

of

system the

Sry

gene

requires and

estrogen. in

the

presence

of

gene.

3

PART

I

|

EARLY

EMBRYOLOGY

Anatomy

AND

HISTOLOGY:

EPITHELIA

Immunology MIF:

Müllerian

TDF:

testis

inhibiting

determining

factor

factor Primordial

Pharmacology

germ

Biochemistry

Yolk

cells

sac Urogenital

Physiology

MIF: TDF:

Pathology

Medical Genetics

Müllerian testis

inhibiting determining

ridge

Mesonephric

factor

duct

(Wolffian)

Paramesonephric

factor

duct

(Müllerian)

BehavioralScience/Social Sciences

Indifferent

gonad

TDF No

Testosterone

factors

MIF Microbiology Testis and genital

Figure

I 1

1.

Development

Figure

I 1

and

system

of

1. Development

Ovary

male

Testis

and

female

genital

system

process

of

Ovary

of Testis

and

Ovary

is

specialized

GAMETOGENESIS

Meiosis Meiosis,

occurring

division

that

within

produces

(oogenesis).

the the

There

are

testis

male

notable

and

ovary,

a

gamete

(spermatogenesis)

differences

between

and

female

cell

gamete

spermatogenesis

and

oogenesis.

Two

cell

Synapsis:

pairing

•

Crossing

over:

•

Disjunction:

23

meiosis

occur

take

•

(no

In

divisions

with

of

in

46

chromosome

synapsis

centromere

meiosis.

In

meiosis

homologous

exchange

of

separation

centromere

II,

place

of

splitting)

46

the

following

events

occur:

chromosomes

segments

into

I,

of

homologous 2

DNA chromosome

daughter

cells,

pairs

each

containing

pairs

does splitting.

not

occur,

nor

does

crossing

over.

Disjunction

does

CHAPTER

Type

B

Spermatogonia

(46,

2n)

(Diploid)

Oogonia

Meiosis

I

Primary spermatocyte

DNA

(46,

Primary

replication

4n)

oocyte

Synapsis

Crossover

Cell

division

Alignment Centromeres

and

disjunction do

not

split

Secondary spermatocyte (23,

2n)

Cell

division

Secondary oocyte Meiosis

II

Alignment

and

disjunction Centromeres

Gamete

split

(23, (Haploid)

Figure

I 1 Figure

2. I 1 2.

Meiosis Meiosis

1n)

1

|

GONAD

DEVELOPMENT

PART

Anatomy

I

|

EARLY

EMBRYOLOGY

AND

HISTOLOGY:

EPITHELIA

Immunology Spermatogenesis At

week

4,

dormant Pharmacology

Biochemistry

•

Pathology

Medical Genetics

a

cells

boy

reaches

Some

•

Type

•

Primary

•

Secondary

•

Spermatids

arrive

puberty,

spermatogonia,

•

BehavioralScience/Social Sciences

germ

in

the

indifferent

gonad

and

remain

puberty.

When A

Physiology

primordial until

type B

primordial

which A

serve

spermatogonia enter

spermatocytes spermatocytes

2

cells

I to

in

the

meiosis

B

type

life.

spermatogonia.

primary

II

to

form

which

mature

adult

type

form

into

spermatocytes.

spermatocytes.

spermiogenesis,

resulting

differentiate

throughout

secondary

enter

cells

into

meiosis

form

undergo

stem

differentiate

spermatogonia

changes

as

germ

is

2

a

spermatids.

series

of

morphological

spermatozoa.

Oogenesis Microbiology

At

week

into

4,

primordial

oogonia.

oocytes

are

prophase

formed

Primary

•

When

a

girl

polar

The

secondary

At

month

5

reaches

in I to

of

fetal

meiosis

in

puberty, and

the

indifferent

gonad

form

primary

oocytes.

life;

I and

arrested

they

remain

present

each

monthly

meiosis

I to

during

the

until

I are

at

primary

first

time

in

puberty.

birth. cycle

form

differentiate

All

arrested

arrested

meiosis

completes

are

and

a

primary

a secondary

oocyte oocyte

body.

II

oocyte and

is

fertilization

meiosis

arrive

meiosis

unarrested

and

meiosis

cells

enter

of

oocytes

becomes

•

by

(diplotene)

•

•

germ

Oogonia

II

becomes

within to

form

arrested

the

second

time

in

metaphase

ovulated. the

a mature

uterine oocyte

tube, and

the polar

secondary body.

oocyte

completes

of

First

LEARNING

Weeks

of

2#

Development

OBJECTIVES

❏

Solve

❏

Demonstrate

❏

Solve

EARLY

8

problems

concerning

beginning

understanding

problems

of

concerning

of

the

development

formation

embryonic

of

the

bilaminar

embryo

period

EMBRYOLOGY

Week

1:

Beginning

Fertilization

of

occurs

pronuclei

fuse

completes

to

in form

meiosis

Development

the

ampulla

of

a zygote.

At

the

uterine

tube

fertilization,

the

when

secondary

the

male

oocyte

and

female

rapidly

II.

C l

e

a a v

ti o

m

: g e

Day 2

cell

s

s

2

Day

Blastula

4

cell

3

Embryoblast

(forms

embryo)

Blastula

Day

4

Trophoblast

(forms

placenta)

Morula Day (46,

2N)

5

Zygote Blastocyst

Day

1

Fertilization

Day

6

(Implantation begins)

Ovary

Zona

Corona

pellucida

radiata

Cytotrophoblast cells

of Secondary in

metaphase

oocyte of

Blastocyst

Ampulla

cavity

Embryoblast

oviduct

arrested meiosis

Syncytiotrophoblast

II

Figure

I 2 1. Figure

Week I 2

1 1.

Week

1

7

PART

Anatomy

I

|

EARLY

EMBRYOLOGY

AND

HISTOLOGY:

EPITHELIA

Immunology Prior

to

•

fertilization,

spermatozoa

Capacitation

consists

membrane Pharmacology

7

Biochemistry •

Physiology

of

hours

in

of

the

prevents

other

the

female

2 changes

removal

acrosome

of

of

the

are

zona

several

the

female

genital

proteins It

from

occurs

tract:

the

over

plasma

about

tract.

released

from

pellucida.

This

spermatozoa

in

spermatozoa.

reproductive

enzymes

penetrate

the

acrosome

results

in

penetrating

a

the

used

cortical

zona

by

the

sperm

reaction

to

that

pellucida

thus

preventing

polyspermy.

Medical Genetics

the

first

(cleavage)

in

4–5 the

blastomeres.

days

oviduct

This

becomes

forms

as

of

week

1,

to

form

a blastula,

the

the

zygote

undergoes

rapid

consisting

morula

(32

cell

of

mitotic

division

increasingly

smaller

stage).

BehavioralScience/Social Sciences A

blastocyst

inner

cell

mass

At

the

of

week

1,

Pregnancy

Tubal

the

(most

the

transport.

Risk

factors

pelvic include

pain

(may

LMP

60

be days

showing

CLINICAL

CORRELATE

usually

include and or

confused

with

ago),

Abdominal

begins.

of

surgery,

when

uterine

tube

blastocyst

outer

cell

to

consists

of

an

known

as

the

mass

in

delayed disease,

(DES.) sudden

Clinical

onset

menstrual

of

abdominal

period

gonadotropin

positive

the

of

inflammatory

missed

and

blastocyst

because

bleeding,

chorionic

occurs

the

cytotrophoblast

diethylstilbestrol

appendicitis),

and

the

pelvic

uterine

human

usually

occurs

exposure brisk

blood,

form

the

endometriosis,

positive

The

into

implantation

ampulla

abnormal

the

differentiates

then

intraperitoneal

morula.

placenta.

form

within

the

and

trophoblast

common)

implants

in

embryoblast, the

and

Ectopic

signs

the

becomes

syncytiotrophoblast

tubular

develops

as

which

end

fluid

known

trophoblast,

Microbiology

the

the

Hydrolytic

During

Pathology

undergo

test,

(e.g., culdocentesis

sonogram.

rectouterine

pouch

(pouch

of

Douglas).

For

implantation

usually

to

implants

blastocyst

implants

endometrium

Week In

2:

week

from

cells fusion

the

of

to

form and

the

primary

hypoblast

the

degenerate.

uterus.

implants of

The

The

within

phase

the

the

blastocyst

embryonic

pole

functional

menstrual

layer

of of

cycle.

Embryo

differentiates The

must of

Bilaminar

disk.

epiblast

wall

blastocyst

the

embryoblast

of

pellucida

progestational

embryonic migrate

zona

posterior

The

the

Formation 2,

the the

first.

during

a bilaminar blast

occur,

within

into epiblast

the

forms yolk

cells,

sac. is

epiblast the

the

The site

and

amniotic

cavity

prechordal of

the

hypoblast,

forming and

plate, future

mouth.

hypo formed

the

CHAPTER

2

|

FIRST

CLINICAL

Hypoblast Bilaminar

8 WEEkS

OF

DEVELOPMENT

CORRELATE

disk

Epiblast

Human

chorionic

glycoprotein

gonadotropin

produced

by

(hCG),

a

the

Endometrial blood

syncytiotrophoblast,

vessel

Lacuna

spaces

stimulates

production

by

the

be

assayed

in

maternal

the

basis

for

detectable

corpus

early

progesterone

luteum. blood

pregnancy

throughout

hCG or

can

urine

and

testing.

hCG

pregnancy.

Endometrial gland

•

Low

hCG

abortion

may or

predict

ectopic

a spontaneous pregnancy.

Syncytiotrophoblast Prechordal plate

•

Implantation

•

hCG

•

High

hCG

may

predict

pregnancy,

hydatidiform

gestational

trophoblastic

a

multiple mole,

Chorionic cavity

Connecting

Yolk

stalk

sac

Amniotic

cavity

Primary

villi

Chorion

Extraembryonic

mesoderm

Cytotrophoblast

Figure I 3I 21. 2. Week Week

Figure

Extraembryonic

mesoderm

somatic

mesoderm

covers

The of

the

amnion.

connecting the

mesoderm,

The

with

weeks)

endometrial

bone

marrow.

in

fetal

vessels

the

stalk,

covers

the

the

chorionic of

and

yolk

sac.

cavity.

The

extraembryonic

wall

somatic

syncytiotrophoblast.

growth

into

and

glands. is

spleen,

connecting

mesoderm

within

the

Extraembryonic the

consisting

its

in liver,

epiblast.

forms

chorion,

cytotrophoblast

initially the

the

conceptus

and

blood The

later

the

continues

occurs and

the

cytotrophoblast,

syncytiotrophoblast.

Hematopoiesis

from

visceral

is called

syncytiotrophoblast

contact

derived

cytotrophoblast,

suspends

cavity the

the

Extraembryonic

stalk

chorionic

is

lines

2 2

mesoderm thymus

the

endometrium

No

mitosis

mitotically

occurs

make in

the

active.

surrounding (6

to

weeks

the to

third

yolk

sac

trimester),

(up

to and

6

disease.

or

is is

PART

Anatomy

I

|

EARLY

EMBRYOLOGY

AND

HISTOLOGY:

EPITHELIA

Immunology Weeks All

3–8: major

period, Pharmacology

Biochemistry

Physiology

Medical Genetics

organ the

systems

Embryonic systems

embryo

start

Period

to

begin

to

to

look

Week

3

begins develop.

develop

during

human,

the

and

corresponds

the to

weeks

3–8.

nervous

the

By

and

first

missed

Dorsal

the

end

of

this

cardiovascular menstrual

period.

View

Cranial

Prechordal Pathology

plate

BehavioralScience/Social Sciences Primitive

node

Primitive

pit

Primitive

streak

B Microbiology

Cloacal

membrane

Caudal A

Sectional

View

Cranial

Primitive

node

&

streak

Epiblast (ectoderm)

Amnion

Notochord Yolk

sac

Hypoblast

Mesoderm Endoderm B

Figure

During

this

3 primary It

1

begins

time germ

with

Figure I 4 I 21. 3. Week Week

gastrulation layers

the

also

are

Ectoderm

forms

•

Mesoderm

forms

mesoderm,

and

takes

produced:

formation

•

3 3

of

the

primitive

neuroectoderm paraxial lateral

place;

this

ectoderm,

streak

and mesoderm

mesoderm.

is

the

process

mesoderm, within

neural (35

and

crest pairs

the

by

which

endoderm. epiblast.

cells. of

somites),

intermediate

the

CHAPTER

CLINICAL

Sacrococcygeal

teratoma:

streak;

various

contains

Chordoma:

a tumor

intracranially

or

Hydatidiform trophoblast

•

In

by

the

•

typical

Molar malignant

the

arises

dilated

villi

ovum

of

there

and

reduplicates

karyotype

pregnancies trophoblastic

that tissue

from

is

paternal

have

from nerve,

remnants

of

no

partial

or

embryo; so

and is

arises (bone,

the

origin.

chromosomes

FIRST

8 WEEkS

OF

DEVELOPMENT

remnants hair,

the

of

the

primitive

etc.)

notochord,

found

either

region

mole,

of

|

CORRELATE

from

sacral

results

chromosomes maternal

that

in

mole:

a complete

blighted

a tumor types

2

In

usually

complete

a

that

haploid

the

karyotype

a partial

mole,

2

sets

replacement

of

sperm

fertilizes

is 46,XX, there

paternal

of

is

the

a with

a

all

haploid

chromosomes

set so

of that

69,XXY.

high disease,

levels

of

including

hCG,

and

20%

develop

into

a

choriocarcinoma.

1

PART

I

|

EARLY

EMBRYOLOGY

Anatomy

AND

HISTOLOGY:

EPITHELIA

Immunology Table

I 2

1.

Germ

Layer

Derivatives

Ectoderm

Surface

ectoderm

Pharmacology

Mesoderm

Endoderm

Muscle

Forms

epithelial

Epidermis

Smooth

Hair

Cardiac

Nails

Skeletal

GI

Inner

ear,

tract:

foregut,

external

ear Medical Genetics

midgut,

Lower

respiratory

of

Connective

Lens

of

teeth

All

eye

and

Anterior

pituitary

(Rathke’s

Pathology Parotid Anal

Blood,

BehavioralScience/Social Sciences

organs

gland canal

below

pectinate

line

membranes

and

pouch)

lymph,

Adrenal

cortex

Gonads

and

internal

Kidney

and

Pineal

gland

ureter

system Dura

Retina

and

optic

lower

and

middle

mater

nerve Notochord

Auditory

tube

•

Palatine

tonsils

•

Parathyroid

•

Thymus

glands

parenchyma

•

Liver

•

Pancreas

•

Submandibular

of:

and

sublingual

glands Nucleus

pulposus •

Neurohypophysis

Follicles

of

Parafollicular

Astrocytes

thyroid (C)

gland

cells

Oligodendrocytes Neural

crest

Adrenal

ectoderm medulla

Ganglia Sensory:

pseudounipolar

neurons Autonomic:

postganglionic

neurons Pigment

cells

Schwann

cells

Meninges Pia

and

Pharyngeal

arachnoid arch

mater cartilage

Odontoblasts Aorticopulmonary Endocardial

septum cushions

Extra Yolk

embryonic sac

vessels

1

structures

derivatives:

Primordial Early

vagina

pouches:

•

Forms

Spleen

urinary

and

reproductive

tube nervous

urethra,

Pharyngeal cardiovascular

organs

Central

system:

bladder,

cartilage

Neuroectoderm Neural

larynx, lung

tissue

serous

Bone

and

system:

bronchi,

Genitourinary Enamel

Microbiology

of:

hindgut

trachea, Physiology

lining

Biochemistry

germ blood

cells

cells and

blood

ear

Histology:

LEARNING

OBJECTIVES

❏

Demonstrate

❏

Use

❏

Interpret

❏

Explain

information

❏

Answer

questions

Histology organs,

Each

understanding

knowledge

of

study

organ

on

consists

of

cell

normal organ

4

cells

elements

to

about

form

epithelial

cytoskeletal

related

of

organs

of

epithelium

scenarios

is the

form

3#

Epithelia

types

cell

adhesion

surface

specializations

tissues.

Groups

systems,

and

of

tissue:

molecules

of

cells

make

systems

epithelial,

up

make

up

tissues, the

connective,

NOTE

tissues

organism.

nervous,

Only

certain

reviewed

and

appear

muscular.

aspects here;

elsewhere

of

other in

epithelia

aspects this

will of

be

histology

book.

EPITHELIUM Epithelial

cells

apical is

surface

often

by

junctions

Many

simple

epithelia

•

•

Tight

and

Paracellular

transported

in

mechanisms

used

permits

keep

of

pathway,

basolateral

to

that

other

(kidney

transports:

and pass

a combination

through

between

apical

and

nutrients,

these

because and

the

molecules

movement

polarity

regions. polarity

transport

ions

the

epithelia.

side

for

of

The 2

Membrane of

larger

case

these

cell.

one

epithelia

paracellular

and

the

function

surfaces.

separate

functions

from

the

and

basolateral that

which in

that

the

material

the

intestinal

through

pumping

regulate

of

junctions

transport

2 basic

pathway

junctions

the

sugars;

pathway

diffusion

composition,

substances

and are

those

tight

transport

There

structure,

symmetrically for

salts

Transcellular of

situated

epithelia

etc.).

of

essential

transport

antibodies,

from

presence are

are

the

differ

the

organelles

tight

polarized:

membrane

established

Internal

of

are

the

cell

cells

they

prevent

membrane

backflow components

separate.

Epithelial polarity bronchi, to

lumen

polarity is

is

disrupted,

intestine, via

pumps

essential

to

disease

can

and

pancreatic in

the

basolateral

the

proper

functioning

develop. ducts

For transport surface

of

example, chloride and

channels

epithelial

epithelia

cells; lining

from in

basolateral the

apical

when the

trachea, surface

surface.

1

PART

Anatomy

I

|

EARLY

EMBRYOLOGY

AND

HISTOLOGY:

EPITHELIA

Immunology The of

transport the

apical the Pharmacology

provides

epithelium. Cl

channels

mucous

cells detected

open.

Na

across,

Failure

the

may

by

basolateral

lose

using

surfaces.

eventually

by

producing

and

of

electrical

water

water

follows.

transport

polarization

In

cystic

results

in

fibrosis

the

thickening

of

epithelia.

their

Loss

become

polarized

antibodies

useful

organization,

against

of

polarity

in

as

an

index

early

and

proteins the

distribution of

this

specific

for of

change either

can the

membrane

be

apical

or

proteins

may

neuroplasticity.

Medical Genetics Epithelia

BehavioralScience/Social Sciences

are

vessels.

Since

oxygen

and

Epithelia

always

the into

solutes

from

Epithelia

renew

linings),

at

continuously in

the

Epithelial

basal

side

by

connective

interstitial

compartments

absorb

one

side

each

the

barrier

tissue

tissue

fluids

they

containing

provide

to

means

daughter

the

blood

epithelia

with

very

rapidly

the

differentiate.

(e.g.,

renal

cells

may

selectively

(skin

tissue

resulting

or

epithelial

may

trans

other.

that cells

cells

The and

some

This

dividing

separate.

compartment,

continuously, rate. The

of

that

from of

a slower

pool

and

contains

from

intestinal

stem

each

cell

cells

that

division

either

Subtypes

epithelial

subtypes

•

Simple

cuboidal

•

Simple

columnar

•

Simple

are

the

Stratified

as

epithelium

of

the

squamous

Pseudostratified

•

Transitional

•

Stratified

salivary

gland

acini)

intestine)

endothelium,

glomerular

mesothelium,

epithelium

capsule)

nonkeratinized

(e.g.,

esophagus)

and

skin) columnar

epithelium

epithelium

(e.g.,

(urothelium)

cuboidal

CYTOSkELETAL

tubules,

small

(e.g., renal

epithelium:

(e.g.,

•

(e.g.,

epithelium

inside

keratinizing

follows:

epithelium

squamous

lining •

2

or

proliferate.

remain

the

avascular,

themselves

some

The

on are

nutrients.

secrete

port

lined

epithelia

modify

either

Microbiology

not

covering

for

moves

Biochemistry

easily

Pathology

force

NaCl

do

layer

Transformed

Physiology

a driving

Thus

epithelium

trachea,

(e.g., (e.g.,

ureter

salivary

epididymis) and

gland

bladder)

ducts)

ELEMENTS

Microfilaments Microfilaments G

actin

is ATP

are that

barbed site

1

of

to The

ongoing end

proteins.

polymerize

dependent.

constantly

actin

(the

depolymerization.

F

form

is Tread

are

disassembly.

the

site

milling

composed

of

filaments

filaments and

end)

are

helical

actin

assembly “plus”

They

of

of 7

nm F

F

actin.

actin

balance

that

a distinct and the

the activity

of

polymerization

filaments

has

in

monomers

Actin

diameter

polymerization is the

globular

are

polarity. pointed at

the

The end

is

2

ends.

the

CHAPTER

In

conjunction

forces for

with

of

cells

myosin,

including

cytokinesis

during

membranes

at

actin

the mitosis

tight

microfilaments

formation

of

and

junctions

a

provide contractile

meiosis.

and

at

Actin

the

contractile

ring

that

filaments

zonula

to

form

HISTOLOGY:

EPITHELIA

a basis

linked

and

|

motile

provides

are

adherens,

and

3

cell

the

core

of

microvilli.

Intermediate

Filaments

Intermediate

filaments

formed.

These

•

CLINICAL

Type

are

filaments

I:

10

nm

diameter

provide

keratins

(keratins

filaments

structural

stability

are

in

found

that to

all

are

cells.

usually

There

epithelial

stable are

4

once

types:

When

Type

II:

intermediate

filaments

•

Type

III:

intermediate

•

Type

IV:

3

comprising

filaments

a

of

cells)

forming

diverse

malignant

epithelium,

the •

CORRELATE

the

expression

filaments

of

inside

lamins

the

forming

nuclear

meshwork

envelope

of

all

first of

step

to

invade

results

cadherins,

an

from

which

a

loss

weakens

group

neurofilaments

a

begin

epithelium.

in

neurons CLINICAL

types

cells

rather

than

CORRELATE

individual Changes

cells

evident

in in

cirrhotic

intermediate neurons

liver

filaments in Alzheimer’s

are and

disease.

Microtubules Microtubules

consist

undergo

of

continuous

lular

transport

of

particularly

nm

diameter and

vesicles

important

molecules;

25

assembly and in

dynein

tubes.

Such

Transport

retrograde

Like

They

molecules.

axons.

drives

hollow

disassembly.

transport

in

specific

and

microtubules

“tracks”

exists

requires

transport

actin,

provide

for all

ATPase

kinesin

intracel

cells

but

is

drives

are

motility

to

found

these

in

true

structures.

cilia

and

flagella,

Microtubules

and

form

the

utilize

dynein

mitotic

to

spindle

neutrophil

migration

vincristine

are

during

because

ADHESION adhesion

another

to

molecules

on

with

•

are

components the

cells

Cadherin

surface of

surface

adjacent

The

in

to

gout.

prevent

used

in

Vinblastine

cancer

and

therapy

they

inhibit

the

formation

of

the

spindle.

MOLECULES molecules

or

is used

mitosis

mitotic

CELL

and

microtubule

convey

meiosis.

tion

prevents

polymerization

Microtubules

Cell

CORRELATE

Colchicine

anterograde

transport.

and

CLINICAL

motor

and

of or

that

extracellular

a given the

cell

are

portion

allow

matrix. may

cells

The

change

extracellular

selectin

extracellular

molecules

the

to

adhere

expression

with

time,

to of

altering

one

adhesion its

interac

matrix.

calcium binds

ion to

dependent

a cadherin

adhesion dimer

on

molecules. another

cell

(trans

binding). –

Cytoplasmic

portions

filaments •

by

Integrins

are

membrane tin

and

laminin,

Cytoplasmic

–

Integrins interactions

of

catenin

calcium

surface

–

the

are

complex

of

independent molecules

which

a portion between

of

integrins of

leukocytes

bind

cytoplasmic

actin

They

domains

that

extracellular to

hemidesmosomes and

to

molecules.

extracellular

components of

linked

proteins

adhesion with

are

portions form

cadherins

basement

actin but

endothelial

bind

are to

trans fibronec

membrane.

filaments are

also

important

in

cells

1

PART

I

|

EARLY

EMBRYOLOGY

Anatomy

AND

HISTOLOGY:

EPITHELIA

Immunology CELL

SURFACE

Cell Pharmacology

Biochemistry

CLINICAL Pemphigus

• Physiology

Vulgaris

Autoantibodies proteins

•

against in

Painful

skin

•

Postinflammatory

•

Treatment:

cell

must

(blisters)

whether

ment

membrane

and

of

skin

that

rupture

easily

3

form

membrane

against

basement

blistering

•

Less

than

proteins

These

proteins

with

direct

virtually

collagen, and

cells

transport

other,

and

include

all

which

[e.g.,

laminin],

(composed

seal

of

boundaries

communication

anchoring,

base

epithelia,

lamina

each

environ The

glycoproteins

reticular

to

external

between

between

tight,

and

gap

cells.

junctions.

bind

pemphigus

affects

oral

or

drug older

the

mucosa

induced patient

(e.g., on

end

junctions

span

between

actin

as

a series or

are the

of

barriers

punctate

luminal

surface

occludens

(ZO

adjacent

cell

to

diffusion

contacts

of

of

and adjacent

epithelial

1,2,3)

and

membranes

cells.

The

claudin and

major

proteins.

their

cytoplasmic

microfilaments.

adherens

forms

a

cell

below

belt

membranes. parts

the

around

Like of

tight

the

entire

the

cadherins

junction

tight are

of

apicolateral

circumference

epithelium.

junctions

Cadherins

of

immediately

associated

with

span

the

above

actin

them,

between the

cyto

filaments.

middle multiple

Desmosomes

the corticosteroids

apical

tight

immediately

provide

medications)

the

function

form

vulgaris

plasmic be

to

occludens) They

pruritus

cell,

(macula a

cell

adherens)

structural

and

membranes

intermediate

in

and

2

underlying

lamina.

The

basal of

fibronectin

that

cell

basal

of

are

lamina.

reticular

and

the

integrins, membrane

by

Internally,

like Below

of

thus

and

basement

to

like

of

with

basal

basal

to

lamina

a desmosome,

and

layer

in

the

The

membrane

of the

composed

binds

turn

bind

is

the

integrins

on

collagen

in

are

reticular

pre

and

hemidesmosomes

lamina

of

to

to

a cell

reticular

proteoglycans,

Fibronectin

laminin

basal

between

anchored

membrane.

the

laminin,

cells.

and

the

basement

extracellular

epithelial

therefore

to These

matrix

embryogenesis,

have

and

Gap

junctions

tion

between

extracellular

components

fibronectin

membrane.

extracellular

(cAMP).

the

the

felt

fibronectin

filaments.

binding

and

as

to consists

associated

are

the

linked

lamina,

to

composed

fibers.

Through

such

a thin

collagen

secreted

membrane,

intermediate

is

IV

that

span

tonofilaments.

components,

lamina

type

cells

structure

Desmosomes

Cadherins

desmosomes

called

epithelial a

junctions.

cells.

internally

bundles

extracellular

dominantly

the

is

anchoring

between

and

large

adhere membrane

as

link

desmosomes

filaments

basement

function

mechanical

of

Hemidesmosomes

1

IV

anchor

complex

near of

Zonula severe

Treatment:

type

its

membrane.

underlying

sulfate]),

for

(zonula

cells

parts Widespread

•

polarity.

components

hemidesmosomal

•

aged

cell

junctions

determine

Autoantibodies

Can

of

with

basement

Junctions

epithelial

•

(made heparin

channels junctional

molecules or

structure

junctions

of

surface matrix

like

lamina

Cell

cell

corticosteroids

Pemphigoid

Rarely

sheet

[e.g.,

types

via

extracellular

BehavioralScience/Social Sciences hyperpigmentation

Microbiology

•

the

is a basal

and

The

Tight

•

interact be

fibers).

Cell

Bullous

it

proteoglycans

cells,

in

physically

ment,

reticular

bullae and

Adhesion

consists

desmosomal Medical Genetics

cells

flaccid

oropharynx Pathology

A

CORRELATE

SPECIALIZATIONS

cell

and the

calcium The

cytoplasm and

transcellular

small

the

extracellular between

implications invasion

for by

adjacent

molecules channels

that

to

attached

cell

permeability,

to

the

outside

cytoplasm cell

and

motility

basement the the

during

neoplasms.

function cells

such

is

components the

malignant

junctions) of

hemidesmosomes

cell

matrix

interactions

(communicating the

of

laminin,

by

in

cell

providing

as

cyclic

make

up

a

adenosine a gap

junction

cell

communica

passageway

to

for

monophosphate consist

of

ions

CHAPTER

connexons,

which

connexon gap

are

consists

junctions

hollow

of

are

channels

6 connexin

not

spanning

molecules.

associated

with

the Unlike

any

plasma other

cytoskeletal

membrane.

3

|

HISTOLOGY:

EPITHELIA

Each

intercellular

junctions,

filament.

Apical surface Microvilli

Plasma

Tight

membrane

Actin

microfilaments

junction Intermediate Zonula

filaments

(keratin)

adherens Desmosome Gap Cell

A

Cell

B

Cell

C

Cell

junction

D

Hemidesmosome Basal lamina

Figure

I 3 1.

Junctions

Connexon space Intracellular

2–4

A

cell of

bilayer Lipid

nm

B

cell of

bilayer

spac

Lipid Intracellular

1.5

nm

7

nm

Figure

I 3 2.

Gap

Junction

Microvilli Microvilli

contain

absorptive cells on

a core

surface

of

the

area

small

columnar

and

epithelial

Stereocilia

are

tract

epididymis).

(e.g.,

long,

of of

actin

an

large

microfilaments

epithelial

intestine,

respiratory

branched Short

and

cell. cells

They of

the

are

function

to

found

in

proximal

increase

columnar

tubule

of

the epithelial

the

kidney

and

cells.

microvilli

that

stereocilia

cap

are all

found sensory

in

the

cells

male in

the

reproductive inner

ear.

17

PART

I

|

EARLY

EMBRYOLOGY

Anatomy

AND

HISTOLOGY:

EPITHELIA

Immunology

Glycocalyx

Pharmacology

Microvilli

Biochemistry

Zonula

occludens (tight

Physiology

junction)

Medical Genetics Zonula

adherens

Desmosome

Pathology

BehavioralScience/Social Sciences

Microbiology

Figure

I 3

3. Apical

Cell

Surface/Cell

Junctions

Cilia CLINICAL

CORRELATE Cilia

kartagener absence

of

flagellar

motility.

dynein It

spermatozoa

associated

with

respiratory

of

is that

immotile

because

1

syndrome

is

is

epithelium.

by an

required

and

defects

infertility.

in

beat

by

cilia

infections of

on

cells It is

respiratory

contain

9 peripheral

microtubules

for

characterized

chronic

similar

caused

tail

to of

convey the propel sperm

cell

surface overlying

cells.

pairs motility of

of to

microtubules

cilia

pseudostratified

mucous.

They

and

through

the ciliated

also

form

2

central

ATPase

microtubules. dynein.

columnar the

core

Cilia

respiratory of

the

flagella,

The bend

and

epithelial the

motile

PART

GROSS

ANATOM

II

Back

and

LEARNING

Autonomic

Nervous

System

1#

OBJECTIVES

❏

Solve

❏

Demonstrate

❏

Use

knowledge

of

spinal

❏

Use

knowledge

of

autonomic

problems

concerning

vertebral

understanding

VERTEBRAL

of

column

spinal

meninges

nerves

nervous

system

COLUMN

Embryology During

week

surround of

the

one

4,

the

sclerotome

spinal

cells

cord

sclerotomes,

the

sclerotome

and

and

of

vertebrae

the

the

somites

notochord. are

cephalic

After formed,

part

of

(mesoderm)

migrate

proliferation

of

each

the

consisting

the

of

medially caudal

the

to portion

caudal

part

of

next.

Vertebrae The

vertebral

column

functions

in

is

muscle

the

central

attachments,

component

of

movements,

the

and

axial

skeleton

articulations

which of

the

head

and

trunk.

•

The of

vertebrae the

body

provide to

the

a flexible lower

support

limbs

and

system

also

that

provides

transfers

the

protection

for

the

weight spinal

cord. •

The 12

vertebral thoracic,

intervertebral

5

column

is

lumbar,

and

disks,

synovial

composed the

fused articulations

of

32–33

5

sacral,

vertebrae and

(7 3–4

(zygapophyseal

cervical,

coccygeal), joints)

and

ligaments.

2

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Pharmacology

Biochemistry

~33 ~33

Physiology

31 31

vertebrae vertebrae spinal spinal

nerves nerves

Anterior

Pathology

Atlas Axis

(C1)

Medical Genetics

view

Lateral

view

Posterior

view

BehavioralScience/Social Sciences Cervical

Cervical

(C2)

vertebrae

curvature

(7) C7

C7

T1

T1

Microbiology

Intervertebral Thoracic

disk Thoracic

vertebrae

curvature

(12)

Inter vertebral foramen

T12

T12

L1

L1

Lumbar vertebrae

(5)

Lumbar curvature L5

L5

Interlaminar space

Sacrum (S1–5)

Sacrum

(5)

Sacral Sacral

curvature

(caudal

Coccyx

Coccyx

Figure Figure

2

II 1 1. Vertebral II 1 1. Vertebral

Column

Column

hiatus block)

CHAPTER

A

typical

vertebra

consisting

of

(foramen) form

nerves.

and

that

dorsal

an

anterior

body

2 laminae.

houses

the

intervertebral

The

provide

of

pedicles

canal

pedicles

es

consists

2

The

spinal

cord.

foramina

projecting

attachment

sites

for

and

vertebral encloses

the

exit

projecting

|

BACk

AND

AUTONOMIC

NERVOUS

SYSTEM

arch

the

notches for

lateral

and

Spinous

arch

provide

the

muscles

a posterior

Vertebral

that

spines

and

vertebral

1

vertebral

of

adjacent

of

the

spinal

transverse

process

ligaments.

process

Lamina Pedicle Transverse

process

Vertebral

Pedicle

Body

foramen

Inferior vertebral

Body

process

Facet AB

on

superior

articular

Superior

process

inferior

Figure Figure

Intervertebral The

Spinous

notch

II 1

II 1

2.

2.

Typical

column.

They

provide

limited

Vertebra

Vertebra

disks form

contribute

the

to

cartilaginous

movements

about

joints

between

25%

individual

intervertebral

disk

is

numbered

by

•

Each

intervertebral

disk

is

composed

of

lage bodies

fibrosus and

fibrous and

pulposus

functions

as The

of

connective

provide

Nucleus

column.

consists

a

nucleus

an

the

inner

The

pulposus

vertebral

the

vertebral

bodies

and

above

the

disk.

following:

annuli

elastic, external

is the

of

body

rings connect

between

soft, for

the

concentric

movement

absorber

length

vertebral

the

outer

tissue.

limited is

shock

the

the

vertebrae.

Each

Annulus

of

between

the

•

–

processes

disks

intervertebral

–

Typical

and

articular

postnatal

the

compressible forces

of

fibrocarti

the

adjacent

individual

vertebrae.

material placed

remnant

on of

the the

that vertebral notochord.

2

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Intervertebral

disk Intervertebral

foramen

Ventral Biochemistry

Pharmacology

Pedicle Anterior

longitudinal

Physiology

ligament

Medical Genetics Zygapophyseal Annulus

Nucleus

fibrosus

pulposus

Pathology

joint

L4

BehavioralScience/Social Sciences

Posterolateral

Posterior

herniation

ligament

Spinal

nerve

longitudinal Posterior

Microbiology

longitudinal

ligament Dorsal Anterior

longitudinal

ligament

A.

Intervertebral

Disk

B.

Figure

CLINICAL

The

commonly

of in

a

a

Intervertebral II 1 3. Intervertebral

Intervertebral

CORRELATE

herniation

II 1 3. Figure

nucleus

pulposus

posterolateral

is most

direction

due

The

Foramen

Disks Disks

ligaments

vertebral

which

Intervertebral

bodies

are

firmly

are

strongly

attached

to

supported the

by

2

intervertebral

longitudinal

disks

ligaments,

and

to

the

both

bodies

of

of

the

vertebrae. to

the

longitudinal

strength

and ligament

position (Figure

of

the

II 1 3

posterior A).

•

Anterior

longitudinal

connects

the

cervical and •

and is

the

vertebral

positioned

2

is

bodies

prevents

located This

band of

the

of

fibers

that

vertebrae

hyperextension

“whiplash”

between of

the

the

vertebrae

accidents.

ligament and

column.

connects in

the

the

posterior

vertebral

ligament

causes

surfaces

canal. the

It

of

limits

herniation

the

flexion of

a

disk

of to

foramen

intervertebral

provide

in

It

a broad

the

posterolaterally.

Intervertebral The

involved

bodies

of

regions.

longitudinal

vertebral

forms

surfaces

sacral

often

Posterior

ligament

anterior

for

•

Anterior:

•

Posterior:

•

Superior

foramina the

passage

bodies

are of

of

zygapophyseal and

inferior:

the

the

formed spinal

by

successive

nerve.

vertebrae

joint pedicles

The

and

and of

intervertebral boundaries

intervertebral

articular the

vertebrae

notches

of

the

disks

processes

foramina

and are:

be

CHAPTER

Herniated The

nucleus

pulposus pulposus

involved

spinal

may may

BACk

AND

AUTONOMIC

NERVOUS

SYSTEM

The

occurs

(C5/C6 herniated

number

or disk

below

compress

the

nerve

through the

the

spinal

annulus

nerve

fibrosus.

roots,

resulting

in

The

herniated

pain

along

the

(sciatica).

usually

cervical

herniate

compress

nerve

Herniation

•

|

Disk

nucleus

•

1

C6/C7)

lumbar

the

the of

or

spinal

nerve

herniation

the

L5/S1)

or

lower

column.

the

(e.g.,

herniation

(L4/L5

vertebral

compress disk

or

lower of

usually

involved roots,

the

parts

will

the L5

in

C7

of

disk

will

roots the

one

L4

disk

compress

will the

C8

roots).

4th Nucleus

lumbar

spinal

nerve

pulposus

L4

Herniation L4

of

nucleus

into

Compresses

the

roots

pulposus

vertebral

spinal

canal

of

5th

lumbar

nerve

L5

S1

Figure

SPINAL

The vertebral

II

II 1 4. 1 Figure 4. Herniated

Herniated Intervertebral Intervertebral

Disk Disk

MENINGES

spinal

cord canal:

is

protected

the

dura

and mater,

covered arachnoid,

by

3 connective and

pia

tissue

layers

within

the

mater.

2

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Epidural

space

Vertebral Pia

Pharmacology

Biochemistry

Arachnoid Dura

mater root

spinal Physiology

Medical Genetics

Epidural

mater

Ventral

body

mater fat

Subarachnoid space

of

nerve

Spinal nerve

Pathology

BehavioralScience/Social Sciences

Intervertebral foramen Dorsal

root

spinal

of

Denticulate

nerve

ligament

Microbiology Internal

Figure II

Figure

Dura

vertebral

5. Cross 1 II5. 1 Cross

venous

Section Section

plexus

of Vertebral of VertebralCanal

Canal

Mater

The

dura

dural

•

mater

is

sac

which

envelops

The

dura

tough,

cylindrical the

mater

vertebra •

a

and

covering

entire

spinal

dural

sac

mater

continues

of

cord

connective

and

terminate

tissue

cauda

forming

a

equina.

inferiorly

at

the

second

sacral

level.

Superiorly,

the

continuous

dura

with

the

meningeal

through layer

of

the

the

foramen

cranial

magnum

and

is

dura.

Arachnoid The the

arachnoid dura

sacral

is

mater

a

delicate

and

membrane

dural

sac.

It

which

continues

completely inferiorly

lines and

the

inner

terminates

surface

at

the

of

second

vertebra.

Pia

Mater

The

pia

mater

delicate

is tightly

covering

•

The

of

spinal

cord,

vertebral •

There

the

levels are

attached

to

the

surface

of

the

spinal

cord

and

provides

a

cord.

with in

its the

covering

of

pia

mater,

terminates

at

the

L1

or

L2

adult.

2 specializations

of

the

pia

mater

that

are

attached

to

the

spinal

cord: –

2

The

denticulate

run

continuously

separate

the

the

mater.

dura

ligaments on ventral

the and

are

bilateral

thickenings

lateral

sides

of

the

midpoint

dorsal

roots

of

the

spinal

of

pia of

nerves

mater

the and

that

cord. anchor

They to

CHAPTER

–

The

filum

lower equina

the

are

of

the

vertebral

with

and

of

The

filum

composed

of

ventral

and

extend

below

the

inferior

to

the

vertebral

meninges. canal

plexus.

The

and The

the

in

the

space

is a

mater is

distal part of

of

the

space

mater.

plexus

It

the

is

the

foramen

BACk

subarachnoid

located

between

fat

and

pia

mater

cord

layers.

and

sacral

vertebral

There

are

of

spinal

the

the

dural

It

spinal

contains

nerve

cerebrospinal

roots

within

located

length

magnum

fluid the

dural

between

CLINICAL

of

to

(CSF),

sac,

and

the

which

bathes

terminates

at

SYSTEM

The

the

internal

the

vertebral

valveless

connect

arachnoid

the

CORRELATE

the

pelvis,

space

NERVOUS

and

cavity.

pressurized

AUTONOMIC

cord.

and

of

venous

connects

abdomen,

route The

AND

cauda

lumbar

entire

|

the

the

spinal

contains

runs

to

of

roots

limit

epidural

through

cranial

pia

dorsal

dura

venous

superiorly

sinuses

the

terminale

is

continues

venous

continuation

cord.

that

venous

space dural

a

spinal

related

walls

epidural

is

the

nerves

2 spaces

inner

internal

of which

sacral There

terminale

end

1

with

and

metastasis

plexus

thorax. of

veins

is of

the

It provides

cancer

cells

to

a the

and vertebral

spinal

column

and

the

cranial

cavity.

second

level.

2 important

sac

vertebral

cord

in

and

the

adults

levels. (conus

The

L1

or

medullaris).

subarachnoid

space

L2

vertebrae

S2

vertebra

is the is

(cerebrospinal

the

inferior

limit

inferior

limit

of

fluid).

Epidural

anesthesia

Lumbar

puncture

Thoracic vertebrae

Pia

mater

Skin

Lamina

Fascia

vertebra

L2

Epidural Lumbar

Conus

vertebrae

space

medullaris

Subarachnoid

End

space

containing

vertebra

S2

Ligamentum

flavum

of

dural

sac

Arachnoid

CSF S1S2S3S4S5

Dura

Sacrum

mater

Epidural

L1

SPINAL

There

L5

Filum

B

1

6.

Important

Figure

II 1

each

segment

Sacrum

6.

Vertebral

Important

Vertebral

terminale

(Pia

mater)

Levels Levels

NERVES

are

cervical, the

L4

Coccyx

A

II

L3

space

Coccyx

Figure

L2

cranial

31 12

pairs

of

thoracic, nerves

spinal 5

form

nerves

lumbar, part

attached 5

of

the

sacral, peripheral

to and

1 coccygeal. nervous

of The

the

spinal

spinal nerves

cord:

8

with

system.

2

PART

II

|

GROSS

Anatomy

ANATOMY

Immunology

Dorsal

ramus Supplies:

(mixed) Arachnoid

•

Pharmacology White Gray

matter

• Pia

matter

back neck

Deep

intrinsic

muscles

and

back

(Erector

spinae)

root

(sensory)

Medical Genetics

of

dorsal

mater Dorsal

Physiology

Skin

Biochemistry Dura mater

Dorsal

root

ganglion

Pathology

BehavioralScience/Social Sciences

Ventral

root

(motor)

Spinal

nerve

(mixed)

Supplies:

Microbiology

Ventral

ramus

•

Skin

(mixed)

of

trunk •

anterolateral and

limbs

Skeletal

muscles

of

anterolateral Sympathetic

trunk

and

limbs

ganglion

Figure

II

1

7.

Cross

Section Figure

II 1of 7. Spinal Cross

Cord Section

Parts

Each

spinal

•

nerve

Dorsal

of

fibers

carries

that

of

bodies

of

horns

the

Spinal

nerve

it

the

exits

in

arises

axons

in

is

the

ventral the

vertebral

by

into

there

is

a

cell

the

dorsal

dorsal

root

bodies

of

the

nerve

root

from

gray

periphery

root

pseudounipolar

aspect

of

spinal

ventral

cord

the

dorsal

dorsal

the

formed

from

each

the

from

spinal

Nerve

components:

the

neurons

the

of

on

containing

motor

Spinal

following

fibers

cord;

found

root

axons

the

sensory

spinal

are

of and

Nerve

by

(sensory)

Ventral

of and Spinal Parts Cord

Spinal

formed

the

ganglion

•

is

root

aspect

•

of

cord

root

are

the to

spinal the

located

cord

and

periphery; in

the

carries the

ventral

cell

or

lateral

matter

the

union

column

by

of

the

passing

ventral

through

and the

dorsal

roots;

intervertebral

foramen •

Dorsal

rami

innervate

zygapophyseal •

Ventral the form

2

rami skeletal the

the

joints,

and

innervate muscles

brachial

the of

and

skin

of

intrinsic

the

skin

the

dorsal

skeletal of

the

anterolateral

anterolateral

lumbosacral

surface muscles

trunk plexuses)

of of

the the

trunk and

limbs

back, deep and

(ventral

neck, back limbs, rami

and

CHAPTER

The

spinal

nerves

vertebrae. the

pedicles

the

inferior

beginning of

Lumbar

same

T1

the

vertebral nerves

to

with

pedicle

the

cervical

of

foramen

A

exit

The

C7

and

This

will

numbered

exit

a

the

specific

The is

the

relationship

intervertebral

vertebrae.

pedicle.

below

by

exit

numbered

the

same

column C1–C7

the

to

foramina

C8

nerve

exits

transition

intervertebral

BACk

AND

AUTONOMIC

NERVOUS

SYSTEM

to

intervertebral

All

foramina

|

the

superior the

point.

1

nerves inferior

to

the

vertebrae.

Puncture

lumbar

puncture

withdraw

CSF

•

A

spinal

•

A

horizontal

L4 •

tap

a

through

•

The

the

is

to

inject

anesthetic

subarachnoid

typically

line

drawn

material

in

the

epidural

space

or

to

space.

performed at

the

top

at

the

L4

L5

of

the

iliac

interspace. crest

marks

the

level

of

the

vertebra.

When

the

is used from

lumbar the

laminae

puncture

is

interlaminar of

interlaminar

the

performed

space lumbar

spaces

of

in the

the

midline,

vertebral

the

column

needle found

passes between

vertebrae. are

covered

by

the

highly

elastic

ligamenta

flava.

CLINICAL During

a lumbar

passed

through

the

vertebral

passes

Lumbar

Interlaminar (covered ligamentum

spaces

vertebrae

CORRELATE puncture, the column

through

the

a needle

interlaminar is

flexed.

following

•

Skin

•

Superficial

•

Deep

•

Supraspinous

•

Interspinous

ligament

•

Interlaminar

space

•

Epidural

•

Dura

•

Arachnoid

•

Subarachnoid

is space

The

while

needle

layers:

fascia

by flavum)

Sacrum

Coccyx

Figure Figure

II 1 II 1

8. Interlaminar 8. Interlaminar

Spaces

fascia

ligament

space

Spaces

space

2

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology AUTONOMIC

The

autonomic

smooth Pharmacology

NERVOUS

muscle,

functionally,

Biochemistry

nervous

and

is

Preganglionic

•

Postganglionic

Central

BehavioralScience/Social Sciences

both

have

nervous

2

their

have system

the

cell (PNS)

body.

neurons

motor

innervation

Anatomically

form

an

cell

axons

exit

bodies

in

(formed

Motor

the

of

and

sympathetic

neuronal

their

nervous

system

of

with

divisions:

divisions,

neurons

concerned

glands

motor

neuroectoderm);

peripheral

Pathology

2

neurons by

is

and of

In

(formed Medical Genetics

(ANS)

muscle,

composed

parasympathetic.

•

Physiology

system

cardiac it

SYSTEM

autonomic

bodies

in

in

cranial

the

and

autonomic by

pathway.

CNS

spinal

nerves.

ganglia

neural

crest

in

the

cells)

ganglion

(CNS) Preganglionic

Postganglionic

nerve

fiber

nerve

fiber Target

Microbiology

Figure

Sympathetic The

Nervous

preganglionic

lateral

horn

The

II

Origin

Spinal

1 1.

Sympathetic

of

Chain

•

Collateral

=

levels

of

ganglia

or

Nervous Nervous

System System

of

bodies in

the

the

spinal

sympathetic

cord

segments

the

sympathetic

of

nervous T1–L2

system (14

system

or

prevertebral

(found

only

in

abdomen

of

Synapse

Sympathetic

(Postganglionic)

are

found

or

chain

ganglia

Smooth

ganglia)

muscle,

muscle

and wall

Prevertebral (e.g.,

ganglia celiac,

superior

L1–L2

splanchnic

nerves

(e.g.,

(collateral)

mesenteric

ganglia inferior ganglia)

mesenteric

ganglia)

of

limbs

head

(T1–2)

viscera

Smooth glands

aorticorenal,

Prevertebral

pelvic

3

of

cardiac glands

and

thoracic

Lumbar

one

(Target)

(T1–L2),

nerves

in

pelvis)

Innervation

body

splanchnic

in

Outflow

Site

T5–T12

found

PNS:

(paravertebral

Thoracic

are

muscle of

the

and

Smooth glands

and foregut

viscera

muscle of and

the

and

(T1–5)

midgut

(collateral)

the

segments).

paravertebral

Thoracolumbar

T1–L2

bodies

matter

cell

motor

•

(Preganglionic)

cord

cell gray

9. Autonomic II 1 9. Autonomic

System

postganglionic

types

Table

II 1 Figure

and pelvic hindgut

and

2

CHAPTER

1

(sweat

glands,

superior

V

dilator

tarsal

AND

AUTONOMIC

NERVOUS

SYSTEM

pupillae

m.,

m.) m:

VI Internal

VIII

BACk

Head

III IV

VII

|

IX

carotid

External

a.

carotid

a:

muscle artery

a.

X X

XI

(Periarterial

carotid

nerve

plexus)

C1 Superior

cervical

ganglion

Lesions

at

ipsilateral Middle

cervical

ganglion

Cervicothoracic

T1

Heart, bronchi,

miosis,

Horner

syndrome

and

in (ptosis,

anhydrosis).

trachea, lungs

(thorax) muscle

and

glands

the

of

foregut

and

midgut

*

*Gray

Thoracic

*

result

ganglion

Smooth

*

arrows

Prevertebral

Splanchnic

ganglion

ganglia

nerves

rami

sympathetic

carry

postganglionic

axons to the

from

spinal

the

sympathetic

nerve.

(T5–T12)

Lumbar splanchnic Smooth

L1

L2

nerves

(L1

L2)

muscle

and

glands

the

hindgut

and

pelvic

of

viscera

Prevertebral ganglia

Sympathetic chain Preganglionic Postganglionic

Figure

II

1 Figure 10.

II 1 10. Overview

Overview of

of Sympathetic Sympathetic

Outflow Outflow

3

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology Preganglionic Postganglionic

Pharmacology

Biochemistry

Physiology

Medical Genetics

Lateral

horn

(T1

)

–L2

Dorsal

Pathology

BehavioralScience/Social Sciences

ramus

Ventral

To

ramus

smooth

muscles Spinal

and

glands

nerve

of

wall White Gray

and

body limbs

ramus

ramus

Microbiology communicans–preganglionics communicans–postganglionics (to

body

wall) Sympathetic

Figure Figure

II

1

11.

II 1

Cross

(14)

(31)

11.

Cross

Section

Section

of

of Spinal

Spinal

Parasympathetic

Cord

Cord

Nervous

chain

Showing

ganglion

Sympathetic

Showing

Outflow

Sympathetic

Outflow

System

NOTE The White that

rami all

enter

ganglia. point

are

of

preganglionic the

They

may

entry

or

above

or

below

ramus

does

sympathetic synapse go

up

point

not

sympathetics

or of

synapse,

trunk with

the

and

entry.

If a

•

at

lumbar

and

becomes

splanchnic

2

•

a

thoracic

or

nerve.

II

1 2.

X,

Spinal

of

(Preganglionic)

Cranial

nerves

Cranial

cord

brain

gray

terminal

the

stem

in

or

in

nerve

the

=

cell ganglia

wall

of

in the

parasympathetic

nervous

Pelvic

associated

with

cranial

nerves

sacral

segments

S2

3,

and

4

are

III,

(pelvic

found

VII,

IX,

splanchnics)

VII,

X

IX

4

splanchnic 3,

4

of

Synapse

cranial

of that

the

parasympathetic are

usually

nervous located

ganglia of

viscera)

of

viscera)

Terminal walls

(Postganglionic)

near

system the

Innervation

ganglia

Terminal

nerves

PNS

are

organ

found

innervated

Outflow

Site

III,

bodies the

ganglia

(in

or

near

the

and

muscle

of

the

Viscera

of

the

foregut,

(in

or

near

the

(Target)

Glands

Hindgut

smooth

and

and

viscera

(including

bladder,

rectum,

erectile

3

system

organ.

Craniosacral

walls

2,

of

or

postganglionic

in

Parasympathetic

Origin

S

bodies

places:

through

of

Table

of

matter

and

white

it passes a root

cell one

Gray

synapse

The ganglion

in

of

ganglion

down

preganglionic CNS

tissue)

head

neck,

thorax,

midgut

pelvic the and

in

CHAPTER

Parasympathetic

Nervous

1

|

BACk

AND

AUTONOMIC

NERVOUS

SYSTEM

System

Ciliary ganglion Pupillary

sphincter

Ciliary

III Submandibular

m.

Midbrain

ganglion Submandibular

gland

Sublingual

V Pterygopalatine

gland

Head Lacrimal

Pons

VII

ganglion gland

Nasal

and

mucosal

oral

IX

glands

Parotid

Medulla

X Otic

gland ganglion

Viscera thorax

of and

(foregut

C1

the Terminal

abdomen and

ganglia

midgut)

T1

Preganglionic Postganglionic

L1

Terminal Hindgut

and

(including tissue,

pelvic the

and

ganglia

viscera

bladder,

erectile

rectum) S2 S3 S4

Pelvic splanchnics

Figure

Figure II 1

II 12. 1

12. Overview Overview

ofof Parasympathetic Parasympathetic

Outflow

Outflow

3

2#

Thorax

LEARNING

OBJECTIVES

❏

Solve

❏

Use

knowledge

of

embryology

❏

Use

knowledge

of

pleura

❏

Interpret

❏

Use

❏

Answer

❏

Solve

❏

Interpret

❏

Solve

CHEST

problems

concerning

scenarios

knowledge

the

of

of

and

on

problems

problems

histology

alveolar

heart

sacs,

of

the

on

system

cavity

embryology

concerning

scenarios

respiratory

pleural

ducts,

about

wall

lower

respiratory

alveolar

questions

chest

the

and

the

alveoli

heart

mediastinum

histology

concerning

the

diaphragm

CLINICAL

WALL

Breast The

breast

pectoral

(mammary region.

It

tion

and

secretion

and

duct

system

•

gland)

Cooper

is

There

is

an

A

are

skin

for

the

run

of shape

in

fat

surrounds

and

size

ligaments

from

the

organ

specialized

amount

suspensory

and

glandular

gland,

variable

is responsible

ligaments the

subcutaneous

sweat

milk.

and

to

a

a modified

of

gland

is

to

the

the

women

the

female

attach deep

the

the

presence

can

distort

extensive

prominent

blood

blood

supply

supplies

to

the

Internal vian

thoracic artery

Lateral utes chest nerve,

thoracic to

the wall,

blood the

superficial

(internal

supplies

mammary

mammary

tissues.

mammary),

medial

aspect

artery,

a branch

of

supply

to

part

lateral

thoracic to

the

skin

the

breast

which

(orange

results

peel

CLINICAL

CORRELATE

fascia. The

2

a

radical

thoracic

a branch of

the

of

the

subcla

mastectomy,

nerve

lesioned

the

(serratus

serratus

lateral artery anterior

the

anterior

long muscle)

may

courses muscle

the

artery gland; with

ligation

of

the

lateral

artery.

gland

axillary of

during

thoracic

A few –

of

within

ligaments,

are:

artery

which

tumor

tissue

be –

a

breast.

During •

of Cooper

appearance).

produc

glandular

The

in dimpling

superficial

for the

of

that

skin

of

CORRELATE

which lateral

the

long

weeks

after

surgery,

the

patient

may

contrib aspect thoracic

of

the

present

with

in abduction thoracodorsal dorsi

muscle

mastectomy, and

medial

a

winged of the

scapula arm

nerve may resulting rotation

above

supplying also

be

weakness

90°. the

The latissimus

damaged

in weakness of the

and

during in

extension

arm.

3

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology •

The in 2

lymphatic of

primary

– Pharmacology

drainage

metastasis

the

cancer.

breast The

is

critical

due

lymphatic

to

its

drainage

important

of

the

role

breast

follows

routes:

Laterally,

most

of

the

lymphatic

flow

(75%)

drains

from

of

breast

the

nipple

and

Biochemistry the

superior,

nodes, –

Medical Genetics

Pathology

BehavioralScience/Social Sciences

From

the

and

to

medial

the

route

inferior

the that

quadrants

pectoral most internal

cancer

the

to

the

axillary

group.

quadrant,

accompany

medial

Subclavian

lateral,

initially

which Physiology

lymph thoracic

can

spread

to

drains

to

the

vessels.

It

is

the

parasternal also

opposite

nodes,

through

this

breast.

nodes

(Parasternal) internal

of

breast

Interpectoral

nodes

Sagittal

thoracic

nodes

Axillary

View

of

Breast

nodes

Microbiology Subcutaneous

fat

Suspensory ligaments Brachial

(Cooper)

nodes Gland

Subscapular

nodes

Pectoral

Figure

II

2

1.

nodes

Breast

Figure

II 2 1.

EMBRYOLOGY During

OF

week

and

4

lungs)

of

epithelium

to

respiratory

•

The

diverticulum

•

The segments

as

a

from

from

The

lower single

the

tertiary

and

(main,

the

respiratory

sinus

system

the

(trachea,

bronchi,

(laryngotracheal)

wall

while

enlarges lung

a series

segmental of

Lactiferous

of

the

foregut.

muscles,

The

connective

respiratory tissues,

and

mesoderm.

undergo tree

duct

SYSTEM

respiratory ventral

endoderm

diverticulum

then

bronchial

RESPIRATORY the

develop

from

•

which

LOWER

endoderm

develop

Lactiferous

Breast

development,

develops

cartilages

3

of

begins

diverticulum

lobules

lungs.

secondary, bronchi

bud of

distally

then

bifurcate

divisions and are

to

to

into form

tertiary related

form the the

bronchi) to

the

the

lung

2

bronchial

major by

part month

bronchopulmonary

bud. buds, of

the 6.

CHAPTER

•

To

separate

geal •

A

the

septum critical

the

Type

factant can

initial

forms

communication to

separate

time

in

lung

I and

II

pneumocytes

production survive

is are

possible.

intensive

foregut,

esophagus

development

are

with

with the

the

and

The

fetuses

amount

of

THORAX

trachea.

weeks. gas

|

tracheoesopha

the

25–28th

present

Premature

care.

the

from

2

By

exchange born

this

time,

and

sur

during

surfactant

this

time

production

is

critical.

Tracheoesophageal

septum

Foregut

Esophagus

Respiratory diverticulum

Trachea Lung

bud

Esophagus

Bronchial buds

Figure Figure

A

tracheoesophageal

and is

IIII 2 2 2. 2.

fistula

esophagus

caused

generally

•

Development Development

by

associated

Esophageal

is

abnormal

a malformation

with

atresia

an

of the

the

and

ofLower the

Lower Respiratory

communication of

the

Respiratory System

System

between

tracheoesophageal

the

trachea

septum.

It

following:

polyhydramnios

(increased

volume

of

amniotic

fluid) •

Regurgitation

•

Gagging

•

Abdominal

•

Reflux

of and

fistula

is

and

distal

third

cyanosis distention

of

The

milk

gastric

most

the

feeding

after

crying

contents

commonly of

after

into

(90%

lungs

of

cases)

causing

located

pneumonitis

between

the

esophagus

trachea.

3

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL

CORRELATE

Pulmonary

hypoplasia

development

occurs

is stunted.

congenital Pharmacology

when

This

lung

condition

causes:

Trachea has

2

Biochemistry Tracheoesophageal

•

Congenital

diaphragmatic

fistula

hernia Esophagus

(a

herniation

into

the

of thorax,

abdominal which

Physiology development

of

contents affects

the

left

Medical Genetics lung) Bronchi

•

Bilateral

renal

agenesis

oligohydramnios, pressure

Pathology

(this

which

on

fetal

causes

increases

thorax and Potter’s BehavioralScience/Social Sciences

sequence

[one

sequence

is bilateral

feature

of

Potter’s

Gastric

acids

pulmonary

hypoplasia])

Figure

II Figure 2 3.

Tracheoesophageal II 2 3. Tracheoesophageal

Fistula Fistula

(Most(MostCommon Common Type)

Type)

Microbiology

ADULT

THORACIC

The

thoracic

ally

by

the

cavity

the

bony

thoracic inlet

with

called

diaphragm

The

thoracic

of

intercostal

instruments space

space

neurovascular

to

through is done

avoid

the

structures

in

the the

•

lower

part

intercostal (as

intercostal

nerve

block

is

are

thoracic

base

of

the

neck.

outlet.)

divided

(Note,

into

from

2

lateral

and

a

most

bounded

posteriorly

clinically

outlet

abdominal

this

is

the

of

closed

region by

lungs

called the

the is

the

cavity.

compartment viscera

by

through

that

compartments:

the

anterolater

and

communicates

thoracic

the

central

of

is

spaces)

however, the

thoracic

and

cavity

Inferiorly,

the

contains

a

•

in

The

11

spaces

fasciae

during

done

There

and costal

portion

of

the

intercostal

intercostal

spaces

are

filled

in

are

bounded

groove

aspect

of

the

and

their

the

thorax.

nerve,

artery,

by

is

located

along

the

and

which

are

thoracic

intercostal

and

space)

vein

the

of

superiorly

intercostal and

within

3 layers

wall

(Figure

muscles

inferiorly

by

inferior

the

border

provides

of

in

the

each for

groove.

4A).

related ribs.

rib the

The

2

their

adjacent

protection

located

II

and

(upper

intercostal

vein

is

most

the superior

and

the

nerve

is

inferior

in

the

groove

(VAN).

space. •

The

intercostal

internal from

and

arteries

thoracic branches

provide

3

the

section

intercostal

Spaces

The

thoracentesis).

upper

Superiorly,

membranes,

which

Intercostal

An

is

cross

and

separates

serous

on ribs,

CORRELATE

Passage

the

shaped

(sternum,

thoracic

cavity of

mediastinum

of

kidney

the

the which

covering

CLINICAL

is

thorax

vertebrae.

thoracic usually

CAVITY

a the

of potential

thoracic

are

artery the

(branch thoracic

collateral aorta.

contributed of aorta. circulation

to the

anteriorly

subclavian Thus,

the between

from artery)

intercostal the

branches and arteries

subclavian

of

posteriorly can artery

the

CHAPTER

First

rib

2

|

THORAX

Sternum

Clavicle Second

Anterior

Posterior

rib

mediastinum

mediastinum Scapula

Rib

Middle

2 Manubrium

of

mediastinum

sternum Esophagus Rib

Sternal

6

(of

Rib

angle

Left Right

T12

8

lung

Louis)

Body

of

lung

sternum

Thoracic

Descending

vertebra

aorta

Costochondral junction

A.

Thoracic

Wall

B.

Figure Figure

PLEURA

AND

Within

the

thoracic

membranes and

PLEURAL

and

which

abdominal

a

viscera

for

there

the

are

lungs

3

serous

(pleura),

mesodermal heart

of

these

by

(peritoneum).

the

viscera

The

outer

double

layered

against

adjacent

distress

a deficiency

permits

friction

reducing

movements

the

inner

the

visceral

of

layer

(pleural

mothers,

is The

membranes

applied 2

directly

layers

between

is referred

are

the

to

the

visceral

the

of

and

and

as

surface

continuous

parietal

to

the

there

is

layers

parietal

layer;

organ

and

Surfactant

space

containing

a

thin

layer

of

ments

of

attaches

the to

innermost and

the

inner

visceral

is firmly

pleura

are

The

thoracic

parietal

attached continuous

pleura

mediastinum

•

Costal and

•

(Figure

parietal intercostal

Diaphragmatic

membrane cavity

(Figure

surfaces layer

that

of reflects

to

and

at

the

2

pleura

the

5).

the

named

the The

wall,

the the

of

2

chest

follows

is regionally II

II

from

root

invests

lungs

in

external

contours

at the

the

lung.

cortisol of

treatment

surfactant.

lines

mediastinum. hilum

may

disease, inhalations Hyaline

to

whereby damage

membrane histologically

(atelectasis)

lead

and

hyaline

repeated the

alveolar

disease by

is collapsed

eosinophilic

(pink)

compart

pleura

and

layer of

lateral

parietal

diaphragm,

parietal

the

and

deficiency

membrane

alveoli serous

diabetic

intrauterine

production

characterized

Pleura the

associated of

is called

a potential

lining.

is

is

infants

prolonged

Thyroxine the

gasping

pleura

caused II

condition

infants,

and

increase

fluid.

The

is (type

of

structures.

serous

which layer.

cavity)

serous

the

syndrome surfactant

This

premature

asphyxia. layer

of

pneumocytes).

membranes

cavity

CORRELATE

Respiratory

derived

(pericardium),

with Each

thoracic

CLINICAL

cavities

covering

section)

Cavity

CAVITY

abdominal

form

II 2 4. Thoracic 4. Thoracic Cavity

II 2

(Transverse

of

Visceral

and

fluid

covering

the

alveoli.

The the

lungs

and

parietal

lung.

by

its

relationship

to

the

thoracic

surfaces

of

wall

and

5):

is

lateral

and

lines

the

inner

the

ribs

spaces parietal

pleura

lines

the

thoracic

surface

of

the

dia

phragm

3

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology •

Mediastinal

parietal

mediastinal pleura • Pharmacology

at

the

Cervical

is

reflects

medial

and

and

becomes

extends

into

lines

the

mediastinum.

continuous

with

The

the

visceral

first

rib

hilum.

parietal

pleura

the

neck

above

the

where

it

Biochemistry covers

CLINICAL

The of

the

parietal

pleural

produces

of

the

lung.

visceral

irritation Pathology

pain

of

nerves;

produces

phrenic

nerve

tightly

invests

the

surface

of

the

lungs,

following

all

of

the

and

lobes

of

the

lung.

has

extensive

pain upon Medical Genetics inflammation produces

Costal

intercostal

pleura

sharp

dermatome

the

apex

layers fissures

(pleurisy) Physiology respiration. local

the

CORRELATE

Inflammation

the

chest

whereby

wall

via

mediastinal

The

referred pain via the BehavioralScience/Social Sciences

to

the

shoulder

Innervation

of

parietal

closely

Pleura

pleura

related

to

different

somatic

aspects

of

sensory

the

innervation

provided

by

nerves

portions

of

the

pleura.

dermatomes •

of

pleura

pleura

The

intercostal

nerves

supply

the

costal

and

peripheral

C3–5. diaphragmatic •

Microbiology CLINICAL

Open

nerve

and

the

supplies

the

mediastinal

central

portion

of

the

diaphragmatic

pleura.

CORRELATE

pleural

wound

phrenic

pleura

pneumothorax

the

The

pleura.

cavity

of

through

occurs

the

the

when

following

a

cavity.

Air

during

inspiration

chest wound

air

The

enters

visceral

pleura

autonomic

penetrating moves

is

supplied

by

visceral

sensory

nerves

that

course

with

the

nerves.

freely and Cervical

pleura

expiration.

•

During

inspiration,

wall

and

the

toward

enters

mediastinum

other

opposite

air

side

the will

and

chest

shift

compress

the

Hilum

Costal

lung.

pleura

Lung Parietal

•

During and

expiration, the

air

exits

mediastinum

toward

the

the

moves

affected

wound

pleura

Mediastinal

back

pleura

Visceral

pleura

side. Pleural

Tension of

pneumothorax

tissue

covers

occurs

and

forms

when

a flap

cavity

a piece

over

the

Diaphragm

8th

wound.

rib Diaphragmatic

•

•

During

inspiration,

cavity,

which

air

results

in

mediastinum

toward

compressing

the

During

expiration,

prevents

the

wound, and is

which the

shift

enhanced.

enters

Costodiaphragmatic

the

10th

return threatening.

lung

of

escaping

increases

the the

tissue

Figure

to

the

heart

and

can

side the

The the

pleural

cavity

pleura.

It

of of

the the

Pleura Pleura

is

is a

the

the

closed

potential space

opposing

space which

parietal

between

contains

and

the

parietal

and

amount

of

a small

visceral

visceral

layers

serous

fluid

layers.

venous be

life

The

introduction

resulting

in

respiration. pleural

40

5. Layers II 2 5. Layers

pressure

reduces and

II 2 Figure

the

opposite

severely

function

rib

side,

lubricates opposite

pleur

recess

lung.

piece

from

chest

of

other

opposite

toward This

shift

the

the air

a

the

of

The cavity

air

into

a pneumothorax lung during

the

pleural which

collapses a pneumothorax.

due

cavity causes

to

the

may

cause

shortness loss

of

the of

the

breath

negative

lung

to

collapse,

and

painful

pressure

of

the

that

of

CHAPTER

Pleural

Reflections

Pleural

reflections

direction

•

from

The

one

sternal

the

the to

line

of

mediastinal

2–4).

pleural

where other,

reflection

the

is

the

passes

abruptly

extent

the

to

then

pleura

the

where

posterior

margin

parietal

outlining

of

costal

sternum inferiorly

pleural

is

(from

costal

the

THORAX

changes

the

pleura

to

|

cavities.

continuous

with

cartilages

level

of

the

sixth

the

inferior

cartilage.

Around

the

limit

of

and

visceral

in

areas the

pleura

The

costal •

are wall

2

the

chest

wall,

parietal

there

pleural pleura:

midaxillary

between line,

(paravertebral

are

2

rib

reflections

line),

and

interspaces

from ribs

6–8

in

ribs

10–12

separating

the

inferior

the

midclavicular

at

the

border

of

the

line,

vertebral

lungs ribs

8–10

column

respectively.

Costomediastinal recesses Midclavicular

line

Rib

Rib

Pleural

recesses

deep

line

8

Rib

8

Rib

10

10

Costodiaphragmatic

Costodiaphragmatic

recesses

recesses

recesses

View

Posterior

Figure II 2 6. Figure II 2 6. Pleural

Recesses

Midaxillary

line

Costodiaphragmatic

Anterior

Pleural

Paravertebral

Pleural Reflections

View

Reflections and Recesses

Lateral

and

View

Recesses

NOTE are

potential

spaces

not

occupied

by

spaces

below

lung

tissue

except

during

inspiration.

•

Costodiaphragmatic lungs

•

The

recesses

where

costal

and

costomediastinal

nal

parietal

left

lung.

inspiration.

diaphragmatic recess

pleura This

space

meet, is

are

leaving occupied

is

pleura a space a

space

by

the

where caused lingula

the are

inferior

in

the by

of

Visceral

Parietal

Pleura

Pleura

the

contact.

left

of

borders

the the

costal

and

cardiac left

lung

Midclavicular

mediasti notch

of

the

Midaxillary

line

line

6th

rib

8th

rib

8th

rib

10th

rib

12th

rib

during Paravertebral

line

10th

rib

4

PART

II

|

GROSS

Anatomy

ANATOMY

Immunology LUNGS

The

lungs

and

thoracic Pharmacology

Biochemistry

cavity.

of

Each

• Pathology

BehavioralScience/Social Sciences •

the

the

lung

root

of

located

from is

on

the

in

each the

lung:

the

lateral

other

in

medial the

compartment

the

midline

surface

and

pulmonary

of by

the

serves

vessels,

the

for

primary

lymphatics.

Regions

has

3

surfaces:

The

costal

and

tissues

The

surface

mediastinal

of

is

the

and

lung

smooth

chest

and

the

a deep

and

convex

and

is

related

laterally

to

the

ribs

wall.

surface

mediastinum the

are

separated

of

in and

and lung

are

hilum

structures

nerves,

Surfaces

membranes

lungs

The

bronchi,

Medical Genetics

pleural

The

mediastinum. passage

Physiology

the

is

concave

heart.

and

The

cardiac

is

related

mediastinal

medially

surfaces

impression,

more

to

contain

pronounced

the

middle

the

root

on

the

of

left

lung. Microbiology •

The

diaphragmatic

surface

of

presence

CLINICAL

A tumor tumor)

surface

the of

(base)

diaphragm. the

It

is

is

more

concave

and

superior

on

rests the

on

the

right

superior

owing

to

the

liver.

CORRELATE

at may

the

apex

result

of in

the

thoracic

lung

Apex

(Pancoast outlet

syndrome.

Hilum

Costal

surface

Lung

Mediastinal surface

Diaphragm

8th

rib Diaphragmatic

Costodiaphragmatic

recess

surfac 10th

Figure

The

apex

level

of

Lobes right

fissures, superior

42

first

and

The

the

(cupola) the

inferior

of rib

the

and

II 2 Figure

lung

7. Surfaces II 2 7. Surfaces

projects

is crossed

of the Lung of the Lung

superiorly

anteriorly

rib

into by

the

the

root

of

subclavian

the

artery

neck and

above

the

vein.

Fissures lung

the

is divided

horizontal

from

the lobe.

into and

middle

3

lobes

(superior,

oblique lobe

and

fissures. the

oblique

middle, The

inferior)

horizontal

fissure

separates

separated

fissure the

separates middle

by the from

2

CHAPTER

The

left

lung

fissure.

is

The

divided

lingula

into of

the

2 lobes upper

(superior, lobe

of

inferior)

the

left

separated

lung

by

corresponds

an

to

oblique

the

CLINICAL

of

the

right

The

superior

oblique

fissure

5th

intercostal

the

6th

The

of

both

space

costal

of

the

the

chest

right

lung

projects

in

lungs

the

projects

anteriorly

midclavicular

line,

at ending

approximately

the

medially

deep

to

rib

on

and

the

below

fissure

5th

middle

the

4th

wall

lobe

above

the

projects

4th

anteriorly

rib.

cartilage.

horizontal

right

lobe

lung.

A small •

THORAX

CORRELATE

anteriorly •

|

middle The

lobe

2

runs

intercostal

horizontally

space

to

the

from

right

4th

the

oblique

costal

fissure

in

portion

of

the

inferior

lobe

of

both

the lungs

cartilage.

projects

but

primarily

below

the

6th

projects

to

the

rib

anteriorly

posterior

chest

wall.

CLINICAL •

CORRELATE

To

listen

to

superior lungs, the

the

Horizontal

sounds of

the

area

(above

the

4th

the

and

is of

the

of

right

stethoscope

superior

wall Trachea

breath

lobes

left

placed

on

anterior

rib

for

chest

the

right

lung).

fissure •

Right

lung

Left

For

breath

lobe

of

sounds the

lobe

Middle

lobe

Oblique

fissure

Inferior

Superior

lobe

Oblique

fissure

Inferior

chest

lobe

•

For

sounds

enter

II 2 Lobes 8. Lobes 8.

and and

Fissures Fissures

of

system

vessels,

and

nodes

organs.

The

lymph

vessels, 10A).

subclavian

of

both

primarily

and

lungs, heard

on

wall.

a

right wider,

primary

bronchus.

vertical,

the

foreign

body

primary and

more

bronchus,

more When

foreign

will

body

which

vertical the

often

than

individual

usually

falls

is

the

left

is into

Lungs of Lungs posterior

basal

segment

of

the

right

lobe.

System

lymphatic

2

of

the

inferior

II

lobes

rib

CORRELATE

shorter,

the

phatic

sternum.

chest

anterior

4th

Mediastinum Aspiration

The

the

the

the

are

posterior

CLINICAL

Figure II 2

to

inferior

breath

Figure

middle

the on

inferior toward

the

the

Lymphatic

is placed

wall

medially

lobe

Diaphragm

the

lung,

lung stethoscope

Superior

from

right

consists

that flow

the

right

These

2

veins

on

vessels their

of

drain will

an

extensive

extracellular return

drain respective

fluid to

lymphatic

the

duct into

network

the

from

blood and junction

of most

venous the

of system

thoracic of

lymph

the

duct internal

capillaries,

the

body by on

2

tissues major

the jugular

and lym

left

(Figure and

the

sides.

4

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology •

The

thoracic

duct

diaphragm (Figure • Pharmacology

carries

and II

The

right

and

the

2

on

all

the

left

of

drainage the

trunk

from and

the

head

Medical Genetics

the

diaphragm

lymphatic

duct

The

lymphatic

and

deep

of

drainage lymphatic

pleura.

pulmonary Pathology

side

drains

the

lymph

trunk

flow

above

the

from

the

diaphragm

right

head

(Figure

II

and 2

neck

10B).

Drainage

visceral

of

the

lungs

plexuses. The

nodes

deep which

The plexus

is

extensive

begins

follow

and

superficial

the

drains

plexus

deeply

in

bronchial

is the

tree

by

way

of

immediately

lungs

and

toward

superficial

deep drains

the

to

the

through

hilum.

BehavioralScience/Social Sciences The

major

•

nodes

involved

receive

plexuses,

Microbiology •

lymph and

they

Tracheobronchial they

•

in

Bronchopulmonary They

drain

the

lymphatic

(hilar)

nodes

drainage

of

lymphatic

the

into

nodes into

the

are

right

and

nodes trachea, duct

and or

the

The

the

thoracic

of

located

both

these

at

superficial

left

at

the

hilum

trunk

duct

the

bifurcation

are

Lung

drainage

left

midline

lung

into

lymphatic

of

located

on into

the

the

the

lungs.

lymphatic

trachea, and

the

either

right the

and

trunk. and

left

right

left.

Left

Lung

the trunk

also

from

the

drains

right and

lower

across

lobe

the

To

right

lymphatic

Trachea

To

the

right

lymphatic metastasis

duct.

bronchomediastinal nodes,

pathway This of

thoracic

duct

then

continues

Bronchomediastinal Tracheobronchial

nodes along

of deep

nodes

superiorly on

are:

nodes.

bronchomediastinal

drain

plexuses

and

tracheobronchial

located

2

CORRELATE

lymphatic the

are

and they

Right CLINICAL

drainage

from

drain

Bronchomediastinal sides

to is

lung

the

important cancer.

right to

nodes consider

Tracheobronchial

Bronchopulmonary

nodes

nodes

Bronchopulmonary nodes

Diaphragm

Figure

4

below

the

10B).

right

Lymphatic

with

body

above

Biochemistry

Physiology

of

lymphatic

side

Figure II

II Lymphatics 2 29. 9. Lymphatics

of

the of

Lungs the

Lungs

duct

CHAPTER

From

head

and

Area

neck

to Left

Right

lymphatic

Thoracic

duct

Area to

|

THORAX

draining thoracic

duct

lymphatic

internal

jugular

draining right

2

duct

vein

duct From From

upper

limb

&

neck

upper

limb

and

Left

neck

subclavian

vein Right

bronchomediastinal

trunk Left

A.

Right

lymphatic

bronchomediastinal

and

thoracic

Figure

RESPIRATORY

The

is

an

organ

that

Approximately

breath.

The

enough

air

keep

times

will

air–blood

to

functions

14

Inspired

lungs.

ducts

B.

2 Figure 10. Lymphatic II

II

General

be

blood

in each

over

has cells

the

intake

minute,

spread

barrier the

lungs

mental

to

be

inside

we 120

thin their

of take

oxygen in

square

meters

enough

for

and

about

air

exhaling 500

of

the

to

pass

CLINICAL

of

mL

of

air

surface across

per

Any

area

of

but

tough

the

CORRELATE

disease

affects

are

insults

in

opened the

to

form

of

the

outside

the

lungs.

lungs

blood

receive

components.

metabolic enzyme

entire The

transformation that

the

converts

cardiac pulmonary of

and

they

are

infectious

angiotensin

output

and

endothelium

lipoproteins

and I to

extensive

Bacteria

capillaries capillary

which

susceptible

to

the

environ

bacteria.

the

also bed

colonize

angiotensin

are

positioned plays

an

to active

prostaglandins. II

capillaries,

modify

of

the

the

role

produced

between

gaining (a

the

lungs

may

access

common

to

alveoli

and

the

complication

of

pneumonia).

various in

the

•

The is

barriers

bloodstream

With

allergies,

smooth

constriction by

the

muscle

reduces

the

diameter

of

lung air

endothelial

affects

capillaries.

world,

pollution

that

bacterial The

drainage

2 Drainage 10.

damage Because

lymphatic

HISTOLOGY

lung

CO2.

trunk

tubes

and

results

in

reduced

air

cells. intake.

•

Lung

cancers

bronchi excessive

commonly

(smoking,

develop

asbestos,

radiation

are

from

and the

main

causes).

•

Mesothelioma the

pleura

is a (causative

malignant agent:

tumor

of

asbestos

dust).

4

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology Paranasal sinuses

Pharmacology

Biochemistry

Frontal sinus Physiology

Medical Genetics

Pathology

Olfactory

Sphenoid

area

sinus

BehavioralScience/Social Sciences

Pharyngeal tonsil

Nasal conchae

Nasopharynx Microbiology

Oropharynx

Larynx

Laryngopharynx

Trachea

Figure

Table

II 2

1.

Histologic

Features

of

Trachea,

Bronchi,

Trachea

Epithelia

ciliated

columnar

Glands

(PCC)

goblet

cells

16–20

C

PCC

cells,

columnar

shaped

Irregular

cartilaginous

rings

Seromucous

glands

Respiratory Respiratory

Pathways Pathways

Bronchioles

Bronchi

Pseudostratified

Cartilage

and

Figure II II2 211.11.

Fewer

Bronchioles

to

simple cells

Ciliated, cells

plates

None

seromucous

None

some in

terminal

goblet

cells,

bronchioles

glands

Smooth

Between

muscle

C shaped

Elastic

4

fibers

Present

open

ends

of

Prominent

cartilage

Highest muscle

Abundant

Abundant

proportion in

the

of bronchial

smooth tree

Clara

CHAPTER

2

|

THORAX

TRACHEA

The

trachea

is

diameter),

shaped

for

hyaline

along The

smooth

muscle

Copyright

length free

of

•

12. 2 II

In

in its

most the

trachea. the

length

(and at

the

structures

human

there

rings

overlap

C

about

bifurcation striking

The of

an

Trachea 12. Trachea

of

mucosa

has

shaped

2

cm

carina

to

of

are

16–20

in

the

cartilages

in

the of

them

anterior are

form

a

trachea

are

the

distrib part

of

the

interconnected

by

permission.Copyright McGraw Hill

with a with

Companies.

Used

a hyaline cartilage cartilage hyaline ring columnar columnar

rings

of

with

permission.

(arrow)ring and (arrow)

epithelium epithelium

mucosa,

submucosa,

an

incomplete

adventitia.

3

components:

loose

cells,

with

concentric

complete

vascularized

immune

Used

pseudostratified pseudostratified

composed

and

ing

rings.

Hill Companies.

II 2 Figure

is

The

to

The

ends

and

trachea

cm

larynx

lung.

the

posterior

McGraw

muscularis,

10

cells.

Figure

The

the

each

cartilage

the

trachea.

about

from

bronchus

uted

tube,

extending

primary C

a hollow

and

a

pseudostratified

connective

a thin

tissue

layer

of

epithelium,

(lamina

smooth

an

propria)

muscle

cells

that

underly

contains

(muscularis

mucosa). •

The

submucosa

Collagen •

The

outside

layers

The which

loose

cells The

ductive

tract.

vascular

lie only

service vessels

of

the

connective

lining

surface.

a

lymphatic

covering

of

epithelial all

is

fibers,

of on other

the

the same place

area and

trachea,

containing nerves

the

are

large also

adventitia,

blood

present is

vessels. in

composed

this of

layer. several

tissue.

trachea

and

basal in

the

bronchi

membrane body

is pseudostratified but

with

this

only epithelium

some

columnar reach

the

is

male

the

in luminal repro

4

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL

CORRELATE

If mucosal

clearance

mechanism

In

cystic

Physiology time

this

the

the

it toward

disease

follow.

secreted

and

respiratory

the

pneumoconiosis Biochemistry

may

the

viscous

moving

with

or

disease)

fibrosis,

or

or

infection

bacteria)

related

thick

ineffective,

overwhelmed,

(pathogenic Pharmacology (dust

is

have

is a difficult

Medical Genetics pharynx. Patients

the

have

mucous

cilia

frequent

infections

of

system.

Pathology

BehavioralScience/Social Sciences

Copyright

McGraw

Hill Companies.

Used

with

permission.Copyright McGraw Hill

Companies.

Used

with

permission.

Microbiology Figure II 2

Figure

II Pseudostratified 13. 2 13.Pseudostratified (arrowhead) (arrowhead)

cells

CLINICAL Patients or

lacking

Kartagener

With

dynein

have

immotile

cilia,

cells

respiratory

patients

are

problems

subject

because

Epithelial

Columnar

cilia

syndrome.

immotile

many

Tracheal

CORRELATE

to

cells contain

cilia

are

the

trachea

cannot

trapped immotile

move bacteria. sperm.

this Males

mucous

layer

also

possess

extend

beat

out

of

Goblet

(arrow) cells

Cells with

goblet

(arrow)

to the

basal

cilia

membrane

per

help

cell

move

the

respiratory

to

that

are

the

luminal

surface.

intermingled

secreted

with

mucous

layer

These

microvilli.

over

the

The lining

of

system.

their with

its

cells

chea.

secrete

Mucous

glands. (dust,

bacteria,

ozone

and

where

it

These

is

and

cells

(Diffuse in

Brush

(Amino

have be

have synapses sensory

cells

Precursor

and

may

are

short

in

receptors.

gases by

the

and

tra mixed

such

bacteria)

as

beating

is known

comparable

as

cilia the

is trapped

intraepithelial

on

K

located

at

cells

formation their

to

been

the

given

in

endocrine

the

that of apical

nerves,

have

goblet

surfaces. suggesting

the

These

cells

points.

secreted or

cells

cells. branch

in

names:

DNES

(Kulchitsky) airway

cells

various

Decarboxylase),

and

goblet the

have

Uptake

often

microvilli with

are

System)

represent

stages

(dust

of

substances

soluble

is moved movement

cells

Endocrine

intermediate They

(PNE)

clusters

cells

material

lumen submucosal

digested.

neuroendocrine

Neuro

occur

This

the the

particulate

water layer

swallowed.

of traps

noxious sticky

Most

is removed

epithelial

APUD

absorbs

into

secretions

system

mucous

system.

and

material by

respiratory

and The

neuroendocrine

gut.

•

mucous

the

viruses)

escalator

Pulmonary

of

dioxide.

pharynx

layer,

•

layer

and sulfur

the

mucous

polysaccharide is supplemented

mucous

mucociliary

the

a

production

The

toward

4

the

apical

and and

by Ciliated Cells by ciliated

Types

from

200–300

motile

Goblet cilia

Cell

Columnar with columnar Epithelium epithelium

Surrounded surrounded

their tall

Some that

products

ciliated of

these

these

or

cells. cells cells

may

CHAPTER

Basal

cells

basal

are

stem

membrane

cells

but

for

do

the

not

ciliated

extend

and

to

the

goblet

cells.

lumen

of

The

the

stem

trachea.

cells These

lie cells,

on

the

CLINICAL

the

epithelial

neuroendocrine

cells,

are

responsible

for

the

of

the

irritation. there

When

lobar

tree the

bronchi—3

subdivided

forms

a

primary for

into

10

branching

bronchi the

right

tertiary

bronchopulmonary

airway enter

lung

or

the and

from lung,

2 for

segmental

the

they the

left.

bronchi

trachea

give The

in

to

rise

each

5

to

the

lobes

are

lung,

bronchi

5 secondary

or

further

which

is

cells

Intensive

BRONCHI bronchial

and

McGraw

Hill Companies.

Figure

epithelial cells,

empty

onto

by

fibers.

trachea

of

or

plates

2 II 14.2

the

basal

DNES,

irregular

the

II Figure

lining

columnar

elastic

wall

K)

also

are

number

of

ducts.

and

simple lial absent

a

become the

taller,

submucosal

from

of

glands.

smoking

metaplasia

where

epithelium

becomes

a squamous

epithelium.

This

CLINICAL

CORRELATE

process

number

leads the

to

a

ciliated

is reversible.

metastatic

cells

with

walls

and

of the

the

does together

or

terminal

not by

columnar

airway

arise

from

cells.

permission.

(arrow)

consists

in

of

muscle

tumors

of

ciliated

submucosa

bronchi

fascicles

submucosa

the

contain bound

glands

together

decreases

from

bronchi.

bronchiole

bound

cuboidal

in

in

irritation

CLINICAL

are

lining

cells

increase

neuroendocrine

glands

The

smooth

goblet

It

cells

seromucous

via

circular

Used

plate of cartilage of Cartilage (arrow)

brush

also

surface

Companies.

pseudostratified.

cells,

There

and

permission.Copyright McGraw Hill

with a Plate a with

is

mucous

epithelial

small

with

bronchi

cells.

cartilage

The the

Used

14.Bronchus Bronchus

cells,

the of

to

of

fascicles

sensitive

form

BRONCHIOLES

The

are

segments.

Copyright

that

ciliated

an

squamous

Kulchitsky

(APUD,

cells

The

and

Bronchial

The

goblet

trachea.

goblet

oles.

CORRELATE

columnar

and

The

THORAX

pseudostratified to

appearance

|

along The

with

2

cartilage fibers.

epithelium

is composed bronchioles)

contain

elastic

rather of and

ciliated an

or

The

glands.

The

epithelium

smooth

muscle

ciliated,

but

is still

than

pseudostratified.

cells

(goblet

and

basal

type

called

the

additional

The cells Clara

Cystic is

a

mucous,

CORRELATE

fibrosis in

can part

result due

to

in

abnormally

defective

thick

chloride

epithe are

transport

by

Clara

cells.

cell.

4

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology Clara

cells

serous toxins,

Biochemistry

cigarette

as

Clara

bronchiolar

they

to a

make

cell

up

about

chloride

the

in

cells

ion

cells)

They

for

increases

Clara

with

secretory

surfactant.

stem

cells

smoke.

involved

aid

ciliated

most

80%

of

to

the

detoxification and

in

epithelial

into

nonciliated

the

for

increased

abundant

transport

are the

cells

response

are

in

and

of

cell

like

bronchioles,

lining;

they

the

terminal

of

The

pollutants

terminal

lumens

a

airborne

themselves.

levels the

secrete of

are

also bronchioles.

Medical Genetics CORRELATE

Chronic

obstructive

(COPD)

affects

emphysema Pathology •

serve

of

where

Physiology CLINICAL

called similar

and

number Pharmacology

(also

solution

pulmonary the

and

Emphysema

disease

bronchioles asthma.

is

elastic

fibers

airflow

obstruction.

and

includes

BehavioralScience/Social Sciences

caused

and

by a

results

loss

of

in chronic

Microbiology •

Asthma

is

characterized of

•

a chronic by

process a

reversible

narrowing

airways.

Asthma

is

reversible;

emphysema

is

not.

Copyright

McGraw

Hill Companies.

Figure Figure II 2 15.II

2Terminal 15.

Used

Terminal bronchiole

containing

The

terminal by

alveoli

in

their

respiratory

walls.

the

enters

last

the

with

5

ducts

The

the

epithelium (asterisk)

are

this

prevents

are

absent

from

movement

the

wall

This

of

of

the

permission.

ciliated epithelium

cells

and

bronchiole interrupted

the

is still

with

(arrows)

periodically

epithelium the

Used

containing with

cells

bronchiole.

which cells

Companies.

epithelial lined

with

mucous

of

the

a sparse

into

airway

by

lining

the

disappears

ciliated

alveoli. and

air

alveoli.

alveolar

epithelium

conducting

bronchiole,

DUCTS,

million

last

goblet

which

respiratory

ALVEOLAR

alveoli.

the

however,

epithelium

After

300

The

lumen with

Hill

Clara cells cells and(arrows)Clara

bronchioles

bronchioles;

cuboidal

The

is

respiratory

permission.Copyright McGraw

lumen bronchiole (asterisk)

ciliated

bronchiole

is followed

with

ALVEOLAR

and

sacs

alveoli

constitute

alveoli

in

of squamous

the

the

little

or

80–85% lungs,

respiratory cells

have

SACS,

of

each

~200

bronchioles lining

the

alveoli.

no

AND

walls

the

volume microns

and

the

and

THE

consist of

in alveolar

the

ALVEOLI

almost normal

diameter. ducts

entirely lung.

There

The

cuboidal

are

continuous

of are

CHAPTER

Alveolar Type

2

|

THORAX

macrophage

I cell

Alveolus

Connective

Alveolar

tissue

macrophage

Surfactant

Type

II

cells

Endothelial

cell

Capillary Red

blood

cell

Alveolus

Type

I cell

Basal

lamina

Endothelial

cell

Capillary

16. Figure Figure II II2 2 16.

The

type

called

I pneumocyte

small

•

Represent they Primarily

•

Post

only

or

40%

90–95% involved

major

cell

alveolar

of

the

and

lining

type

the

surface

in

gas

exchange

cell

of

the

barrier

alveolar

surfaces

(also

I cell).

alveolar

of

Blood–Air Barrier and blood–air

lining

cells,

but

are

spread

so

thinly

mitotic

type

cell

cell

cover

•

The

is the

alveolar

Alveolus Alveolus

II

[because

pneumocyte of

alveolar

type

•

Constitute

its

is the size],

other

granular

major

alveolar

pneumocyte,

cell

septal

(also

cell,

called

corner

great cell,

alveolar

niche

cell,

or

II).

60%

of

the

cell

lining

the

alveoli,

but

form

only

5–10%

of

the

surface •

Produce

•

Large,

and

round

represent •

Serve

cells the

as

secrete

stem

surfactant

with

remnants cells

“myelin of

for

figures”

surfactant

themselves

in after

and

the

their

apical

histological type

cytoplasm

which

processing

I cell

5

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Pharmacology

Biochemistry

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Copyright

McGraw

Hill Companies.

Used

with

permission.Copyright McGraw

Hill

Companies.

Used

with

permission.

Microbiology Figure Figure

II 2II 17.2

Alveoli with 17. Alveoli and

pneumocytes

Type with I Pneumocytes type

Alveolar (arrow), Macrophage and in

(arrowhead), I pneumocytes

(curved alveolar the

Type

arrow) in the macrophage

alveolar

II Pneumocytes (arrowhead),

Alveolar

(arrow), type

Wall (curved

II

arrow)

wall.

Surfactant Surfactant CLINICAL

CORRELATE

Corticosteroids

induce

surfactant.

High

mothers

the

insulin

antagonize

is essential

alveoli.

the

fetal

levels

synthesis in

effects

diabetic of

of

neonate

as

it

Infants

of

mothers

have

and

of

respiratory

distress

which

the in

breath.

surfactant

Surfactant

is

essential

is

composed

whose

air–water

the

respiratory

fetus

proteins

alveolar

lowers

normal

the

tension

is

The

of

the

the of

function

interface.

surface

mechanics for

to

of

a

mixture

aid

in

of

the

spreading act

and

the

of

phospholipids

alveoli

the

survival

as

prevents

of

a

alveolar

expiration.

a higher syndrome.

surfactant

undergoes

In

is recycled

the

alveolar from

muscle

elastic

responsible

Gas

exchange

barrier.

Type

II

cells

for

reutilization;

of

some

openings

are

thought can

and

in

the be

as

lumen

wall

of

as

10–15

Type present

of

the

of

it

blood

the

most

alveoli

in

collateral microns.

II

collagens,

primarily

in

of for

and

cells

the the

as

lung

the

and

well

as

walls

of

consists

stretching

of and

microscopic

alveolar

air

squamous The can

that

capillaries of

myofibroblasts,

These

the

alveolus

of

variety

elements

expiration.

endothelium. of

a

mass

responsible

during

surfactant,

network

I and

is

respiration.

lungs

capillary

important

large

the

capillary of

the

are

during of

between

lamina,

to be

alveoli

cells.

percent fibers

rich

contains macrophages,

I collagen

Twenty

consists

and

mast

Type

recoil

is a wall

fibroblasts,

Elastic

barrier

capillary

alveolar

occasional

the

the

epithelium

The

septa.

fibers.

occurs

basal

alveolar

include

bronchioles.

for

This

are

the

elastic

activities

are

cells

and

in

and and

recoiling

pores

The

are

bronchi

collagen

the arteries.

cells,

fibers,

the

to

macrophages.

under

fibers.

smooth

of

wall pulmonary

extracellular

shared

by

Wall

arising

the

back

phagocytosis

Alveolar

5

first

the

during

maintain

surfactant

its

at

surfactant

Most incidence

takes

the

collapse diabetic

of

phospholipids

detergent corticosteroids.

to

Production

form

ventilation.

be the

across

Type distance as

thin

pores The

the

blood–gas

I pneumocytes, between as

0.1

of

Kohn.

diameter

the microns. These of

these

a lumen There pores alveolar

CHAPTER

Alveolar The in

CLINICAL

Macrophages alveolar

the

macrophages

lungs.

form

The

additional

well

as

pass

through

in

are

resident

derived

alveolar

macrophages.

the

alveoli.

from

These

Alveolar

monocytes

macrophages

that

can

cells

can

macrophages

reside that

exit

undergo in

patrol

the

blood

limited

the

interalveolar

the

alveolar

Alveolar

vessels

mitoses

to

septa

pores

of

surfaces

dust

are

15–40

microns

~1–3

mechanism and

of

enter

the

propelled

or

the

OF

Formation

of

heart

within

Heart

begins the

migrate

into

the

which

will

fuse

•

The

develop

into

heart

they

cigarette

have particles,

may heart

failure

cells

be

in

swallowed

out

of

the

moving

and

vary the

the

last

in

size,

into

defense

alveoli

to

heart

the

mucous

the

blood

because

alveolar

space

cells

that

they

during

have

have escaped

congestive

failure.

bronchioles

layer

and

digested.

HEART

from

a

of

cells

condense

the

end

and

play to

heart

tube

undergoes

mesoderm

cranial

heart

single

tube

splanchnic

area developing

cardiogenic

or

other

Tube

to

The

pass

trapped

to

THE

cardiogenic

ment.

macrophages represent

can

become

pharynx

Alveolar

macrophages

Macrophages

lymphatics

toward

alveolus.

These

lung.

EMBRYOLOGY

The

per

diameter.

the

THORAX

Kohn.

macrophages in

several

because

dust

phagocytosed There

have

cells

phagocytosed and

the

|

CORRELATE macrophages

names:

as

2

an

form during

dextral

of

in

the

important a

of

body

latter

half

Neural role

pair

looping

the

embryo.

in

of

crest

cardiac

primordial

week

3

cells develop

heart

tubes

folding.

(bends

to

the

right)

and

rotation. •

The

upper

rapidly •

The

atria

dorsally heart

The

in

and

their

heart

arteriosus.

Arterial

arteriosus

folds

and

primitive

truncus

truncus and

sinus to

(ventricular)

downward venosus

the

left.

tube

ventrally

lower These

postnatal

The

and

anatomic

forms fates

4

of

these

part

foldings

of

end

of

the

tube

and

to

the

right.

the

tube

begin

to

fold place

grows

upward the

more

and

chambers

of

the

positions.

dilatations are

and shown

a cranial

outflow

tract,

the

below.

(outflow)

Truncus arteriosus

Bulbus

flo

Ventral

cordis Blood

Dorsal Primitive ventricle Atria Primitive atrium Sinus

Ventricles

venosus Venous

(Inflow)

Figure Figure

II 2 18. Development II 2 18. Development

of the

Heart of

Tube the

Heart

Tube

53

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology Table

II 2

2.

Embryonic

Structures

Derived

From

the

Dilatations

of

Dilatation

Truncus Pharmacology

Adult

the

Adult

arteriosus

(neural

crest)

Primitive

Heart

Structure

Aorta;

Pulmonary

trunk;

Smooth

part

of

right

part

of

left

Semilunar

values

Biochemistry Bulbus

cordis

ventricle

(conus

arteriosus) Smooth Physiology

Medical Genetics Primitive ventricle

Primitive Pathology

atrium*

ventricle

Trabeculated

part

of

right

Trabeculated

part

of

left

Trabeculated

part

of

right

part

of

left

(aortic

vestibule)

ventricle ventricle

atrium

(pectinate

muscles)

BehavioralScience/Social Sciences

Trabeculated

atrium

(pectinate

muscles)

Sinus Microbiology

not

venosus become

(the

only

dilation

subdivided

by

a

that

does

Right—Smooth

part

of

right

atrium

(sinus

venarum)

septum)

Left—Coronary

sinus

and

oblique

vein

of

left

atrium

*The wall.

smooth The

smooth

walled

part walled

of

the

part

left

atrium

the

right

of

Fetal

Circulation

There

are

3

is

formed

by

is

formed

atrium

major

venous

incorporation by

of

the

systems

parts

of

incorporation

that

flow

the

of

into

the

pulmonary

the

veins

right

sinus

sinus

into

its

the

heart

venosus.

venosus

end

of

tube:

•

Vitelline

(omphalomesenteric)

yolk

stalk;

hepatic •

Umbilical

•

Cardinal they

they

will

portal

coalesce

During

fetal

passes

through

circulation

•

to

The

bypass

blood

ductus

bypass

of

the

ovale

right

into

the

of

atrium, left

the

then

in

blood left

the

veins

of

embryo; the

azygos,

placenta

to

develop

body renal).

in

the the

fetus fetal

lungs:

inferior

oxygenated atrium

cava.

of

cava,

the

and

blood

into

body

shunts

liver

the

(sinusoids, vena

major

from

from

placenta.

vena

flood

liver

the

the

inferior

oxygenated liver

the

the

some

the

blood

inferior

from

vascular

around

of

the

from

blood

the

of

blood

cava,

Three

allows

sinusoids

From

foramen

to

vena

flow

venosus

the

atrium.

contribute

vein.

veins

part blood

oxygenated umbilical

deoxygenated

the

and

deoxygenated and

the

form

vein)

superior

circulation,

drain

oxygenated

carry

(brachiocephalic,

and

hepatic

carries

veins will

coalesce

vein, vein

veins

the

umbilical

vena flows

ventricle

vein

cava

and

mostly and

into

to

to

the

right

through the

the

systemic

circulation. •

The blood shunting

5

foramen to

ovale bypass of

the blood

develops

during

pulmonary during

atrial

circulation. fetal

life.

septation Note

to that

allow this

oxygenated is

a right

to

left

CHAPTER

•

During

fetal

from

the

flow

is

circulation,

upper directed

ductus

the

limbs into

of

from

left

the

the

to

and

into the

shunts

aorta

to

deoxygenated Most

the

of

and

the

drains atrium.

underside

artery

trunk

cava right

ventricle

into

subclavian

pulmonary

vena

into

right

opens

the

the

superior head

the

arteriosus

origin

and

of

this

distal

deoxygenated

bypass

the

THORAX

blood trunk.

just

|

blood this

pulmonary aorta

2

The to

the

blood

pulmonary

circulation.

The

shunting

sus

(right

of to

blood

left)

through

during

fetal

the life

foramen

ovale

occurs

because

and of

through

the

a right

to

ductus

left

arterio

pressure

gradient.

PRESSURE

65% Ductus becomes

Superior vena

arteriosus

GRADIENTS

Fetal

ligamentum

3 arteriosum

cava

40%

Left

R →

L

Postnatal

atrium

50% L → Foramen

ovale

Pulmonary

R

artery

becomes

2 fossa

ovalis

Right

Right

Left

ventricle

atrium

Aorta

ventricle 67%

60% Ductus

Inferior vena

becomes

26%

cava

1

venosus ligamentum

venosum

Portal

vein

26% Liver Umbilical

80%

vein

becomes teres

From

ligamentum of

liver

placenta

To placenta

Right

and

become

Figure

Following in

the

birth,

reduces

increased

3

flow

reduces venous

into

2 II 19. 2 19. Fetal Fetal

shunts,

gradients

blood

expansion and

these

pressure

FigureII

and the

labelled in right

pulmonary return

oxygen atrium. resistance

to

the

left

left

umbilical

medial

Circulation Circulation

1,

2,

and

tensions.

arteries

umbilical

and Shunts

and

3,

will

The

ligament

Shunts

close

because

umbilical

The

ductus

venosus

and

results

in

increased

of

vein also

changes

closes closes.

flow

and Lung

to

the

lungs

atrium.

5

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology •

Closure

of

pressure •

Pharmacology

foramen

Closure

of

several

hours

ovale

reduction the

in

ductus as

a

occurs

right

venosus result

as

atrial and

of

the

a result

of

the

increase

in

left

atrial

pressure. ductus

arteriosus

contraction

of

occurs

smooth

over

muscles

the

in

next

its

wall

Biochemistry

•

and

increased

The

release

birth

Physiology

the

and

Medical Genetics

The

oxygen of

also

changes

tension.

bradykinin

facilitate

which

and

the

occur

the

closure

immediate

of

between

pre

the

drop

ductus

and

of

prostaglandin

E

at

arteriosus.

postnatal

circulation

are

summarized

below.

Pathology

BehavioralScience/Social Sciences

Table

II 2

3.

Adult

Vestiges

Changes

After

Closure

of

right

Closure

of

the

Closure

of

ductus

Closure

of

foramen

Closure

of

ductus

Derived

from

the

Fetal

Birth

Circulatory

Remnant

and

left

System

in Adult

umbilical

Medial

umbilical

ligaments

vein

Ligamentum

teres

Ligamentum

venosum

arteries Microbiology

SEPTATION for

left

ovale

THE

horns,

originally

heart

HEART

The

week

congenital

cardiac

4

the

is

embryonic

of

mostly

anomalies

arteriosum

result

the

heart

tube

atrial,

and

will

undergo

chamber,

septation

and

liver

TUBE

ventricular,

a common

structure. in

of the

of

ovalis

Ligamentum

venosus

left

beginning

Fossa

arteriosus

sinus

and

are

Atrial

atria

finished

and in

from

that

initially

truncus

parts

septation

ventricles

week

defects

8. in

develops

of

the

into

a

occurs

Most

of

the

formation

the

left

the

heart

tube,

right

and

simultaneously common of

these

septa.

Septation

During

fetal

ovale

(FO).

left

due

to

and

to

high

The

FO

oxygenated

5

the

right

which

venosus

OF

Except into

umbilical

has

life,

blood

Note the

is shunted

that large

during bolus

pulmonary

to

of

blood

the

right

circulation,

to right

directed

into

atrial

the

atrium pressure

right

atrium

via

the

is

higher

from

the

foramen than placenta

resistance.

remain

blood

from fetal

open from

the

and

functional

right

atrium

during into

the

the left

entire atrium.

fetal

life

to

shunt

CHAPTER

Septum R

primum

–

Foramen

THORAX

(SP)

primum

Endocardial

(FP)

cushions

(neural

(SS)

|

L

+

Septum

2

(EC)

crest)

secundum (rigid)

SP Septum

Foramen

secundum

+

primum

(SP)

(flexible)

–

(FS) EC

SP

SS

FS +

–

EC

FO

Foramen ovale

(FO) –

+

Membranous

part

Muscular

20. Formation IIFigure 2 20. II 2Formation

Figure

Beginning series

week of

•

4,

events

The

flexible

of fuse

with

right

and

the •

•

the

the

and

and

The

foramen

and

the

primum

endocardial

The

foramen

before

the

blood

that

is

left

atria

endocardial

and

contribute part

of

Neural

the

by

roof

of

centrally the

The

membranous

cushion;

a

Initially,

canals

(FP)

endocardial

the

cushions.

their

and

from

cushions,

septum.

facilitate

right

inferiorly

heart.

atrioventricular

aorticopulmonary

cushions

grows

developing

valves,

Septum Septum

into

endocardial

endocardial

left

Atrial of of Atrial

divided

septum

a

foramina.

(SP) the

atrioventricular

septum,

2

primum

in

is

and

toward

mesoderm

the

the

atrium

2 septa

atrium

and

of

common

septum

common mass

the

involving

Interventricular

part

SP

does

not

cushions to the

crest

the

located

the

reach form

formation

interventricular cells

migrate

into

development. located it

is

between

the

obliterated

inferior

when

the

edge SP

of

later

fuses

the

SP with

cushions. secundum FP

(FS)

closes

entered

to the

forms

maintain right

the atrium

within

the

right via

to the

left

inferior

upper

part

shunting vena

of

the

of

oxygenated

SP

just

cava.

5

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology •

The

rigid

roof

of

with • Pharmacology

septum the

the

The

secundum

atrium, endocardial

foramen

(SS)

descends,

forms

and

to

the

partially

right

covers

of the

the

SP

FS.

It

from

does

the not

fuse

cushions.

ovale

(FO)

is

the

opening

between

SP

and

SS.

Biochemistry Closure

Physiology

of

the

FO

increased

left

decreased

right

normally

atrial

occurs

pressure

atrial

immediately

resulting

pressure

after

from

due

to

birth;

changes

the

closure

of

it

in

pulmonary

the

umbilical

is

caused

by

circulation

and

vein.

Medical Genetics

Aorta Superior Pathology

vena

BehavioralScience/Social Sciences

cava

Tricuspid

valve

Septum secundum Sinus

Limbus

venarum Fossa

Microbiology

Pectinate

ovalis

(septum Coronary

sinus

Inferior

vena

Figure

Atrial

Septal

Atrial

septal

defect in

shunting

and

are

•

Postnatal

•

Right

to

left

shunts

are

cyanotic

conditions.

•

Left

to

left

atria

in

is

small,

Primum

5

type

failure

shunts

are

non

of

may

ASDs

be

occur

formed

right

Atrial Septum Atrial Septum

fossa also

be

of

in

ASD

is of

the

ovalis. associated the

defects. result

clinically

is

common

or

an

It

in

is

left

important

in

part

of

the

common

lower

to

aspect the with

atrioventricular

atrial be

than

defects

more

to

right

ASDs

is

caused

the

with

the

are

endocardial of valves.

above as

the

the

the as and

limbus. age

is

membranous

involved,

If

30. from

cushions,

cushions. usually

of

right

results

endocardial

an size

the

late

ASD

wall,

cushion

a defect

septum delayed

either

reduced

between

endocardial

atrial

by

and

secundum

fuse of

of

It

openings

may

premium with

If

variable

symptoms less

ASD.

underdevelopment

cyanotic and

heart ASDs

Two

most SP

central

septum

the

congenital

Postnatally,

results

clinical

combined in

the the

ASD

ASD

the

several

male.

types.

This

ASD

septum conditions.

both.

the

can

Postnatal 21. Postnatal

conditions.

primum

type

or

one

than

resorption

SS

and

21. II 2

cyanotic

and

a

Shunts

non

and

excessive

NOTE

2

is

births

Secundum

the

II Figure

(ASD)

female

secundum

•

cava

Defects

common

the

muscles

primum)

Primum

with a

a

normal

primum

interventricular

ASD

CHAPTER

2

|

THORAX

Aorta

Superior vena

cava Tricuspid

Secundum

valve

ASD CLINICAL

Fossa

CORRELATE

ovalis Ventricular

Primum

ASD

Inferior

septal

common

vena

of

Figure

and

more

common

in

The

most

common

form

II 2 Figure

22. Secundum II 2 22. Secundum

and and

Primum Primum

Atrial Septal

Atrial

Septal Defect

associated

crest

Defect

by

development

of

completed

develop

and

the

most

defects,

than

to

the

by

close

interventricular

the

end

of

completely

(IV) week

by

7.

week

septum

Unlike

atrial

8 without

any

begins

in

week

septation,

the

shunting

4 and

the

IV

septum

between

will

the

migrate

failure

it results

is

is

in

females.

of

into

the

left

the

of

the

neural

endocardial

VSD

is

caused

membranous

(IV) in

through

a membranous

failure

A membranous

interventricular

Septation

usually

is

heart males

with

cells

cushions.

The

(VSD)

congenital

cava

VSD,

Ventricular

defect

the

septum

to

right

to

develop,

shunting

and

of

blood

IV foramen.

the Patients

with

left

to

right

shunting

complain

ventricles. of The

adult

most the

of

IV the

superior

•

•

septum septum aspect

The

muscular

and

partially

consists and of

a the

IV

of thin,

2

parts:

a large,

muscular

membranous

part

component

forming

forming

a small

right

component

at

the

septum

develops the

right

in and

the left

floor

of

the

ventricles,

ventricle,

leaving

of

increased lungs

IV

of

The

membranous

Ultimately,

fusion

of

resistance

becomes

resistance

and

dial

cushion

cushion

IV

septum

(neural and

closes

conotruncal crest

conotruncal

ridge, cells

are

the

IV

the

foramen.

left

It

forms

conotruncal

associated

with

ridge, the

by

the endocar

endocardial

ridges).

of

pulmonary

blood

condition

flow

is

called

pressure

to

marked

intima

and

arteries the

media

and

pulmonary

higher

causes late

to

but

and

causes tunica

muscular

and

Left

hypertension).

the

arterioles.

exertion.

is noncyanotic

hypertension

proliferation of

right

blood blood

foramen.

the

upon

(pulmonary

Pulmonary

ascends, the

fatigue

shunting

causes

septum.

separates

excessive

right

cyanosis.

than to At

systemic left this

Eisenmenger

shunting stage,

the

complex.

Foramen ovale

Endocardial cushion – Interventricular foramen

+

Membranous Muscular

Muscular

septum

A

part

+

–

part

Interventri cular

septu

B

Figure

II

Figure

II 2 23.

2

23.

Interventricular

Interventricular

Septum Septum

59

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Patent A

Ductus

patent

tion Pharmacology

Biochemistry

Arteriosus

ductus

arteriosus

between

the

is common

•

in

(PDA)

pulmonary

premature

Postnatally, trunk)

and

occurs

trunk infants

and

a

PDA

causes

is

non

cyanotic.

when

and

a

the

aorta) in

cases

left

to

The

ductus

fails of

to

arteriosus

close

after

maternal

right

rubella

shunt

newborn

(from

(a

birth. infection.

aorta

presents

connec

PDA

with

to a

pulmonary

machine

like

murmur. Physiology

Medical Genetics •

Normally,

the

smooth

muscle

glandin

E

arteriosus Pathology

BehavioralScience/Social Sciences

•

PGE of

•

is

used

PGE

arteriosus

closes

contraction

(PGE) in

great

ductus

and the

to

to low

fetal

form

oxygen

within the

a

few

hours

ligamentum

tension

after

birth

via

arteriosum.

sustain

patency

Prosta

of

the

ductus

period.

keep

the

PDA

open

in

certain

heart

defects

(transposition

vessels). inhibitor

amines

(e.g.,

promote

indomethacin),

closure

of

acetylcholine, the

ductus

histamine,

arteriosus

in

a

and

catechol

premature

birth.

Microbiology

Ligamentum arteriosum

Patent

ductus

arteriosus

Left

pulmonary

artery

A.

Normal

obliterated

ductus

arteriosus

Figure

II 2

24.

Figure

Septation The

of

septation

migrate grow septum. pulmonary

6

the of

into in

a

the

spiral The

Truncus the

trunk.

septum

Ductus

II 2 24.

Patent

ductus

arteriosus

Arteriosus

Ductus

Arteriosus

Arteriosus

truncus

conotruncal fashion

AP

B.

and divides

arteriosus

occurs

and

ridges

fuse

bulbar to the

form truncus

the

during of

the

week

8.

truncus

aorticopulmonary arteriosus

Neural

crest

arteriosus,

which

(AP) into

the

aorta

and

cells

CHAPTER

2

|

THORAX

Aorta Aorticopulmonary

Pulmonary

septum

Trunk

RV

Figure

There

are

defects the

II

25. Figure

3 classic

in

the

failure

•

2

cyanotic

neural

of

crest

Tetralogy

of

birth.

right

ventricle.

–

Pulmonary

–

Membranous

–

Right

–

Overriding

the of

common)

typically

There stenosis

are

shows 4 major

(most

a

the

right.

boot

AP

This is

related

septum

causes

usually

shaped in

with

are

to

arteriosus:

when

that

defects

right present

heart

tetralogy

of

fails

due

to

to left

sometime to

the

enlarged

Fallot:

important) septal

hypertrophy aorta

the

occur

They

truncus

cyanosis

interventricular

ventricular

the

occurs to

resultant

that septum.

into

anteriorly

with

Imaging

migrate

Septum Septum

abnormalities

aorticopulmonary

to

shifts

blood

Aorticopulmonary the Aorticopulmonary

heart

the

(most

and

of

after

cells

Fallot

properly

shunting

of Formation

congenital

development

of

align

Formation II 2 25.

LV

defect

(develops

(receives

blood

from

secondarily) both

ventricles)

Aorta 1

Pulmonary

1.

Pulmonary

stenosis

2.

Ventricular

septal

3.

Hypertrophied

4.

Overriding

defect

trunk

RA

right

ventricle

LA aorta

2

4

LV RV

3

Figure II Figure II 2 26.

2 26. Tetralogy

Tetralogy of Fallot

of

Fallot

6

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology •

Transposition

of

develop

in

ventricle

and

causes Pharmacology

the

a spiral the

right

to

great

vessels

fashion

and

pulmonary left

occurs results

trunk

shunting

when in

the

arising

of

blood

the

from

with

AP

aorta

septum

arising

from

left

ventricle.

the

resultant

fails

to

the

right This

cyanosis.

Biochemistry –

Transposition

is

persists closed – Physiology

most at

circulation

Infants

Medical Genetics

the

immediately

born

ASD)

that

common birth.

cause

of

severe

Transposition

cyanosis

results

in

that

producing

2

loops. alive

allow

with

this

mixing

of

defect

usually

oxygenated

have and

other

defects

deoxygenated

(PDA, blood

VSD, to

sustain

life.

ASD Pathology

BehavioralScience/Social Sciences

Aorta 1.

Aorta

arises

2.

Pulmonary

from

right

ventricle

Microbiology trunk

arises

from

RA

left

Pulmonary

ventricle

trunk LA

3.

Usually ASD,

associated or

patent

with ductus

a VSD, arteriosus VSD

RV

LV

1 2

3

Figure

•

Persistent of

the

leaves cles. cyanosis.

6

II 2 Figure

27. Transposition II 2 27. Transposition

truncus

arteriosus

AP

septum.

This

the

heart

This

causes This

that

receives

right defect

occurs results

to is

in

when a

blood left

always

of the Great of the Great Vessels

there

condition from

shunting accompanied

only

where both

of

is

the

blood

partial

only right

with by

Vessels

development

one and

large left

vessel ventri

resultant

a membranous

VSD.

CHAPTER

2

|

THORAX

NOTE

Aorta

Non

cyanotic

heart

Pulmonary

defects

•

Atrial

•

Ventricular

•

Patent

Cyanotic

Interventricular

II Persistent 2 28. Persistent

Truncus Truncus

to

right)

birth:

septal

defect

septal

ductus

defects

arteriosus

congenital

(right

to

left)

heart

arteriosus defects

II Figure 2 28.

at

(left

artery

Truncus

Figure

congenital

septal

defect

at

birth:

•

Transposition

•

Tetralogy

•

Persistent

of

of

great

vessels

Fallot

truncus

arteriosus

Arteriosus Arteriosus

MEDIASTINUM The is

mediastinum

is the

bounded

laterally

•

anteriorly by

the

pleural

Superiorly,

•

contains

lungs

(and

The the

and

collateral

(prevertebral) after

the

the 12

between

important

clinical

subdivided

into

of

by the

are

thoracic

cavity.

thoracic

It

vertebrae,

and

ganglia

divided sternal

T4

and

T5

anterior,

the

mediasti

except

from

the

least

sympathetic diaphragm,

and (of

Louis)

posteriorly.

The inferior

and

just and

outside thoracic

fibers enter

the

to

the

posterior

trunks.

superior

The middle,

the

The

lesser,

preganglionic

angle

landmarks.

through

paravertebrally,

greater,

sympathetic into

the

neck

cavities

located the

below

the

the diaphragm.

trunk.

primarily

convey

the thoracic

sympathetic

leaving

from

with

closed

However,

is

passing disc

of by

continuous

viscera

the

which

mediastinum

tebral

is

the

trunks

nerves,

plane

is

mediastinum.

splanchnic

The

of and

sympathetic

mediastinum •

compartment posteriorly

inferiorly,

most pleura)

posterior

midline sternum,

mediastinum

inlet;

num

the

cavities.

the

thoracic

central,

by

posterior

inferior

mediastina

anteriorly sternal

to angle

mediastinum

the and

is

by

a

interver plane

are

classically

mediastina.

6

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Thoracic First

inlet

Pharmacology

Biochemistry

Sternal

angle

(second

rib)

rib

T1

Superior T4

mediastinum

Anterior

Physiology

Medical Genetics

Horizontal plane

mediastinum

Inferior

(thymus)

mediastinum

of

sternal

angle

Aorta

Middle mediastinum

Esophagus Posterior

Pathology

BehavioralScience/Social Sciences

Left

mediastinum

T9

atrium

Microbiology T12

Figure

II

2

29.

Divisions Figure

Anterior The

anterior

mediastinum surface

inferior

part

the

of of

or

is

the

the

anterior

Posterior The

29.

the

small

the

Mediastinum

Divisions

of the

Mediastinum

Mediastinum

anterior

in

of II 2

pericardium.

thymus

gland.

superior

interval It

A

between

contains

fat

tumor

of

the

and

the

sternum

areolar

thymus

and

tissue

the

and

(thymoma)

the can

develop

mediastinum.

Mediastinum

posterior

mediastinum

pericardium

and

diaphragm.

There

the

is T5

are

T12

located

between

thoracic

4 vertically

the

vertebrae. oriented

posterior

surface

Inferiorly,

structures

it

is

coursing

of

closed

the

by

within

the

the

posterior

mediastinum:

•

Thoracic –

–

branches

intercostal

arteries

Passes

through level

are

the to

the

aortic become

bronchial,

hiatus the

esophageal,

(with abdominal

the

and

thoracic

duct)

posterior

at

the

T12

aorta

Esophagus –

Lies atrium,

6

aorta

Important

vertebral

•

(descending)

immediately forming

posterior an

important

to

the

left

radiological

primary

bronchus relationship

and

the

left

CHAPTER

–

Covered

by

derived –

Passes

–

the the

T10

Is

constricted

of

the

–

(1)

•

its

hiatus

origin

posterior of

to

Ascends

the

junction

of

from to

the

the

the

which

are

respectively

(with

the left

the

vagal

nerve

trunks)

at

pharynx,

(2)

primary

posterior

bronchus,

to

and

the

(4)

at

arch

the

diaphragm

and

from the

mediastinum

system

of

Drains

–

Communicates

the

the

between

cisterna

the

thoracic

superior

aorta

and

chyli

in

and

internal

the

abdomen

the

drains

jugular (at

aortic

into

the

veins vertebral

hiatus

of

level

the

L1)

and

diaphragm

veins

and

thoracic

the

arching

vena a

mediastina

and

through

with by

superior

subclavian

posterior

terminates

Forms

and

left

enters

vena

esophagus

posterior the

Arises

–

Middle

plexuses,

nerves,

vein

Azygos

–

esophageal

at

(3)

posterior

azygos

–

esophageal

vagus

THORAX

duct

Lies

–

posterior

right

|

level

hiatus

Thoracic

and

the

vertebral

aorta,

and

left

through

the

esophageal •

anterior

from

2

inferior over

cava

root

the

venous

wall

vena

the

above

collateral

lateral

cava

in

the

right

of

the

abdomen lung

and

to

empty

into

the

pericardium

circulation

between

the

inferior

and

superior

cava

Mediastinum

The

middle

which

mediastinum

will

Superior The

be

superior

mediastinum and

parietal

pleura

the

the

•

•

•

heart

The

lungs

and

great

vessels

and

pericardium,

superior

the

The

and

phrenic

The

pulmonary

mediastinum

and

mediastinum the

vagus

form

neck

with

mediastinum.

between 1

4,

the

manubrium

posteriorly.

the

lateral

the

horizontal

As

boundary. plane

of with

The

all

the

thoracic

through

sternum,

mediastina,

the

inlet the

con

sternal

angle

boundary.

associated

the

located

vertebrae

the

with

inferior

is

thoracic

and

superiorly

forms

the

later.

Mediastinum

anteriorly,

nects

contains

discussed

trunk and

contains upper

are

aspect nerves

and not

the of

and

arteries found

in

the

thymus, heart,

the

thoracic

are

located

the

superior

great

arteries

trachea, duct

and also

completely

and

veins

esophagus. course

in

through

the

middle

mediastinum.

6

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology Esophagus

Trachea Pharmacology

common

Left

vagus

Left

internal

carotid

vagus

Right

subclavian and

nerve

vein

vein

Physiology

phrenic

brachiocephalic

nerve

Left

Medical Genetics

vein

subclavian

Left

brachiocephalic

Left

vagus

artery

and

vein

vein

Brachiocephalic

Superior

mediastinum BehavioralScience/Social Sciences

Pathology

(X)

jugular

Left

Right

artery

Biochemistry nerve (X)

Right

artery

Left

Right

Middle

artery

nerve

phrenic nerve

mediastinum

Left Superior

(X)

vena

recurrent

laryngeal

nerve

cava

Microbiology Ligamentum Aortic

Ascending

Pulmonary

aorta

Figure

II

2

The

relationships

ized

in

•

CORRELATE

30.

of

left

under

recurrent the

laryngeal

aortic

arch

nerve

distal

to

Thymus:

arteriosum

•

it may

Right

pathology

(e.g.,

malignancy

aneurysm

of

the

arch),

resulting

and

nerve

the

left

vocal

is not

folds.

affected

in

The

from

the

of

neck

and

the

right passes

vagus

The

in the

–

it the

•

or

nerve

may

be

lesioned

surgery.

6

the

left with

recurrent thyroid

veins

the

the

manubrium,

usually

atrophies

in

the

tissue veins:

obliquely

right

crosses

the

vein

descends

superior

almost

mediastinum

verti posterior

to

join

to

form

the

superior

vena

cava

posterior

to

the

right

cartilage.

superior

laryngeal gland

right

Aortic

– right

visual

and

vena third

cava

costal

descends

and

drains

into

the

right

atrium

deep

to

cartilage.

root

subclavian

artery.

the

to

fatty

brachiocephalic vein

costal

The

the

Either

best

anteriorly

right

because nerve

under

are

sternum

remnants 2

the arises

as

left left

thymic

first of

mediastinum the

or –

laryngeal

superior

between

posterior

remains

and

the by

paralysis

the

orientation

Mediastinum

be

damaged

aortic

in

of the

curves

the

where

structures

dorsal

located and

cally ligamentum

these

to

of II 2the 30. Mediastinum Structures

Figure

trunk

posteriorly:

adult The

Structures

a ventral

vertebrae

CLINICAL

arteriosum

arch

arch sternal

As 3 and

a

and

its

angle very

branches left

brachiocephalic

3

and

branches:

important of

the

aortic

is located

just

radiological aortic

subclavian)

arch are

vein.

directly

arch inferior landmark,

begins to

and the

the

origins

(brachiocephalic, posterior

left

left to

the

left

ends

at

the

plane

brachiocephalic of common

of vein.

the carotid,

CHAPTER

•

Trachea:

lies

vertebra –

•

The

•

Right

and

left

plexuses.

In

rent

in

larynx.

Note:

the

The the

The left

vagus

superior

The

•

the

and

left

information

through

the

of

Coarctation

of

•

the

parts

the

–

DA

(Figure

This

results

in

supply will

limbs) –

the

the

the

of

root

is

right

trachea not

recur artery

to

in

the

recurrent

to

reach

the

mediasti

laryngeal

the

aortic

in

nerve

arch

the

the

and

body.

left

cervical

It

returns

internal

nerves

diaphragm

both

the

pleura.

the

3,

and

jugular

and

and

5. sensory

inferior

phrenic the

4,

convey

superior Both

between

of

of

usually

nerves

fibrous

pass

pericardium

lung.

via

the

aorta

identified

opening

II

flow

the

Patients

the

of

of

of

lateral

of

(infantile

II

between

–

are

to

coarctation

blood

cardiac

the

31A).

ductus

the

DA

is

The to

on

the if

origin

the

and

left is

occurs

remains

descending

the

(DA).

common

usually

of

constriction

arteriosus

less

DA

the

to

based

the

type)

2

distal

proxi

patent

aorta

and

and

the

lower

body.

Postductal the

and

right

duct.

larynx.

parietal

a narrowing

(Figure

blood of

the

subclavian

nerve left

rami

portion

to

types

distal

DA

provides

to

right

junction

supply

and

coarctation

to

left

thoracic

and

channel

the

contains

the

rise

under

the

ventral

central

is

Two or

Preductal mal

•

aorta

artery.

T4

Aorta

the

proximal

the

anterior

the

to

mediastinum

and

the

passes

lymphatic

motor

the

to

pulmonary

the

to

at

diaphragm

middle

pleura,

Coarctation

found

the

of

vein.

sole

from of

rise

of

gives

laryngeal

largest

from

the

the

esophagus

circulation

arise are

portions

the

level

bifurcation.

also

nerve

which

subclavian

nerves nerves

subclavian

is

to

ascend

the

posterior

end

under

gives

to

venous

the

Phrenic

and

nerve

duct

to

The

the

the

courses

mediastinum

recurrent

mediastinum,

thoracic

vein

between

at

superior

vagus passes

at

THORAX

mediastinum

contribute

which

arteriosum

lymph

and

the

right

bifurcates

cartilage

posterior

and

the

right

of

superior

nerves

neck,

groove

ligamentum •

the

and

|

bronchi

trachea

the

nerves

nerve,

ascend

the

enter

vagus the

laryngeal

num.

to

phrenic

arch

primary

projection

structures,

and

aortic

left

posterior to

these

the

and

internal

bronchus

vagus

in

an

lies

to

left

to

right is

Esophagus:

addition

and

form

carina

primary

ln

posterior

to

2

and

(adult 2

31B).

the

The

be

the

lower

closes

of in

with

of

the

intercostal

lower

of

the

ribs,

the

weak

and the

in

and

upper

results

thoracic

body the in

distal

to

obliterates.

(Figure

in

occurs

collateral

the

body

pulses

arteries evident

and

providing

artery

hypertensive

common

usually

parts

Enlargement border

more

arteries

thoracic

hypotensive

is

DA

intercostal

internal to

type)

circulation aorta

II

2

to

(head,

neck,

lower

limbs.

costal

provide

31C).

notching

and

upper

on

the

imaging.

6

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Subclavian

Common

carotid

Pharmacology

artery

Subscapular

artery

Biochemistry arteries

Patent

Postductal

ductus

coarctation

arteriosus Medical Genetics

Physiology

Intercostal arteries

Pulmonary artery

Ligamentum arteriosum

Pathology

BehavioralScience/Social Sciences

Inferior

AB

Microbiology

epigastric

artery

C

Figure

II

2

31.

Coarctation

Figure

II

2 31.

of

the

Coarctation

Aorta: of the

Aorta:

Middle The vessels,

The

(A)

Preductal;

(B)

(A) Preductal;

(B)

Postductal;

Postductal;

(C) (C)

Collateral

Collateral

Circulation

Circulation

Mediastinum middle

mediastinum and

the

pericardium

serous

membranes

parietal

and

contains

phrenic

is

the

serous

that visceral

the

pericardium,

the

heart,

parts

of

the

one

of

great

nerves.

has

sac 3

serous

covering

layers:

an

the outer

heart.

It

fibrous

is

layer

the

only

and

a

double

the layered

layers.

Position

of

pericardial

transverse sinus

Heart

Fibrous

pericardium

Serous

pericardium Parietal Visceral

Pericardial

6

II

2Figure 32.

Layers II 2 32.

of theof Layers

Pericardium the Pericardium

layer

cavity

Diaphragm

Figure

layer (epicardium)

CHAPTER

The

fibrous

upper

pericardium

aspect

of

diaphragm

and

sternal

angle

serous

that

lines

covers

pericardial containing

beating

heart.

The

base

cavity

is

and

veins.

The

The

that

the

the

4

vessels

at

tendon

of

at

the

is

very

plane

the the

of

the

strong

and

by

the

The

outer

the

parietal

inner

reflection

layer

visceral

layer

between

these

2

between

expanded

is

anterior

the

that to

a

the

the

useful

in

to

the

superior

great

cardiac

visceral

movement

of

the

2 sinuses:

posterior to

and

free

form

space

separates

parietal

allows

ascending

vena

arteries

from

surgery

to

CLINICAL

cava the

allow

Cardiac

great

isolation

of

heart

and

tamponade

accumulation within

sinus

is

the

blind,

bounded veins

and

inverted,

by

reflection

the

inferior

U of

shaped

serous

vena

as

they

the

compresses

space

filling

pericardium

cava

CORRELATE

and

trunk.

pulmonary

THORAX

mediastinum.

and

fluid

and

is

vessels

formed

heart.

sinus

it

sinus

pericardial to

around

Note

pulmonary

oblique

posterior

is

trunk

transverse and

the

central

pericardium

and

serous

cavity

great

middle

space of

the

great

the

|

vessels.

potential

pericardial

veins.

aorta

of

the

to

pericardium

great

amount

pulmonary

pulmonary

•

the

pericardial

transverse

layered

the

and

fibrous the

fibrous

surface

of

a small The

aorta

the

the

the

The within

the

heart below of

rib).

double of

entire

adventitia

heart

is

at

firmly the

the

aspect

that is

layers

attached

is

second

of

inner

layers

•

the

pericardium

(epicardium) serous

the

It to

of

position

the

surrounds

superiorly

the

The

heart.

(level

maintains

The

the

2

enter

the

heart.

of

infrasternal of

the

with

left

(serous

and

diastole

angle

pathological or

cavity.

heart

To remove

is performed

the

fluids

pericardial the

during

output.

is

and the a

fluid, needle

through

The

blood) fluid

restricts

venous

reduces

cardiac

pericardiocentesis at the

the

left

cardiac

notch

lung.

HEART The

heart

sternum.

lies

obliquely

Borders

of

the

the

The

right

•

The

left

border

•

The

apex

is

intercostal The

•

The

border

inferior

middle

can

be

mediastinum,

described

by

mostly its

posterior

borders

and

to

the

surfaces.

is is

the

tip

formed

mainly of

by

the

right

formed the

left

by ventricle,

atrium.

the

left and

ventricle. is

found

and

left

in

the

left

fifth

space.

superior

arteriosus

the

heart

Heart

•

•

within

Externally,

border of

the border

is right

formed

by

the

right

auricles

plus

the

conus

ventricle. is

formed

at

the

diaphragm,

mostly

by

the

right

ventricle.

6

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology

Aorta Superior vena Pharmacology

Ligamentum

cava

Biochemistry

arteriosum

Left

Right

pulmonary

pulmonary

artery

Pulmonary

trunk

artery Left Physiology

Medical Genetics

atrium

Right pulmonary

Left

veins

pulmonary veins

Pathology

BehavioralScience/Social Sciences Left

ventricle

(Left Right

border)

atrium

(Right

Right

border)

ventricle

Microbiology

Inferior vena

Apex

cava

Figure

Surfaces

of

•

The

the

II 2 33. Sternocostal Figure II 2 33. Sternocostal

View View of

the

of

the Heart

Heart

Heart

anterior

(sternocostal)

surface

is

formed

primarily

by

the

right

ventricle. •

The

posterior

•

The

diaphragmatic

There lar)

are that

heart

and

3

surface

main on

epicardial

formed

surface

sulci

course

is

is

(coronary

the

primarily

and

surfaces

of

the

by

formed

the heart;

the

primarily

anterior

by

and

they

left

contain

atrium. the

left

posterior the

ventricle.

interventricu major

vessels

fat.

Coronary sulcus Anterior LA

interventricular RA

Posterior

sulcus

surfac

RA LV RV LV

Diaphragmatic

RV

surface

Posterior interventricular sulcus Anterior (Sternocostal

Figure

70

Posterior

surface)

Figure

II

2 34. II 2 34.

Surfaces Surfaces

of Heart of Heart with

with Sulci

Sulci

of

the

CHAPTER

Surface

Projections

Surface

of

projections

•

The

of

upper

the

the

right

2

|

THORAX

Heart

heart

may

aspect

of

be

the

traced

heart

on

is

the

deep

anterior

to

the

chest

third

wall.

right

costal

cartilage. •

The

lower

right

upper

left

aspect

of

the

heart

is

deep

to

the

sixth

right

costal

cartilage. •

The

aspect

of

the

heart

is

deep

to

the

left

second

costal

cartilage •

The

apex

of

the

heart

midclavicular •

The

right

border

cartilage •

The

to left

left

The

•

left

The

the

left

fifth

extends

intercostal

the

costal between

space

at

the

margin

cartilage

just

the

left

fifth

of

the

third

right

to

the

right

of

intercostal

costal the

space

to

extends space

border to

from at

the

extends the

the

from

superior

sixth

right

midclavicular

margin

the

costal

cartilage

inferior of

the

margin third

of right

the

to

left

cartilage.

2

Upper

Left

Right

Rib

Lower Rib

the

second

costal

3

Upper

the

line.

Rib

Rib

sternum.

cartilage.

border

cartilage

between

right

intercostal

superior

costal

sixth

costal

inferior

fifth

in

extends

the

border

second •

is

line.

5

Apex

Right 6

Figure

II Figure

2

35. II

Surface 2 35.

Surface

Projections Projections

of of the

the

Heart

Heart

7

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Chambers The

right

blood Pharmacology

Biochemistry

of

receives

the

The

auricle

is

as

The

Medical Genetics

•

is from

sinus

crista

BehavioralScience/Social Sciences

SA •

The

fossa

Microbiology

•

in

cava

The

to

right

entire

atrium;

body

it

walled and

has

with

the

rough

portion

inferior

vertical

of venae

is

pass

ridge

muscles) superior

upper

to

of

the

the

blood to

(tricuspid)

the

exception

of

myocardium

the

atrium,

cavae.

which

It

developed

the

ovale, the

left

valve

to

the

atrium;

smooth it

inferior

from

extends

vena

cava.

The

terminalis.

foramen

the

separates right

cava crista

entering

directly

that

of

vena

part

close

allows

AV

the

the

the

which

vena

smooth

is

ovalis

septum

fetal

superior

(pectinate from

is

the

venosus.

portion

node

the

the

the

terminalis

rough

from

muscles.

longitudinally Pathology

from

venarum

the

The the

derived

blood

from

blood

veins.

pectinate

sinus

receives Physiology

venous

pulmonary

known •

Heart

atrium

from

•

the

an

right

side

opening

atrium

of

the

in from

the

interatrial

the

inferior

heart.

communicates

with

the

right

ventricle.

Aorta

Superior

Crista

vena

cava

terminalis

Tricuspid valve

Sinus venarum

Pectinate muscles Fossa ovalis Tricuspid Coronary

valve

sinus Inferior vena

cava

Figure

The

left

atrium

There

are

4

veins.

The

The

left

AV

blood

right

outflow

ventricle is

to

trabeculae

•

The

papillary of

is

to

from

pass

the

valve

by

from

trunk

via

are project by

the

the

the the

into strands

lungs

lower

mitral

right

the

of

the

and

atrium

cavity the

pulmonary

left

via

in of

it

allows

ventricle.

the

tricuspid

semilunar

chordae

veins.

pulmonary

valve;

left

myocardium the

via

right (bicuspid)

to

pulmonary

of

Atrium Atrium

the

and

atrium

ridges

Right Right

from

left,

left

blood

carneae

AV

and

guarded

muscles the

the the

blood

right

orifice

pulmonary

The

II36.2 36.Inside Inside

oxygenated upper

receives

the

•

cusps

7

receives openings:

oxygenated

II 2 Figure

the

valve;

valve.

the

ventricular

ventricle tendineae.

wall. and

attach

to

CHAPTER

•

The

chordae

and

the

of •

the

tendineae

valve

infundibulum

is

pulmonary The

septomarginal

the

left

out

the

smooth

of

the

the

area

of

the

papillary

valve

right

muscles

during

contraction

ventricle

papillary

•

The

chordae

•

The

aortic

the

the

the

are

of

leading

to

the

of

tendineae

act

vestibule

leads

to

of

cardiac

papillary

muscle

the

mitral

valve

and

in

the

ventricular

wall,

ventricle.

large

ones,

are

attached

by

the

chordae

valve.

same the

band

through

myocardium

bicuspid in

a

system.

atrium

right

2

the

is

anterior

valve.

of the

usually

cusps

left

aortic

ridges

those

and

conduction

from

muscles, to

cardiac

through

than

band)

septum

the

carneae thicker

tendineae

(moderator

enters

aorta

trabeculae

The

of

blood to

normally •

part

ventricle,

The

the

interventricular

conducts

pumped

•

between

closure

trabecula

between

which

is

cords

control

THORAX

valve.

muscle

In

fibrous

that

|

ventricle.

The

•

are

leaflets

2

way aortic

as

the

right

semilunar

ventricle. valve

and

ascending

aorta.

Interventricular septum

Aortic

semilunar

valve Tricuspid AV

valve

Valve

Bicuspid

AV

(mitral

leaflet

Valve Chordae

valve

valve)

leaflet

Chordae

tendineae

Papillary

muscle

tendineae

Papillary muscle

Trabeculae

carneae

Septomarginal trabecula (moderator

band)

Figure

II

2

Figure

HEART

Cardiac being located

37.

Right

II 2

37.

and Right

Left and

Left

Ventricles Ventricles

HISTOLOGY

muscle composed centrally,

is

striated of

in

smaller

instead

the cells

of

same (fibers)

manner with

as only

skeletal 1

or

muscle, 2 nuclei.

but The

it nuclei

differs

in are

peripherally.

7

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Layers

of

The

the

heart

Heart

wall

is composed

myocardium Pharmacology

Biochemistry

and

serous its

underlying

of

fat

the

lines

epithelium,

is

chambers endothelium,

nuclei.

Cardiac

system

compared

simple

The

the

muscle,

epicardium,

a

is

but that

wall

heart

squamous

with well

at

endocardium,

tissue.

less

located

the

number

is the

The

simple

smaller,

somewhat is

the

connective

are

of and

a large

cells. a

middle

layer

(mesothelium)

of

of of

a

visceral

contains

composed

cells

muscle

or

muscle

layer

these

epicardium,

tissue

cardiac

thin

a similar

skeletal

outer

epithelium

muscular of

heart,

but

has

to

an

The squamous

mainly

and

muscle

layers:

connective

vessels.

of

skeletal

Cardiac placed

developed

Z

muscle

centrally T

tubule

line.

BehavioralScience/Social Sciences Discs

Intercalated

discs

intercalated

are

discs

disks

contain

spread

of

heart,

special

appear

gap

during

allow

Purkinje

cells are

are

due

to

are

modified

cells

are

in

Points

of

heart

ning

of

auscultation

of

sound systole

pulmonary

Heart

disposition

of

the

muscle

cells,

the left

of

the

While squeezing

ventricle)

myocytes.

cells

with

fewer

contractile

rather

system

HEART

walls

chambers.

the

conduction

conduction

the

the

heart

myocardial

cardiac

permit

through

the

The

These

junctions

effects of

cells.

microscope.

(particularly

impulse

the

of

the

filaments.

than

contraction.

heart.

VALVES

semilunar

(tricuspid

occurs

at

and

the

valves and

the

closure

second

of

heart

valves

at

or

the

sound

the

(aortic

mitral

end

pulmonary) are

and

shown

atrioventricular occurs

of

and

bicuspid)

valves

at

the

closure

or

stenosis

the

below. at

of

the

the

The begin

aortic

and

systole.

Murmurs in

valvular

regurgitation valves).

heart

(the The

heart

valves

aortic

and

disease fail

mitral

result

to

close

when

there

completely)

valves

are

more

is

valvular

insufficiency (narrowing

commonly

involved

or of

in

the

valvular

disease.

most

valve

of

ventricular

should

be

insufficiency should valvular

A

of

chambers

valves

semilunar

Murmurs

For

These

myocardial

Auscultation

atrioventricular first

light

action

heart

the

join

the

junctions.

pumping

cardiac

that in

(adhering)

action

the

OF

of

the

electrical

found

AUSCULTATION

Points

adhering

for

the

for

lines

mechanical

of

specialized

Purkinje

complexes

transverse

coordinated

movements

systole

They

and

activity

discs

twisting

dark, and

(gap)

synchronizing

and

junctional

as

junctions

electrical

intercalated

heart

direction

7

a

The

composed

the like

distinct

tissue.

the

Intercalated

Microbiology

of

coronary

and

3

endocardium.

consists

and

is striated

Pathology

of

inner

connective

cells

which Medical Genetics

an

pericardium,

myocardium

Physiology

Wall

and be

open defects”

systole,

open,

so

aortic and

is

from

valve

the

the

aortic

and

valve

valve

downstream insufficiency

should

systolic For

mitral

heard

mitral

“common

stenosis.

include

murmur

that

most

of

should

stenosis

from is

closed

closed, aortic

the

retrograde

and

defects”

ventricular

be and

be

valvular

diastole, so

that

the

include the

aortic mitral mitral

“common

diastolic

insufficiency.

valve.

Thus, direction

stenosis

is

from

valve.

orthograde

valve

CHAPTER

VALVES •

OF

Left

Aortic

tricuspid bicuspid

Semilunar

Pulmonary

valve

THORAX

HEART

heart: heart:

Aortic

Pulmonary

valve

|

Atrioventricular Right

•

THE

2

(3

cusps) (3

cusps)

Tricuspid valve

Mitral

Figure

Right –

upper

FigureII

2 II 40. 2 38. Surface Surface

Projections Projections

of the

ofHeartthe

Heart

sternum

Systolic • Aortic

Rib

stenosis Rib

2

Upper

3

–

lateral

Rib

Rib

6

lower

insufficiency

5

Apex –

Right

chest

Systolic • Mitral

–

valve

Diastolic • Mitral

stenosis

• Aortic

insufficiency

sternum

Systolic • Tricuspid

insufficiency

Figure

IIFigure 2 41. II 2Auscultation 39. Auscultation

ofof Heart Heart

Murmurs Murmurs

7

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology Table

II 2

4.

Heart

Murmurs

Stenosis

A V Pharmacology

Valves

Insufficiency

Diastolic

murmur

Systolic

murmur

Biochemistry Tricuspid Mitral

Outflow Physiology

Medical Genetics

(left)

Valves

Pulmonic Aortic

Pathology

(right)

Systolic

murmur

Diastolic

murmur

(right) (left)

BehavioralScience/Social Sciences

Arterial The

Supply blood

coronary Microbiology

and

supply

to

arteries.

arise

tively.

of

Blood

from

the These

the flow

the

right enters

Heart myocardium 2 and the

arteries left coronary

is are aortic

provided the

by

only

sinuses arteries

branches

branches of

the

during

of of

the

ascending

the

right

and

ascending aorta,

aorta respec

diastole.

Left

coronary

artery

Circumflex SA

artery

nodal artery

Left

anterior

descending Right

(LAD)

artery

coronary artery Diagonal CLINICAL

AV

CORRELATE

artery

nodal In

myocardial

descending cases, circumflex

infarction, artery

the

right artery

the

is coronary in

left

obstructed

20%

in of

anterior in

30%,

artery

50%

and

of Marginal

Posterior

artery

interventricular

the

cases.

artery

Figure

7

FigureII 2 II 42. 2 40. Arterial Arterial

Supply Supply

to

the theto Heart

Heart

left

CHAPTER

Right The of

coronary right

the

|

THORAX

artery

coronary

right

•

2

artery

atrium

courses

and

Sinoatrial

the

(SA)

coronary,

it

in

right

nodal

the

the

sulcus

The

artery:

encircles

coronary

ventricle.

One

base

of

of the

and

branches

the

supplies

include

first

branches

superior

vena

major

the

cava

parts

following:

of

the

to

supply

right the

SA

node. •

Atrioventricular right

(AV)

coronary

penetrates •

the

Posterior

supply

The

left

parts

coronary

the

of

courses

right

and

the

artery

and

descending

from

It

is

in

the the

the

left

the

distal

end

interventricular

supply

AV

of

the

artery

and

node.

terminal

distribution

posterior

ventricles

interventricular

The

travels

divides

into

(LAD)

of

the

interventricular and,

sulcus

importantly,

the

septum.

(2)

and

and

short

course

and

descends

branches

thirds The

left

auricle or

and left

anterior

artery.

artery

apex.

the

interventricular

circumflex

two

(4)

between

anterior

provides

anterior

His,

a

branches:

interventricular sulcus

wall,

2

artery

anterior

tricular

of

to

and

arises

posterior

artery:

of

third

It the

artery

ventricle,

•

forms septum

artery

posterior

coronary

artery:

it

interatrial

coronary

Left

as

interventricular

right to

nodal

artery

of LAD

to

the is

in

the

(1)

the

anterior

anterior

interventricular

the

most

interven

left

ventricle

septum,

common

site

(3)

of

bundle

coronary

occlusion. •

The

circumflex

coronary

artery sulcus

marginal and

Venous

branch

supplies

major

arteries

cardiac but

•

not

sinus

posterior

coronary

develops •

Great LAD

•

Middle

from

•

Venae directly

it

cardiac

the same

the

main

to

left

border of

posterior

of the

the

heart

heart

aspect

ventricular

the vein

in

chambers

of

of

the

in

via

the

left

ventricle

the

wall.

an

sulci

veins

and

are

accompany

the

following:

the

right

circulation;

opening

in

it

the

lies

in

the

atrium.

It

venosus. anterior

the artery;

interventricular of

posterior it

(thebesian of

the

coronary to

tributary in

in major

the

drains

the

main lies

course The

vein

sinus

lies

minimae the

left

border

left

heart

and

interventricular cordis

the

names.

sulcus

is

on

left

Heart

vein

artery;

posterior

is

the

the

inferior

the

the

cardiac

ends

draining

carry

Coronary

(2)

the

veins

do

(1)

posterior

of

around

supplies

and

the

Drainage

The

courses

and

the

joins veins)

the

sulcus

coronary

and

coronary anterior

the

sinus.

interventricular the

with

sulcus

with

the

sinus. cardiac

veins

open

heart.

7

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology

Coronary sinus Pharmacology

Biochemistry Great cardiac LA

vein RA Coronary Physiology

Medical Genetics

RA

sulcus

LV

RV LV

RV

Small cardiac

Pathology

BehavioralScience/Social Sciences

vein Anterior interventricular

Posterior

Middle

interventricular

cardiac

sulcus

vein

sulcus

Anterior

Microbiology

Posterior

Figure

II

2

43.

Venous

Figure

Conducting The

System

cardiac the rate

walls

of

fibers

the

to

through

atria

from

atrioventricular

the

bundle

interventricular muscle

•

•

known

The

Purkinje

and

initiate

The

SA

the

terminalis,

•

initiates

SA

the

node

bundle

Heart Heart

in

the

impulse

way

at

a

the

internodal activity

bundle

passes

branches

in

specialized

the

cardiac

walls.

along

the

apex a

of

node, left

that

depolarize

through

additional

the

section,

endocardial

of

the

surface

ventricles.

cytoplasm

with

few

contractile

glycogen.

for

contraction

heart).

It

vena

is

cava

by

by

ventricular

at

to

spreads

and

bundles

cells

ability

passed

right

starting

of

myocardial

their

atrioventricular

reach

several

content

supplied

quickly

the

cross

of to

activity

branches

in

the

due

the

fibers

superior

is

is

down

a large

of

group

heart

and

activity

the

the

of the

Electrical

then

run

have

“pacemaker”

the

From

Purkinje

a large

where

The

and

fibers

and

node

The as

fibers

node

termed

His

ventricle

Purkinje fibrils

SA

node. of

of

Drainage

a specialized of

myocytes.

the

septum. fibers

is

cardiac

the

Venous

Heart

contractions

other

Drainage

41.

system

periodic than

2

the

conduction

initiates faster

of

II

the

of

located

enters

SA

the

nodal

heart

at

the

right

branch

muscle

(and

superior

is

end

of

therefore the

crista

atrium.

of

the

right

coronary

artery. •

Impulse is

The

AV

septum

node

it

•

the

reaches

The

by

is

AV

node

up

of

ventricles

is

supplied

by

(vagal)

impulses

opening the

speeded

parasympathetic

receives

near

that

7

production

slowed

from the

the

SA

coronary

after

it

by

has

the

sympathetic

sinus. reached

right

nervous

stimulation;

it

stimulation.

node;

it

is

The

AV

the

atria.

coronary

located node

artery.

in slows

the

interatrial the

impulse

so

CHAPTER

The

bundle

left

ventricles.

•

of

In

His It

the

right

contains •

originates by

ventricle, the

Impulses

AV

node.

LAD

It

conducts

impulses

to

the

right

|

THORAX

and

artery.

moderator

bundle

from

and

the the

the

right

pass

muscles

in

is supplied

2

band

(septomarginal

trabecula)

branch.

the

right

ventricular

and

left

bundle

branches

to

the

papillary

myocardium.

Innervation The

cardiac

plexus

is a

combination

of

sympathetic

and

parasympathetic

(vagal)

fibers.

•

Sympathetic

stimulation

associated

with

pathways •

back

into

Parasympathetic carry

increases

coronary

artery

spinal

cord

stimulation

the

afferent

limb

the

rate. (angina)

segments

T1–T5.

slows of

heart

ischemia

cardiac

the

heart

reflexes

Nerves

that

follow

the

rate. travel

Sensory with

sense

nerves

the

vena

node)

Left

atrium

nerve.

node

cava

Sinoatrial (SA

(AV

that

vagus

Atrioventricular Superior

pain

sympathetic

node

Pulmonary

node)

veins

Common

Left Right

atrium

Right

ventricle

AV

bundle

ventricle

Right

and

bundle

left

branches

Inferior vena

cava

Purkinje fibers

Figure II 2

Figure

42. Cardiac Conduction Conduction 44.II 2 Cardiac

System System

DIAPHRAGM The dome vated

diaphragm shaped, by

the

is and phrenic

composed descends nerves

of upon that

a muscular

portion

contraction arise

from

and of

spinal

its

a central

muscular cord

segments

tendon. portion. C3

It through

It

is

is

inner C5.

7

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology The

diaphragm

•

is

The

formed

septum

by

the

fusion

transversum

of

gives

rise

tissue

from

to

central

the

4

sources:

tendon

of

the

diaphragm. Pharmacology

•

Biochemistry

The

pleuroperitoneal

portion •

of

The

membranes

the

dorsal

give

rise

to

parts

of

the

tendinous

diaphragm.

mesentery

of

the

esophagus

gives

rise

to

the

crura

of

the

diaphragm. Physiology

•

Medical Genetics

The

body

Apertures

Pathology

Caval

BehavioralScience/Social Sciences

in hiatus tendon.

phrenic

nerve.

muscle

posterior

Aortic transmits

CLINICAL

Pain

the

It

Esophageal Microbiology

contributes

the

the

right the

is

located

the

right

crus.

vagus

hiatus

to

transmits

hiatus of

muscle

to

the

periphery

of

to It

of

the

midline

inferior

the

vena

left

of

transmits

the the

at

cava

and

midline

the

level some

at

esophagus

(motor

and

through the

innervation sensory)

C5

the

is

located

aorta

in

and

the

midline

thoracic

at

the

level

of

T12,

duct.

nerves, (e.g.,

T1

diaphragm

is primarily

spinal

diaphragm

to

from

pain

C3

arising

subphrenic

from

abscess)

is T4

referred

to

shoulder

these

in

the

region.

CLINICAL

CORRELATE

A congenital a

dermatomes

diaphragmatic

herniation

of

hernia

abdominal

is

contents

into

the T9

pleural

cavity

due

to

pleuroperitoneal properly. on

left

pulmonary

An of an the

stomach

abnormally diaphragm.

esophagogastric that

of

hernia

is

to

most

posterolateral

the

develop

commonly side

and

found

Diaphragm phragm

causes

Inferior rior

vena

cava

(T8)

hypoplasia.

esophageal the

failure

membranes The

the

the

contents

hiatal into large This

hernia the

pleural

esophageal condition

sphincter reflux

into

is

cavity hiatus renders

incompetent the

Esophagus ophagus

a herniation due

to

Aorta

ta

(T10)

(T12) (TT122)

to the so

esophagus.

Figure Figure II 2

80

of

T8,

within

level

the

of

of

the

anterior

behind

the

T10,

the

right

within and

trunks.

Referral

the

diaphragm.

branches

the and

CORRELATE

Because

the

Diaphragm

is located

central

the

wall

II 43.

2 45. The The Diaphragm

Diaphrag

2

crura.

It

CHAPTER

2

|

THORAX

RADIOLOGY

Aortic Arch

Left Pulmonary Superior Vena

Artery

Cava

Left Atrium

Right Left

Atrium

Ventricle

From

the

All rights

Figure

IMC, © 2010 DxR Development From the IMC, © 2010 DxR reserved.

II 2 Figure

46. Anterior II 2 44. Anterior

Projection Projection

Group, Inc. Development All

Group,

rights

Inc.

reserved.

of Chest, of Chest, Male

Male

Left

Right

Atrium

Ventricle Left Ventricle

Right Dome

of

Diaphragm

Left Dome

of

Diaphragm From

the

IMC,

© 2010

DxR

Development All

Figure

II 2

45.

Lateral

Projection

Group, rights

of Chest,

Inc.

reserved.

Male

8

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Brachiocephalic Right

brachiocephalic

trunk

vein

Left

brachiocephalic

vein

All Pharmacology

From

Biochemistry

rights the IMC, © reserved. Physiology

2010

Medical Genetics

DxR

Pathology

BehavioralScience/Social Sciences

Development

Group, Inc.

Microbiology Trachea

Left Esophagus

Left

Figure

Superior

Vena

Figure

II

Cava

2 48. II 2 46.

Aortic

Chest: Chest:

subclavian

common

CT, CT, T2

Arch

carotid

Trachea

Esophagus

From From rights the the IMC, IMC, © reserved © 2010 2010 DxR DxR

Development

Development rights Group, Group, Inc. reserved. Inc. T3

Ribs

Figure

82

Figure

II

Vertebra

2 49. Chest: II 2 47. Chest:

Scapula

CT, CT, T3

artery

T2

All

All

artery

T3

CHAPTER

Superior Vena

Ascending Cava

Bifurcation

Aorta

of

2

|

THORAX

Descending

Trachea

Aorta

All From rights the From IMC, the © reserved. IMC, 2010 © DxR 2010 DxR

Development All Group, Development rights Inc. Group, reserved. Inc. Ribs

T4

Figure

Vertebra

Scapula

Figure II 2II 250.48.

Chest: Chest:

CT, CT, T4

T4

Right Pulmonary Artery

Superior Vena

Body Cava

of

Ascending

Sternum

Pulmonary

Aorta

Trunk

All From rights the From IMC, the © reserved. IMC, 2010 © DxR 2010 DxR

Development All Group, Development rights Inc. Group, reserved Inc. Descending

Aorta

Figure

T5

Figure

Spinal

Vertebra

II

2 51. II 2 49.

Chest: Chest:

CT, CT, T5

Cord

T5

83

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology PA

= pulmonary

artery Used

RA =

Pharmacology

right

atrium

AA = ascending

LA = left

withCopyright

Biochemistry aorta

PA Lippincott permission.

atrium

AA E = esophagus Physiology DA

= descending

Williams &

LA

Medical Genetics aorta

p

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Figure

Lippincott II

Figure

2

Williams

52.

II 2

Chest: 50.

Right

Right

Atrium

Ventricle

Chest:

& Wilkins. CT,

Used

with

T5

CT, T5

Left Ventricle

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Vertebra

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Left

Aorta Esophagus

Figure

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Abdomen,

LEARNING

Pelvis,

and

Perineum

3#

OBJECTIVES

❏

Explain

information

❏

Answer

questions

❏

Solve

❏

Answer

related

to

about

problems

region

embryology

concerning

questions

inguinal

of

the

and

GI

canal

system

peritoneum

about

GI

histology,

innervation,

and

immune

functions

❏

Solve

problems

concerning

abdominal

Explain

information

❏

Answer

questions

❏

Use

❏

Demonstrate

linea

the

xiphoid

to

about

knowledge

alba to

The

components

The

of

posterior

urinary

male

and

venous

drainage

abdominal

histology

female

understanding

linea

pubis.

The

anterior

and

lines.

The

subcostal

to

body

and

function

reproductive

of

radiology

wall

histology

of

the

abdomen

and

pelvis

WALL

sheath

curved

wall

plane at

vertically

right

in

and

intersect

line

and

abdominal

(variable),

fundus the

is divided

(horizontal) the

plane pubis

important

of

rectus

runs the

at

defining

left the

the

the

median

rectus linea

plane

abdominis

from muscles.

alba.

lateral

border

of

the

rectus

Regions

transpyloric

part

that

separates

feature.

abdominal

the

groove It

is a

cartilages

between

the

bilateral

and

costal

a shallow

semilunaris a

Planes

is the

of

abdominis,

first

and

Anatomy

The

The

related

ABDOMINAL

Surface

supply

viscera

❏

ANTERIOR

arterial

passes

level

of

passes the

duodenum,

the

third

through

jugular

landmarks of

into

through

the notch.

neck and

origin

L1

for

of

inferior

vertebra, plane

several

margins

being passes

radiology: body

the

by

planes

of

the

10th

vertebra.

The

and

separated

the

lumbar

useful

gallbladder,

9 regions

half

pylorus of

superior

the

the

through

pancreas, mesenteric

distance

several of

the

stomach

hila

of

kidneys,

artery.

8

PART

II

|

GROSS

Anatomy

ANATOMY

Immunology The the

Pharmacology

RH:

right

LH:

left

RL:

right

LL:

left

RI:

right

LI:

left

hypochondrium

lines to

the

(vertical)

midpoint

are

of

the

the

2 planes

inguinal

that

ligament

pass on

each

from

the

midpoint

of

side.

Biochemistry

hypochondrium

lumbar

Physiology

Pathology

midclavicular clavicle

Medical Genetics lumbar

inguinal

inguinal BehavioralScience/Social Sciences

Microbiology

Epigastrium

RH

LH

Subcostal plane RL

LL

Umbilical

Intertubercular plane

Hypogastrium RI

Anterior

LI

Inguinal

superior

ligament

spine

iliac

Pubic tubercle

Figure

Muscles The

and anterolateral

(with flat

their

pubis. childbirth,

8

3

1.

Regions II 3 1.

Regions and

body

wall

abdominal that

muscles adjacent

Abdominal etc.

and Planes Planes

ofof the the

Abdomen AbdomenFigure

Fasciae

aponeuroses)

abdominal

vertically

II

to

are the

muscles

is

support arranged

midline, are

a multilayer

and in

protect

layers

extending important

and between

in

respiration,

of

fat,

the

abdominal

the

rectus the

fasciae,

and

muscles

contents. abdominis

costal defecation,

margin

Three is and

micturition,

oriented the

CHAPTER

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

NOTE

Skin Superficial

fascia

of

the

anterior

abdominal

wall

below

the

umbilicus

consists

of

2

Anterior

Abdominal

Wall

Layers

layers:

•

Camper that

(fatty) is

fascia

variable

in

is

the

outer,

thickness

subcutaneous

owing

to

layer

the

presence

of

of

superficial

•

Skin

•

Superficial

fascia

fat.

Scarpa •

Scarpa of

(membranous)

fat.

It

is

fascia

continuous

layers

(Colles’

clitoris

or

is

into

fascia,

the

the

dartos

deeper

layer

perineum

fascia

of

with

of

the

superficial

various

scrotum,

fascia

perineal

fascia

of

of

external the

and

3

penis).

abdominal

flat

inguinal

•

the

spermatic

spermatic

cord

the

ring

sheath: rectus

most

the

superficial

abdominal

and fascia

is at

external

the

the

inguinal

as of

a

inguinal outer

superficial aponeuroses

in

opening tubercle.

•

External

oblique

•

Internal

oblique

•

Transversus

abdominis

•

Transversalis

fascia

•

Extraperitoneal

•

Parietal

connective

tissue

peritoneum

and

form

a deeply

ligament.

hernia.

cleft

medial

(fibrous)

the

spine

attaches

pectineal

femoral

triangular

pubic

that the

and

wall

of

iliac ligament

ligament

border

the

fibers

superior

continues

the

male

the

lacunar

a vertical

to

aponeurotic

anterior of

and

represents lateral

female

The

fibers

medial is

that

formed

the to

under the

the

pubis the

and

the

is

contributions

rolled

called the

forms

External

of

of

superior

aponeurosis

Its

between the

shelf line

of

inferior

Medially,

aponeurosis just

structures

Rectus

the extend

inguinal

oblique

•

is that

ligament

and wall.

following:

horizontal

Superficial

canal

the

pectineal

Lacunar

muscle

abdominal

tubercle.

flattened

•

are

oblique

pubic

the

the

ligament

external

•

of

region

Inguinal

to

oblique

muscles

(fatty)

the

Muscles The

Camper

devoid

fascial

superficial

fascia:

the of

It

external the

inguinal

transmits

the

canals. layer

of

inguinal contribute

the

3 coverings ring

in to

of

the

males. the

anterior

layer

sheath.

8

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology

Lumbar vertebrae Pharmacology

Biochemistry

Physiology

Medical Genetics

Anterior

superior iliac

Sacrum

spine

Ischial spine Coccyx

Pathology

BehavioralScience/Social Sciences Inguinal ligament Pubic tubercle

Microbiology Pubic symphysis

Figure

II

3

Figure

Internal flat

abdominal

muscles

ment. in

The

internal with of

inguinal

region

•

•

Conjoint of

insert

on

the

Rectus

inguinal

middle of

arch

the

over

the

abdominis to

the

layer

of

inguinal

the

inguinal

muscle.

abdominal

3

liga canal

The

wall

and

is and

the

posterior

internal

formed

by

the

transversus

to

the

combined

abdominis

superficial

aponeuroses

arching muscles

inguinal

contribute

to

that

ring.

the

layers

of

the

and

the

Transversalis cavity.

represent

spermatic

cord

muscle

transversus and to

the

and

middle

testis

in

of

the

fascia:

the

layer

the

and This

contributions

the

of

This in

tendon.

layers

spermatic

Fasciae

Its

over

conjoint

to

aponeurosis:

originates,

arches

the

contribute layers

and

muscle

contribute

the

fascia

of

spermatic

male.

It

the forms

in

the

canal.

Abdominopelvic

8

The

ligament

also of

and

oblique

oblique crest

abdominis

to

thirds

transversus

inguinalis)

muscle

The

muscle

pelvic

(falx

covering

Transversus

fibers

This

two

medially

the

abdominal

pubic

Cremasteric

muscles.

of

Cavity Cavity

aponeurosis: lateral

course

Abdominopelvic

Abdominopelvic

following:

internal

the

inguinal

any

internal the

the

the

the

sheath.

fascia

the

fibers

sheath:

rectus •

fibers

the

of

and

from

arching

tendon

fibers

part,

oblique

are

of

Osteology

muscle

in

the

contributions

Osteology 2.

oblique

originates,

parallel

2.

II 3

part,

inguinal The

the

rectus

is

from canal

the the

with

of It

does

of one

the

aponeuroses sheath.

deepest lateral

the

flat

third

internal the

transversus

not

contribute

fasciae.

Peritoneum fascia

forms to

the

a continuous inguinal

region

lining include

of

the the

entire following:

of

oblique

abdomino

to

CHAPTER

•

•

Deep

inguinal

fascia

immediately the

epigastric

vessels

Internal

•

inguinal

vein

and

at

Rectus

the

Parietal

an

into canal

The

deep

the

thigh

(site

AND

PERINEUM

transversalis ligament

inguinal

and

canal.

of

the

coverings

of

the

transversalis

containing

of

transversalis

the

PELVIS,

The

inferior

of

the

spermatic

male.

extension the

the

inguinal

ABDOMEN,

ring.

deepest

in

of

the

of

the

the

inferior

femoral

of

opening to

ring

ligament

outpouching

|

femoral

the

femoral

fascia

deep

artery

and

to

hernia).

fascia

contributes

to

the

posterior

layer

of

sheath.

Extraperitoneal

connective

surrounding

deep

is

deep

an

midpoint

medial fascia

the

by

the

and

is

sheath: rectus

formed

are

sheath

the

gonads

lateral

spermatic formed

Femoral

the

is above

represents

cord •

ring

3

the

tissue

abdominopelvic

develop

from

peritoneum

the

is

is

a

cavity, urogenital

the

outer

thin

ridge

serous

layer

most

of

loose

prominent

within

membrane

connective around

this

tissue the

and

kidneys.

fat The

layer.

that

lines

the

abdominopelvic

cavity.

Parietal

Extraperitoneal

peritoneum

Deep

fat

inguinal

ring Inferior

epigastric

artery

&

vein

Transversalis fascia

Weak

area Rectus

abdominus

Transversus Conjoint

abdominus

(falx

tendon inguinalis)

Internal abdominal

oblique

External abdominal

oblique

External

oblique

External

spermatic

Internal Cremasteric

muscle

Cremaster

igure FFigure

inguinal

ring

II 3II 3. 3 Layers of Anterolateral Abdominal 3. Layers of Anterolateral

Internal

WallAbdominal and Inguinal

Canal Wall

and

Inguinal

fascia

oblique

fascia

muscle

Transversalis Superficial

fascia

and

fascia

fascia spermatic

fascia

Canal

8

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Nerves,

Blood

Vessels,

Innervation

of

branches Pharmacology

Biochemistry

of

(includes of

the

the

The

Pathology

Medical Genetics

BehavioralScience/Social Sciences

deep

drainage

thoracic

veins

Lymph

from

The

canal

aspect

medial

half

because

The

of

it

The

pubic

via

branches

the

wall

is

superior

epigastric

epigastric,

the

lateral

inferiorly.

to

axillary

nodes

(approximately running

4

parallel

the

the

inferior

artery.

superficial

Clinically,

deep

from

the

iliac

vein

hernias

the

as

cm

and

inguinal

superiorly

long)

in

superior

region

is

the to

the

important

occur.

inguinal

immediately

ring,

located

superior

just

to

the

midpoint

of

the

canal

lateral

to

of

the

the

of

the

medial

opening

superolateral

to

of of

the

the

Ilioinguinal

nerve skin

Inguinal

the

nerve

the

spermatic

cord

that

are

to

related

a branch

of part

the

and

the

of

and

a branch lateral

is the

canal

Testicular

between

ligament

uterus

the

and

labia

homologue

of

majora,

and

the

male.

anterior

(L1),

of

The

the

the

(L1),

of

skin

inguinal

of

extends

genital

lumbar

the

plexus,

mons

exits

pubis

and

the

labia

superficial

ring

to

ring

to

majora.

Canal

Ilioinguinal the

uterus

caudal

testis

the

Canal

Canal

gubernaculum

supply

is the

Inguinal

ligament remnant

supply

ring

tubercle.

Round

•

is

to

wall

inguinal

inguinal

Inguinal

contains

is

nerves

ilioinguinal

derived

well

external

passageway

ligament.

is

as

the

is

abdominal

and

wall

anterior

CANAL

canal

wall

spinal

ligament.

Female

the

the

oblique

vessels

abdominal thoracic and

saphenous

AND

where

the

of

inferiorly.

inguinal area

into

Contents

9

the

superficial

Male

the

6

artery,

nodes

anterior

epigastric

inguinal

is a

is

the

is the

entrance

inferior

the

of

anterior

great

of

REGION

inguinal

lower

the

wall

the

tissues

inguinal

INGUINAL

iliohypogastric

anterior and

from

superficial

Wall

anterior

lower

the

branches

the

the

the

thoracic

iliac

superiorly

drainage to

to

internal

circumflex

Abdominal

L1.

supply

the

of

plus of

blood

of

rami

nerve),

of

of

musculature

rami

arterial

Venous

and

Microbiology

subcostal

branch

the

and

Lymphatics

primary

primary

major

and

skin

ventral

ventral

epigastric Physiology

the

the

and

and

formed testis.

the

during The

exits

of

the

lumbar

anterior

plexus,

descent

cord

of

begins

superficial

exits

the

superficial

scrotum.

at ring

the

the to

testis deep

enter

and ring the

contains and

structures

courses

scrotum.

through The

cord

following:

artery,

branch

of

the

abdominal

aorta

that

supplies

the

testis

CHAPTER

•

Pampiniform testis

•

venous

located

plexus

coalesce

plexus

assists

Vas

Autonomic

•

Lymphatics:

the

to in

deferens

•

plexus,

within

form

the

an

extensive

scrotum

and

the

testicular

regulation

of

(ductus

deferens)

network

vein the

and

of

spermatic

cord.

at

the

deep

temperature its

veins

draining

The

veins

ring.

of

the

|

ABDOMEN,

CLINICAL

venous

testis.

the

artery

develops

pampiniform

(aortic)

nodes

nodes

of

which

the

lumbar

drain

the

region

rest

of

the

testis

and

the

will

not

to

male

perineum.

from

the

drain

the

into

the

superficial

are

that

3 fascial

surround

•

components

the

External

spermatic

or

internal

cremasteric

formed at

the

by

the

muscle

of

This

enlargement

of

and

causes

may

result

the

in

in

enlargement

of

the

spermatic

scrotum

the

Varicoceles

cord

or

above

inguinal scrotum.

the

abdominal

wall

standing

into

the

size

when

are

because

scrotum.

of

more the

prominent

blood

A varicocele

will

pooling reduce

in

aponeuroses

and

helps

is

formed

of

the

the

individual

is

horizontal.

external

ring.

fascia

within

testis

the

superficial

and

oblique

elevates

the

is

muscle

abdominal

muscle

•

fascia

oblique

Middle

layers

and

plexus

veins.

collects

cord:

spermatic

abdominal •

derived

tortuous

blood

lumbar

when There

when

venous

and

swelling of

PERINEUM

CORRELATE

A varicocele

nerves drainage

AND

the

dilated

Lymphatic

PELVIS,

the

of

The

3

are

the

formed

inguinal

regulate

by

fibers

canal. the

The

thermal

of

the

cremasteric

environment

of

testis.

Internal

spermatic

fascia

by

the

transversalis

fascia

at

the

deep

ring.

CLINICAL Boundaries The

of

roof

is

abdominis

the

Inguinal

formed

by

muscles

arching

fibers

of

the

over

internal the

abdominal

spermatic

oblique

and

the

Cancers

transversus

anterior

wall

throughout

the

The

floor

the

lacunar

The

is

formed

inguinal

formed

by

and

inguinal at

wall

aponeurosis

canal

ligament

posterior

by

is

of

the

internal

ligament

the

medial

divided

the

external

abdominal

abdominal

throughout

oblique

oblique

the

entire

muscle

the to

and

medial

metastasize

to

Lateral

area

area •

of

the

Medial the

is

by

posterior

area

is

internal

(conjoint

formed

the

inguinal

canal

fascia

In

and

the

males,

represents

the

weak

the

by

formed

and

abdominal

epigastric weak

of testis

area

the

develops

extraperitoneal posterior fibrous

will

(lumbar)

nodes.

upper

reflex

lightly

medial

thigh,

can

be

touching

the

resulting

in

skin

of

a slight

wall. reinforced

oblique

by

and

the

fused

transversus

aponeurotic

fibers

abdominis

of

muscles

elevation

of

the

are

reflex

the

testis.

The

carried

ilioinguinal

nerve

artery and

just

and

vein

medial

to

ascend the

the

deep

posterior

wall

just

lateral

to

of

by and

sensory

the the

L1

fibers fibers

motor

of

of the

genitofemoral

gubernaculum.

genital

response

nerve

branch that

of

is

innervates

the the

muscle.

Testes from connective

abdominal

the

ring.

CLINICAL The

aortic

a cremasteric

cremasteric

Descent

cancer

tendon).

Inferior the

inguinal

testicular

CORRELATE

a function •

will

and

areas:

transversalis

scrotum

superficial

and

demonstrated •

and

the

nodes,

CLINICAL

lateral

penis

laterally.

end.

into

of

metastasize

cord.

lymph The

CORRELATE

Canal

the

mesoderm tissue

wall

inferiorly

of

layer. toward

the

During

urogenital the

the

deep

ridge

last

within

trimester,

inguinal

it descends ring

CORRELATE

the

guided

by

the

Failure

the

descend

of

one

or

completely

in cryptorchidism, sterility

both

of into

which

the

testes

the

scrotum

may

lead

to results to

if bilateral.

9

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology •

An

evagination

extends

of

into

the

connection

of

before Pharmacology

the

parietal

inguinal the

peritoneum canal

processus

and

called vaginalis

the

the

processus

with

the

peritoneal

cavity

vaginalis. peritoneal

The cavity

open

closes

birth.

Biochemistry •

A

portion

of

surrounds

Physiology

Medical Genetics

Peritoneum

Testes

the

the

processus testis

vaginalis

as

the

remains

tunica

patent

in

the

scrotum

and

vaginalis.

Peritoneum

Testes

Pathology

BehavioralScience/Social Sciences

Microbiology Tunica Pubis

vaginali

Processus vaginalis Gubernaculum

A

BC

D

Figure

II

3

4.

Figure

CLINICAL

A persistent in a

Inguinal

CORRELATE

process

congenital

vaginalis

indirect

often

inguinal

results hernia.

Herniation

of

abdominal

abdominal

wall

(e.g.

the

most

in

are

males

occur

due

to

to

of

serous

fluid

in

the

Indirect

vaginalis

forms

enlarged

scrotum. in

size

a hydrocele,

resulting

A hydrocele when

the

in

does

not

is

lying

patient

an

viscera

can

common

the

occur

femoral, of

inherent

in

one

of

umbilical,

the

or

abdominal

weakness

inguinal

inguinal the

After

of

several

hernias

the

male

weak

aspects

diaphragmatic). and

occur

inguinal

of

the

Inguinal

canal.

more

frequently

Inguinal

hernias

ligament.

–

–

•

NOTE

and

Indirect

inferior

epigastric

inguinal

hernias vessels.

found

medial

vessels, occur

and lateral

to

the

They

Direct

the

indirect to

when

are

the

inferior

coil

inferior

in

abdominal

covered

epigastric

the

by

area

to

the

contents

canal

and

inferior

protrude

epigastric

superficial

vessels.

ring,

the

viscera

scrotum. the

route

taken

by

the

testis

and

are

found

cord. the

hernias weak

lateral

inguinal

follow

spermatic

inguinal the

ring the

hernias the

through are

result

inguinal

through

continue

within

hernias

hernias

deep

passing

can

down.

92

Testes Testes

tunica through

epigastric

the the

inguinal,

the

superior

•

Direct

of

CORRELATE

A collection

reduce

of

4. Descent

Hernias

hernias

CLINICAL

Descent

II 3

3

layers

result of vessels

the

of

when posterior (in

the

spermatic

the

fascia.

abdominal wall

inguinal

of

contents the

inguinal

[Hesselbach’s]

protrude canal

medial

triangle).

to

CHAPTER

–

Direct

hernias

and the –

are

rupture

usually

superficial

They

may

through

found

on

the

the

posterior

surface

of

wall

the

of

the

spermatic

inguinal

cord

and

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

canal bulge

at

ring. be

covered

by

only

the

external

layer

of

spermatic

fascia.

NOTE CLINICAL

CORRELATE Both

Direct

inguinal

hernias

usually

pass

through

the

inguinal

triangle:

the pass

•

Lateral

border:

inferior

•

Medial

border:

rectus

•

Inferior

Inferior artery

(Hesselbach’s)

border:

epigastric

superficial through

and

indirect ring, the

but deep

hernias only

exit indirect

through hernias

ring.

vessels

abdominis

inguinal

direct

muscle

ligament

epigastric &

vein

Indirect

Inguinal triangle Direct

Superficial

inguinal

ring

Figure

II

Figure

3

5.

Inguinal

II 3 5. Inguinal

Hernia

Hernia

9

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

CLINICAL

CORRELATE

Inguinal

hernias

ligament, below Pharmacology

while it.

pass femoral

Femoral above hernias

the

inguinal

Hernias

Femoral

hernias

most

often

occur

in

women.

pass Biochemistry Inguinal

ligament

Femoral

Physiology

Femoral

artery, BehavioralScience/Social Sciences

Femoral

sheath

contains Pathology

Femoral

Sartorius

Medical Genetics

Site

nerve

and

canal

of

canal

femoral vein,

vein

canal

Femoral

femoral and

Adductor

artery

hernia longus

Microbiology

Figure

EMBRYOLOGY

OF

Primitive The

gut

2 body

externa,

The supplied

9

tube

lining the and

of

lamina

gut by

head the

by to

a

3 6. Hernia

Femoral

Hernia

TUBE

propria,

specific

tube

the

muscularis

is divided and

of

(cranial of

are

artery

incorporation

tail

mucosa

adventitia/serosa

primitive

II

GASTROINTESTINAL

is formed

foldings:

epithelial

endoderm,

Figure 6. Femoral

Tube

primitive

during the

Gut

THE

II 3

primitive

from

the

autonomic

foregut, nerves.

the

yolk

and gut

mucosae,

derived

into

caudal)

sac

lateral

tube

is

submucosa,

into

the

foldings. derived

embryo While

from muscularis

mesoderm.

midgut,

and

hindgut,

each

CHAPTER

Table

II 3

1.

Adult

Structures

Derived

from

the

Foregut

3 Divisions

of

the

Primitive

Gut

celiac

vagus

innervation:

vagus

Sympathetic •

superior

innervation: thoracic

•

innervation:

innervation:

mesenteric

Parasympathetic

innervation:

pelvic

splanchnic

nerves

thoracic

splanchnic

•

cell

bodies:

celiac

•

Pain:

ganglion

•

superior

Derivatives

Esophagus

Pain:

Midgut

Derivatives

Duodenum

Stomach

mesen

teric

Umbilical

Referred

Hindgut

(second,

third,

and

Transverse

parts)

colon

Sigmoid

Liver

Cecum

Rectum

Pancreas

Appendix

Anal

Biliary

apparatus

Ascending

Gallbladder

Development

and

After

body

from

the

ventral

foldings

bud

body wall

in

the

develop

•

The axis.

•

and

dorsal body

develops

Rotation

in

the

dorsal

surface

rotation

will

Foregut

rotation

mesentery), the

•

The

ventral

and

the

The

dorsal

and

the

the

spleen

the

the

embryonic

greater

the

is

and

around

its

The

suspended

and

from

that

spleen

before

anterior

the

the

lower

system,

liver

dorsal

endodermal

respiratory and

pancreas outgrowth

tract, all

liver develop

of

the

and

biliary from

an

foregut.

pancreatic

greater

becomes

the

borders

before

respectively.

omentum

(ventral

duodenum

omentum

longitudinal

posterior

curvatures,

lesser and

rotation and

greater

liver,

embryonic

moving (dorsal

to

the

right;

embryonic

left. will both

mesentery

splenic the

its

mesentery

embryonic

or

the

ligament,

gastro

foregut

Note

(clockwise) stomach

and

and to

falciform

the

stomach,

pancreas, moving

the mesentery

and

and

in of

tube,

mesentery.

lesser

results

spleen,

mesentery) •

the

pylorus

gut

embryonic

90°

of

rotation

become

(proximal

mesentery.

side

after

the

dorsal

rotates

left

colon

mesentery,

foregut original

pectinate

thirds)

embryonic

embryonic

(above

NOTE of

embryonic

abdominal The

the

ventral

colon colon

canal

Foregut

formation by

the

ventral

ventral

and

the

wall

by

of

(distal flexure)

line)

colon

Transverse two

Hypogastrium

third—splenic

Ileum

second

mesen

ganglion

Derivatives

parts)

and

inferior

Pain:

Descending

(first

L1−L2 cell

bodies:

Jejunum

Duodenum

PERINEUM

ganglion

Referred

fourth

nerves,

Postganglionic

cell

bodies:

Epigastrium

AND

lumbar

splanchnic

Postganglionic

teric

Referred

PELVIS,

innervation:

Preganglionics:

nerves,

T9−T12

Postganglionic

Foregut

inferior

Sympathetic

Preganglionics:

nerves,

T5−T9 •

Artery:

nerves

Sympathetic

Preganglionics: splanchnic

mesenteric

Parasympathetic

nerves

ABDOMEN,

Hindgut

Artery:

Parasympathetic

|

Tube

Midgut

Artery:

3

and

of

contribute which

will

contribute

splenorenal

curvature

ligaments, of

the

to

attach

the

to to

lesser

the the all

omentum

liver. greater of

which

omentum attach

to

stomach.

9

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Amniotic cavity Biochemistry

Pharmacology

(AM)

Ectoderm

Pharyngeal

Mesoderm

pouches

Yolk

Physiology

Esophagus

1

Endoderm sac (YS) Medical Genetics

Stomach

Lung

2 3

Hepatic

bud

Aorta

4

diverticulum Gallbladder AM Yolk BehavioralScience/Social Sciences

Pathology

Foregut

stalk

YS Microbiology

Vitelline

Vitelline

duct

duct

270°

along axis

Midgut

and (6–10th Septation

Cloaca

AM

Inferior

Coelom tube

mesenteric

Superior

Figure

rotation

counterclockwise

Hindgut

Gut

rotation right

fold

Allantois

II Figure

9

to

longitudinal

Lateral body

90°

artery

mesenteric

3

7A.

artery

Development

II 3 7A.

Development

Celiac

artery

Dorsal

pancreatic

Ventral

of of

Gastrointestinal Gastrointestinal

Tract Tract

pancreatic

bud

bud

herniation week)

CHAPTER

Development

Dorsal

Aorta

embryonic

of

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

Liver

mesentery

Lesser

Aorta

Dorsal

omentum

Kidney

Kidney

Mesentery GI

tract

Foregut Peritoneum Peritoneal

Ventral embryonic

Falciform

mesentery

ligament 1A

Development

cavity Liver

1B

of

Ventral

1C

Pancreas

Development

Stomach

Dorsal

of

&

biliary

system

Spleen

Spleen Splen

pancreatic

orenal

bud

ligament Spleen Gastro

Ventral

splenic

pancreatic bud

2A

2B

3A

Secondary

ligament

3B

Retroperitonealization

Fusion

4A

fascia

4C

4B

Rotation

of

Foregut

Epiploic foramen Lesser

Splenorenal

sac*

ligament

Greater sac Spleen 5A

5B Lesser

*Lesser

sac

=

omental

omentum

bursa

Figure

FigureII

3 7B. Cross Cross 3 II 7B.

Sectional Sectional

Gastrosplenic

View

of Foregut of View

ligament

Development Foregut

and Rotation Development

and

Rotation

9

PART

II

|

GROSS

Anatomy

ANATOMY

Immunology Development The

midgut

weeks Pharmacology

the

return

This

Medical Genetics

•

It

BehavioralScience/Social Sciences

The

causes

is

is

the

and

caudal

umbilical midgut

intestinal

cord. undergoes

mesenteric

jejunum

loops.

During a

During

herniation

270°

into

counterclockwise

artery.

being

on

the

left,

and

the

ileum

and

right. to

assume

the

shape

of

an

inverted

“U.”

Cavity

serous

into

the

the

colon

the

divided

cranial

the

superior

Peritoneal

peritoneum It

the

in

the

and

cavity.

of

on

the

into cord,

results

being

Peritoneum Pathology

axis

rotation

also

from

umbilical

the

cecum Physiology

Midgut

herniates

the

around

of

develops

midgut

from

rotation

•

Rotation

originally

6–10,

and

Biochemistry

and

2

membrane

layers:

related

parietal

to

and

the

viscera

of

the

abdominal

visceral.

Dorsal CLINICAL Microbiology

CORRELATE

Inflammation

of

(peritonitis) localized

over

the

Aorta parietal

results

in

the

area.

sharp

peritoneum pain

that

is

Kidney Dorsal mesentery Parietal GI

peritoneum

tract Visceral

peritoneum

Peritoneal

cavity

Ventral

Figure

The

parietal

surface. the

lower

the

lumbar

The

layer

the

intercostal

layer

suspend

terms

of

9

covers

the

to

retroperitoneal

somatic

ilioinguinal

surfaces

double GI

describe

lesser of

the

and

pain the

the

postnatal

and

greater

organs and

is

on

innervated

iliohypogastric

colon,

reflections according

of to

their

intraperitoneal

body to

remnants

omenta

organs.

membranes wall.

The

reach

the

of

attach

of

the

visceral

(mesenteries)

mesenteries GI

allow

for

tract.

mesenteries

to

The

in

lesser

the

or

sigmoid

mesocolon

attach

abdomen:

greater

to

the

transverse

or

the

body

respectively mesenteries attachments

between

organs

one by

nerves

respectively and

sigmoid

the

lymphatics

the

stomach,

the

peritoneal

from

and

transverse or

of

layered

tract

nerves,

Mesocolon:

Ligaments:

the

vessels,

Omentum:

named

and sensitive

the

the

forms

parts of

colon •

very

and

encloses

curvatures •

wall

is

nerves

usually

passage

•

body

II Peritoneum 3 7C. Peritoneum

plexus.

visceral

Different

the

peritoneum

peritoneum that

lines

Parietal

II Figure 3 7C.

wall,

CHAPTER

The

peritoneal

visceral

cavity

peritoneal

teries

divide

•

the

The

lesser

The

is

2 sacs

is

by

foramen

viscera

a

shift

(Figures

cul

the of

the

3

7B

II

de

sac

the

larger

area

parietal

and

ABDOMEN,

PELVIS,

AND

PERINEUM

and

embryonic

formed

of

between (of

the

mesen

II

3

9).

posterior

to

the

the

remaining

lesser

sac

peritoneal

and

the

greater

sac

Winslow).

Retroperitoneal are

between

the

|

omentum

formed

versus

abdominal

into

and

communication

epiploic

Intraperitoneal The

is

only

located

rotation

bursa)

lesser

sac

The

space

90°

(omental the

greater

the

potential

The

cavity

sac and

cavity.

the

peritoneal

stomach •

is layers.

3

Organs

classified

according

to

their

relationship

to

the

peritoneum.

•

Intraperitoneal

organs

completely •

enclosed

They

originally In

the

secondary

with

pancreas,

fuse

with

parietal

(and

these

gut

II 3

Major

as

2.

the

structures

(suspended

peritoneum).

and

mesentery)

a

Secondary

during

Liver

and

gallbladder

Duodenum,

1st

gut

2nd

fusion

of

visceral

organs

to

become

within

(most

part

of

of

peritoneum secondarily

the

organ the

Major

is

mesentery

of

Primary

Retroperitoneal had

of

and

Organs a mesentery)

Kidneys Adrenal

neck,

and

glands

Ureters

pancreas

part

Aorta colon

pancreas

Inferior Descending

Lower Upper

vena

cava

colon

Jejunum Ileum

tube

colon,

(never

parts

Ascending of

the

are

development)

body

Tail

Ret

mesentery

Head,

Spleen

of

vessels

Organs

Duodenum, 3rd

organs retroperito

Organs

roperitoneal a

parietal

retroperitoneal.

Retroperitoneal

(lost

Stomach

The

with

secondarily

covering

secondarily

Major by

the

peritoneum

become

Intraperitoneal

causes

visceral

side

descending of

almost

mobile.

one

parts

way

are

retroperitoneal

become

colon, by

and are

on Many

and

wall This

the

parietal

Intraperitoneal

Organs

mesentery

body

peritoneum.

retroperitoneal renamed

fixed.

ascending

the

mesentery

covered or

retroperitonealization,

duodenum,

rectum)

a

a

They

partially

immobile by

by

peritoneum.

are

are

suspended

suspended

visceral

organs

peritoneum.

Table

in

Retroperitoneal

neal.

are

rectum

rectum Anal

canal

Appendix Transverse Sigmoid

colon colon

9

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology The

epiploic

foramen

peritoneal

Pharmacology

Physiology

Biochemistry

•

Anteriorly:

•

Posteriorly:

•

Superiorly:

•

Inferiorly:

is

The

the

opening

boundaries

between

are

hepatoduodenal

ligament

inferior

vena

caudate first

of

as

and

bursa

and

greater

follows:

the

hepatic

portal

vein

cava

lobe part

omental

described

of the

the

liver

duodenum

Medical Genetics

Falciform

Pathology

sac.

ligament

(contains

ligamentum

teres

BehavioralScience/Social Sciences Gallbladder

of

liver)

Spleen

Liver

Microbiology Stomach Lesser D u o

Epiploic foramen

de

u

curvature

Greater

curvature

m

Ascending Greater

colon

omentum

Hepatogastric

ligament

Lesser

Hepatoduodenal

omentum

ligament

1.

Common

2.

Proper

3.

Hepatic

Descending

Figure

100

II

3

8. Peritoneal Figure II 3 8.

Membranes Peritoneal Membranes

bile hepatic

duct artery

portal

vein

colon

CHAPTER

Portal

Proper

3

|

ABDOMEN,

IVC:

hepatic

vein

PELVIS,

inferior

vena

AND

PERINEUM

cava

artery A: aorta

Spl:

spleen

Common bile

duct

Greater

peritoneal

sac

Liver Epiploic

Lesser

omentum

foramen Gastrosplenic Stomach

Omental

ligament

bursa (lesser

IVC

A

Splenorenal

peritoneal Spl

sac) Kidney

tail

pancreas

and

splenic

Figure

DEVELOPMENT

II

OF

3

9.

Figure and

Greater

ABDOMINAL

II 3 9. Lesser

Greater and Peritoneal

Lesser

Peritoneal Sacs

ligament

(contains

of distal

vessels)

Sacs

VISCERA

Liver The

hepatic

foregut the

diverticulum

in

the

develops

region

of

the

as

an

duodenum

outgrowth near

of

the

border

the

endoderm

between

of the

the

foregut

and

midgut.

•

This

diverticulum

becomes duct •

enters

the

liver

the

and

ventral

gallbladder

embryonic and

mesentery

proximately

and

becomes

distally

the

biliary

system.

The

part

tube

of

the

becomes

ventral

ventral the

body

embryonic

lesser

wall

mesentery

omentum,

becomes

the

and

between the

falciform

part

the

between

liver the

and liver

gut and

ligament.

Pancreas The

pancreas

from

the

•

develops

The

The

lining

ventral

together •

from

endodermal

bud to

dorsal

form

of

rotates a

pancreatic

2 pancreatic the

diverticula foregut

around

single

in

the

gut

(buds),

the

tube

which

region

to

of

fuse

evaginate

duodenum.

with

the

dorsal

bud,

pancreas. bud

forms

the

neck,

body,

and

and

uncinate

tail

of

the

pancreas. •

The

ventral

pancreatic

bud

forms

the

head

process.

10

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL

CORRELATE

An

pancreas

annular

defect) and Pharmacology

is fusion

The

result

the

duodenum,

caused of is

the

(rare by

a defect

ventral

constriction with

congenital

and or

in

the

rotation

dorsal buds. Biochemistry obstruction

Week

5

of

resulting Gallbladder

polyhydramnios. Physiology

Ventral

Medical Genetics

pancreas

(forms

Pathology

head,

uncinate)

Week

BehavioralScience/Social Sciences

Dorsal

pancreas

(forms

neck,

body,

tail)

Duodenum

6 Accessory

pancreatic

duct

Common bile

duct

Microbiology

Main pancreatic

Annular

duct

pancreas

(polyhydramnios)

Figure

II

3 10. Development Figure II 3 10. Development

of of

the the

Pancreas Pancreas

and Duodenum Duodenum

and

Spleen The

spleen

(Figure

develops II

becomes

3 the

dorsal

body

from

7B).

The

gastrosplenic wall

narrow

The

occluded

owing colored

Annular

and

atresia

to

incomplete

pancreas the

polyhydramnios.

a small

biliary

stool,

duodenum,

occurs

and

occurs

It

when is

the

at

the

when

when thereby

colored

the causing

and the

GUT

the spleen

gut

tube

and

the

right

the

externa

costal

is

hypertrophies,

polyhydramnios;

lumen It

TUBE

muscularis with

recanalization. dark

mesentery

spleen

between

THE

associated

knot

occurs

embryonic the

ligament.

OF

lumen.

dorsal

mesentery

splenorenal

stenosis

pyloric

vomiting;

Extrahepatic

10

the

pyloric a

nonbilious

around

the between

ABNORMALITIES

Hypertrophic

white

within mesentery

ligament.

becomes

CONGENITAL

causing

mesoderm

embryonic

projectile,

margin.

of

the

biliary

associated

with

ducts

is

jaundice,

urine.

ventral

and an

dorsal

obstruction

pancreatic of

the

buds duodenum

form and

a ring

CHAPTER

Duodenal

atresia

failed vomitus,

An

occurs

recanalization. and

remains

umbilical

ring

umbilical

cord.

It

system,

Gastroschisis into

•

•

the

This

is

the

anterior

Note

are often

with

a

the

feet

duodenum

a

is

occluded

bile

the

owing

PELVIS,

AND

PERINEUM

to

containing

of

the

abdominal

through

amnion

at

the

anomalies

viscera to

of

to

the

base

of

the

of

the

heart

and

(25%).

abdominal usually

return herniate

multiple rate

closure

to

viscera sac

with

cavity,

fails

The

shiny

mortality

the

loop

stalk. in

viscera in

a

do sac

the

the

herniate right

through

of

lateral

protrude

the

body

the

body

wall

umbilicus.

folds

and

a

weakness

of

pouch

but

when

on

can

the

ileocecal

a remnant

umbilical

of

which

if it

vitelline of

contains

may

produce

are

2 inches

junction,

the

border

inflamed

tissue,

the

the

antimesenteric

become

endometrial

through

ring

and

are

duct

persists,

amnion.

occurs

a blind

from

not

of

diverticulum

or 2

high

in

enclosed

pancreatic,

midgut

associated

when

asymptomatic

found

the

contained

is

defect

forming

often

the

polyhydramnios,

ABDOMEN,

wall.

(Meckel)

thereby

the

a

of

with

umbilical

amniotic

that

not

Ileal

when the

occurs

directly

lumen

|

stomach.

in and

the

associated

occurs

and

nervous

is

a distended

omphalocele

cavity

when

It

3

the

ileum.

ectopic ulceration.

long,

It

and

It

is

gastric, is

typically

appears

in

2%

of

population.

Vitelline

fistula

connection

occurs

umbilicus.

It

is

Malrotation and

when

between

in

volvulus

Colonic

midgut

intestines).

cells

to

the

myenteric

associated and

loss

abdominal

the

of

of

ABDOMINAL

of

and the

thereby

outside

of

meconium

from

midgut

in

body

the

umbilicus.

only It

results

the

the

a at

partial

be

rotation with

failure

and

of

rectum.

hindgut,

direct

the

associated

the

colon

of colon

may

from

sigmoid

immobility

transverse

forming the

undergoes viscera.

disease) plexus

peristalsis

distention

persists, the

abdominal

(Hirschsprung

form

with

of

when

position of

duct and

drainage

occurs

aganglionosis

crest

vitelline lumen

with

abnormal

(twisting

the

intestinal

associated

of

results

the

fecal

neural It

is

retention

(megacolon).

VISCERA

Liver The

liver

visceral

has

2

surfaces:

a

It

mostly

surface.

protected

•

by

The of

the

rib

cage.

reflection the

of

liver

and

continues

The liver stomach lesser

superior

or in

The

the

the

liver

visceral the

onto

triangular •

lies

diaphragmatic right

is

peritoneum

the

by

the

the

coronary

and

abdominal

visceral

between forms

as

of

invested

diaphragm liver

surface

aspect

an

inferior

cavity

or and

a

is

peritoneum:

the

diaphragmatic

falciform

surface

ligament,

ligament

and

the

which right

and

left

ligaments.

extension and

of the

forms omentum,

first

visceral part

the

peritoneum of

the

hepatoduodenal

between

duodenum

and and

the the

hepatogastric

visceral lesser

surface curvature ligaments

of of

the the

of

the

respectively.

10

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology The

liver

•

Pharmacology

is divided

Fissures

for

hepatis,

and

the

Biochemistry •

into

right

The

the

lobe

and

The

liver

the

Pathology

of

unequal

the

of

size:

teres for

the

the

quadrate

and

left.

portal

are

and

venosum,

and

subdivide the

receive hepatic

of

blood

artery

and

porta

right

lobe

into

lobe.

part

their

the

the

caudate

anatomically

They

vein

ligamentum further

lobe,

lobes

the

the

gallbladder

caudate

part

hepatic

Medical Genetics

fossa proper,

quadrate

branches

of

ligamentum

the

functionally

Physiology

2 lobes

the

right

supply secrete

lobe

from bile

but

the

to

left

the

left

duct.

has

a

portal

vein

•

central

The

central

hilus,

and

or

arterial

porta

blood

hilus

also

hepatis, from

which

the

transmits

the

receives

hepatic

artery.

common

bile

venous

duct,

blood

which

from

collects

bile

BehavioralScience/Social Sciences produced •

by

These

the

liver.

structures,

known

hepatoduodenal

collectively

ligament,

as

which

is

the

the

portal

right

free

triad,

are

border

of

located the

in

the

lesser

omentum. Microbiology The

hepatic

returning

it

veins

drain

to

inferior

the

the

liver vena

by

collecting

blood

from

the

liver

sinusoids

and

cava.

Ligamentum

Hepatic

vein

venosum

Inferior Caudate Left

vena

cava

lobe

lobe

Proper

Common

hepatic

bile

duc

artery Right

lobe

Hepatic portal vein Quadrate

Ligamentum teres

of

lobe

liver

Gallbladder

Figure

II Figure

3

11. Visceral II 3 11. Visceral

Surface Surface

of

the Liver

of the

Liver

Gallbladder The

gallbladder

quadrate cystic

lies

lobe.

It

in

stores

a

fossa and

on

the

visceral

concentrates

surface bile,

of

which

the

enters

liver

to

and

leaves

the

right

of

the

through

the

duct.

•

The

cystic

duct

joins

the

common

hepatic

duct

to

form

the

common

bile

duct. •

The posterior

104

common

bile to

the

duct first

descends part

of

in the

the

duodenum.

hepatoduodenal The

ligament, common

bile

then duct

passes

penetrates

CHAPTER

the

head

the

hepatopancreatic

of

the

duodenum

pancreas

where

it

ampulla,

at

the

major

joins

the

which

duodenal

main

drains

pancreatic into

duct

the

second

and

part

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

forms of

the

papilla.

Right

and

left

hepatic

ducts

Common

hepatic

duct

Liver Cystic

duct

Pyloric

antrum

Pylorus

Body

Common

Fundus

of

bile

Main

duct

pancreatic

duct

of

Wirsung

gallbladder Hepatopancreatic

ampulla

of

Vater

Duodenum

Major

duodenal

papilla

(Sphincter

of

F

Oddi)

Figure II igure II 3 12.

3 12. Biliary

Biliary Ducts

Ducts

Pancreas The the

pancreas level

and

horizontally of

the

crosses

transpyloric

the

plane.

posterior

The

abdominal

gland

consists

wall of

4

at

parts:

approximately

head,

at

neck,

body,

tail.

•

The

head

of

duodenum

the and

uncinate

process

•

Posterior

to

•

The

body

kidney. of •

the tail

of of

traversed

to

is the

the

left

the

pancreas

the

The

by of

and

passes

formation

the

duct.

of

the

the

II

3

only

the

the

portal

the

vein.

and

to

ligament of

the

vessels.

the

border

posterior

part

by

includes

aorta

superior

splenorenal

is

It

hepatic

to the

coursing

formed

mesenteric

anterior

vein

area

superior

along

splenic

shaped bile

the

undulates

tail

C

common

site

enters

spleen.

the

crossed

the

artery with

within

by is

neck

splenic

the

rests

which

passes

pancreas

hilum

is

the

The

The

pancreas

of

the to

body

body.

reach

pancreas

left the

the

that

is

intraperitoneal.

The

main

and

tail

common

pancreatic of

the

duct

pancreas

bile

duct

(Figures to

to

reach

form

the

12

head

the

hepatopancreatic

receives

its

and of

II

the

3

13)

courses

pancreas,

through

where

it

the

joins

body

with

CLINICAL

CORRELATE

Carcinoma

of

the

in the The

head

of

the

pancreaticoduodenal arteries,

pancreas

branches

respectively.

This

region

of is

blood the

supply

from

the

gastroduodenal

important

and

for

collateral

superior

and

superior

inferior

mesenteric

circulation

mesenteric

are

anastomoses

between

these

branches

of

the

celiac

trunk

head

of

constrict

the

pancreas

commonly

occurs

common

bile

the

pancreas

main

pancreatic

duct.

Obstruction

and

may

duct of

and the

the bile

because duct

there

the

ampulla.

and

may

cause

jaundice.

superior

artery.

10

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology The

neck,

body,

splenic

Pharmacology

and

tail

of

the

pancreas

receive

pancreatic

duct

their

blood

supply

from

the

artery.

Biochemistry Hepatic portal

Main

vein

(of

Wirsung)

Common bile Physiology

duct

Medical Genetics Right Spleen

suprarenal gland

Right Pathology

BehavioralScience/Social Sciences

kidney

2nd

Tail 3rd

Body

Microbiology

Pancreas

Neck Head

Duodenum Superior

mesenteric

artery

Figure

II 3

13.

Adult

II 3

13.

the

upper

Figure

CLINICAL

CORRELATE

The

may

of

spleen the

9th,

be

10th,

11th

with rib

on

a

fracture

the

left

The

spleen

9th,

10th,

colic

side.

is

a peritoneal

and

11th

flexure,

margin,

The

a

CORRELATE

A sliding cardia

hiatal of

the

esophageal can through

hiatus

damage the

the hiatus.

occurs

when

herniates of

vagal

Pancreas Adult

Pancreas

The

normal

splenic

and sized

artery

and

in visceral

left

spleen

kidney. is not

vein

reach

left

surface

quadrant

of

the

Inasmuch

that

spleen as

the

is

is in

deep

to

contact

spleen

lies

the

left

with above

the

the

left

costal

palpable.

the

hilus

of

the

spleen

by

traversing

the

ligament.

Stomach

hernia stomach

organ

ribs.

stomach,

splenorenal

CLINICAL

vein

Spleen

lacerated

or

and

the

diaphragm.

trunks

the

through

as

This they

The the

pass

of

stomach the

liver

curvature

cardiac

the

stomach,

lar

the

region

and

curvature,

omentum the

greater

receives

which

transpyloric

lesser

lesser which

stomach

wall

a right

the

from

The

of

has by

is

is the narrow

body. lumen

plane

(L1

the

normally

which

is connected

(hepatogastric omentum

is

esophagus; filled

and with

pyloric

portion

that

empties

into

of

the

duodenum

main has

hepatis

greater 3

8).

upper

The

stomach

porta

II

shaped

fundus.

the a left

(Figure

dome

is the

the

and

suspended

the

air,

The

to

ligament),

portion central

a thick

of part

muscu

approximately

in

the

vertebra).

Duodenum The the

10

duodenum first

part.

is

C

shaped,

has

4 parts,

and

is located

retroperitoneal

except

for

CHAPTER

•

The

first

artery •

part and

The

second

in

that

wall

the

Jejunum The

the

duodenal

cap

descend

posterior

duct

receives

the

hepatopancreatic

duodenal

at

is

common

the

point

of

as

of

the

the

entry

first

the

PELVIS,

AND

PERINEUM

part.

duct

and

Vater).

main

Smooth

sphincter

of

ABDOMEN,

gastroduodenal

the

bile (of

known

The to

ampulla

papilla

is part

(bulb).

|

of

muscle Oddi.

common

bile

duct;

the

midgut.

Ileum at

the

duodenojejunal

intestine.

the

distal

jejunoileum

The

3/5

is

Although small

as

terminates

begins

of

the

the

the

duodenum

small

proper. of

the

jejunum

remaining

The

of

and

consists

at

foregut

of

to bile

(descending)

duct

the

remainder

referred common

part

pancreatic

Note

is the

3

of

the

intestine

of

the

and

the

comprises

ileum

is

not

2/5

clearly

of

the

demarcated;

it

bowel.

from

root

of

small

suspended the

junction

beginning

the

posterior

mesentery

body is only

is approximately

22

feet

wall

by

6 inches

in

the

mesentery

long,

the

mobile

part

length.

Colon The

cecum

is

ileocecal to

the

first

junction.

the

part

It

vermiform

is

of

a

the

blind

colon,

or

pouch,

appendix.

The

large

which

intestine, often

appendix

has

and

has

its

a

own

begins

at

mesentery

mesentery,

the

and

gives

rise

is

continuous

the

mesoappendix.

The

ascending

with

the

The

colon

colon

The third

of

The

descending

large

bowel

crosses

The

superior

laterally.

The

anal

is

is

canal

is

suspended

bend

The

the

1.5

internal canal. muscle

transverse

the

the

is

straight

at

to

left

mesocolon.

(splenic)

proximal

the

It

flexure

two

sigmoid

of

thirds

colon

mesocolon. pelvis

covered

by

and

of

opens

pelvic

diaphragm,

below

the

maintain sphincter

parasympathetics

to

portion

long the

sympathetics the

joins

sigmoid the

rectum

flexure)

anal

and during

the

component

The

of

It

enters

inches

rectum

helping

anal

muscle

about

puborectalis

The

the

of

(anorectal

forward,

by and

terminal,

the

junction

the at

It

colon.

and

distal

where

the

brim.

intestine

fixed,

with

posterior

•

pelvic

third

the

mesentery. of

called colon

a mesentery.

the

large

one It

continuous

•

lacks

colon the

mesentery

the

a

flexure

descending at

lacks

(hepatic)

colon.

colon

of

own

the

transverse

and

right

terminates

the

sigmoid

portion

the

its

with

midgut

one

at

has

continuous

colon.

retroperitoneally

colon

transverse

becomes

The

lies

transverse

of

the

fecal is

circular (lumbar

It

continue

is

peritoneum the

the

as

terminal

the

rectum.

anteriorly

and

hindgut.

distally

at

where

the it

anus. makes

It

is

a 90

degree

rectum.

pelvic

diaphragm

pulls

the

flexure

continence. smooth

muscle

splanchnics) (pelvic

that increase

splanchnics)

surrounds the relax

the tone

of

the

defecation.

10

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology •

The

external

anal

rounding branch • Pharmacology

of

The

anal

canal

the

pudendal

canal

is

line,

an

is

that

is

nerve

divided

circular

voluntary

voluntarily and

into

the

relaxes

Medical Genetics

Table

II

anal

3

3.

elevation

upper of

by during

and

the

lower

mucous

muscle

the

sur

inferior

rectal

defecation. parts

separated

Portal

Drain

at

by

the

distal

the ends

of

Comparison

of

Features

Above

and

Below

the

Pectinate

Line

Below

Visceral BehavioralScience/Social Sciences

membrane

columns.

Above

Pathology

skeletal

controlled

Biochemistry pectinate

Physiology

sphincter

the

(ANS)

sensory

venous

to

Internal

innervation

Somatic

drainage

iliac

lymph

nodes

hemorrhoids

(painless)

sensory

Caval

venous

Drain

to

innervation

drainage

superficial

External

inguinal

hemorrhoids

nodes

(painful)

Microbiology Endoderm

Ectoderm

Abbreviations:

ANS,

autonomic

nervous

GASTROINTESTINAL

The

alimentary

oral

cavity

submucosa,

Copyright

HISTOLOGY

or to

the

gastrointestinal anal

canal.

muscularis

McGraw

Mucosa serosa

(GI) The

externa,

Hill Companies.

Figure

10

system

(M) Mucosa

and

Used

Figure II

GI

3 II14.3

with

is

walls

a

muscular

are

tube

composed

that of

4

runs layers:

from

the

mucosa,

serosa.

permission.Copyright McGraw

14.Organization Organization

submucosa (M) submucosa

or visceral serosa or

tract

tract

(SB), (SB),

peritoneum visceral peritoneum

of the of

muscularis muscularis

Hill

Companies.

GI tractGI the

tract

externa externa (ME),

(S), mesentery (S), mesentery

Used

(arrow)

(ME), (arrow)

with

permission.

CHAPTER

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

Mucosa The

mucosa

•

is

The

the

innermost

epithelium

whether

lining

the in

•

The

lamina

the

epithelium

capillaries in

Within

the

that

out

production,

The

muscularis

mucosa

and

intestine, and

to

tips

is a

layer

tissue

in

that

the

supports

mucosae. lamina

of

lymphatic

white

propria

lamina

layer

confers

secretions

smooth

tissue),

muscle

muscle

of

(lacteals)

(particularly responsible

for

propria.

smooth The

cells

lymphoid

the

a thin

vessels

blood

associated

discharge

of

absorptive

muscularis

ended and

mucosa.

strands

the

and

connective

networks

within is

the

on

(stratified

secretory

underlying

blind

(gut

located

facilitates a few

up

GALT

of

the

are

mucosa edge

areolar

to

nutrients

is

innermost

of

extensive

propria

The

IgA

or

depending

protective

intestine).

absorbed

lymphocytes).

regions,

and

intestine).

it

small

different

esophagus),

layer

form

the

lamina

carry

a

in

conductive

and

attaches

3 components.

varies

and

is

and

(particularly

lumen

stomach

propria

has

primarily

pharynx

columnar;

Numerous

•

is

the

and

the

function

squamous; (simple

layer

from

muscle

may

that

marks

some glands.

run

the

motility

to

In

into

the

the

the

small

lamina

propria

villi.

Submucosa The

submucosa

mucosa

to

secreting

the

areolar and

connective houses

tissue

the

larger

that

attaches

blood

the

vessels

and

mucous

Externa

muscularis

circular and

loose

externa

glands.

Muscularis The

of

muscularis

externa

and

an

outer

is responsible

esophagus

for

and

is

usually

comprised

longitudinal.

The

peristalsis.

smooth

The

of

2 layers

muscularis muscle

of

externa is

striated

in

muscle:

an

controls

the

the

upper

inner lumen

third

size

of

the

elsewhere.

Serosa The

serosa

(or

epithelium In

the

to

form

peritoneum

lining

the

abdominal

of

cavity,

the

mesentery

anatomy)

thoracic the

and serosa

within

is

composed

abdominal surrounds

which

of

cavities) each

run

blood

a mesothelium and

intestinal

and

(a

loose loop

lymphatic

thin

connective and

tissue. then

CLINICAL

doubles

vessels.

Hirschsprung megacolon per

5,000

INNERVATION

mutations

The

GI

tract

crest

tion

is

entirely

capable

of

has

both

intrinsic

located autonomous

interconnected plexus

alimentary

tract.

the

extrinsic walls

generation

network

Meissner’s

and

within

and

of controls

of

ganglia

the

GI

and

nerves

located

of

the

The

tract.

peristalsis

and much

innervation.

of

intrinsic

The

intrinsic

in

innerva

intrinsic

glandular the

motility

system

secretions.

the

is

Auerbach’s

forms lining

of

cells

deficiency

An

submucosa of

the

motility,

and smooth

is located muscle

between is

plexus the

interconnected

contains

2 muscle

layers by

gap

a of

second the

network

muscularis

of externa.

neuronal All

disease is a

genetic

live

births.

that

affect

into

the

of

or

disease It

and

particularly

may

the gut.

terminal

plexus

aganglionic

in

seen result

in

migration This

results

ganglion

cells

affects

digestive

the

~1

from of

neural

in

a in tract

rectum

the (peristalsis

Auerbach’s

CORRELATE

is not

as

effective

and

ganglia, GI

tract

constipation

results).

junctions.

10

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology The

extrinsic

autonomic

(stimulatory)

Pharmacology

Biochemistry

and

intrinsic

innervation.

mediate

visceral

Visceral

smooth the

Physiology

from

muscle.

fibers

and

the

GI

course

back

to

CNS

pain

is to

as

referred that

to

GI

parasympathetic the

and

the

activity

wall

the

and

fullness. innervation.

of

body

of

nerves rectal

sympathetic

distention the

tract

the

parasympathetic

hunger

with

and/or

from modulate

the

such the

is that

accompany

contraction

innervation

tract

axons

sensations,

excessive Visceral

sympathetic

the

dermatomes

that

match

structure.

Medical Genetics

IMMUNE The Pathology

Sensory

fibers

results

to (inhibitory)

reflexes

pain

Pain

innervation

sympathetic

BehavioralScience/Social Sciences

FUNCTIONS

lumen

of

majority in

of

our

gut,

Most

of

the

the where

these

digestion,

GI

tract

bacteria they

appear

normally

the

enjoy

bacteria

are

protection

microbes

is in

a rich

The

gut

defense

bacterial 500

and but

a K

a

flora.

different

within B12

bacteria) has

abundant

medium

(vitamins

pathogenic

times.

by

about

growth

beneficial

against at

colonized

body—comprising

long,

warm

production,

few

mechanisms

The

species—are tube. additional

species

of

to

these

fight

pathogenic patho

Microbiology gens

(GALT

and

REGIONAL Major etc.) GI

Figure

11

Paneth

cells).

DIFFERENCES differences

and

in

lie the

types

in of

the cells

general

organization

comprising

the

tract.

II 3 15.

Histologic

Organization

of the

Digestive

Tube

of epithelia

the

mucosa and

associated

(glands,

folds, glands

villi, in

the

CHAPTER

Table

II 3

4.

Region

Histology

of

Specific

Major

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

Regions

Characteristics

Mucosal

Cell

Types

at

Function

of

Surface

Mucosal

Cells

Surface

Esophagus

•

Nonkeratinized

—

stratified

—

squamous

epithelium •

Skeletal

muscle

muscularis (upper •

1/3)

Smooth

muscle

(lower

Stomach (body

1/3)

Rugae: and

deep

in

externa

shallow

pits;

Mucous

cells

glands

Secrete

mucous;

against

acid;

these

fundus)

cells

acid

Chief

cells

protective

of

layer

junctions

probably

barrier

Secrete

form tight

between

contribute

the

to

the

epithelium.

pepsinogen

and

lipase

precursor

Parietal

cells

Enteroendocrine (EE)

Pylorus

Deep

pits;

branched

shallow,

Secrete

a

Mucous

plicae,

and

crypts

intestine

intrinsic

variety

cells

Same

as

above

cells

Same

as

above

cells

High

of

factor

peptide

Columnar

concentration

Contain

absorptive

cells

Brunner

glands,

discharge

which

Goblet

cells

the

hormones

gastrin

microvilli luminal

that

surface

greatly

area,

absorption

Secrete

alkaline

of

numerous

increase facilitating

Duodenum

and

glands

EE

Villi,

HCl

cells

Parietal

Small

Secrete

acid

mucosal

glycoproteins

that

protect

linings

secretion

Paneth

cells

Contains

granules

lysozyme.

May

intestinal

EE

cells

High

that play

Villi, plica,

well

developed

crypts

Same

cell

found

in

nal

Ileum

Aggregations

of

nodules

called

patches

Large intestine

Lacks

lymph Peyer’s

M

crypts

as

cells

regulating

concentration

of

Same

as

and

cells

that

secrete

secretin

above

duode

found

lymphatic

over

nodules

Peyer’s

mucous

Endocytose the

lumen

and to

transport

lymphoid

antigen

from

cells

patches

Mainly

and

in

epithelium

and

villi,

types the

contain role

flora

cholecystokinin

Jejunum

a

Transport secreting absorptive

(passively)

Na+ out

(actively) of

and

water

lumen

cells

11

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Oral

Cavity

The

epithelium

serous Pharmacology

Biochemistry

of

secretions

moisten

the

food

Secretions

of

through

the

the of

oral the

for

IgA

is

a stratified

glands

swallowing

from

gland

cavity salivary

and

plasma

help

by

a stratified

rinse

partial

within

to

epithelium.

food,

provide

cells

epithelia

squamous

lubricate

the

protect

Mucous

the

oral

antibacterial

connective

against

and

cavity, protection.

tissue

microbial

are

transported

attachment

and

invasion.

Physiology

Medical Genetics Esophagus The

Pathology

BehavioralScience/Social Sciences

esophagus

is

of

the

esophagus

of

the

stomach.

also

lined

there

is

an

abrupt

Langerhans

present

in

the

striated

muscle

combination

of

lining.

the

The

upper

both

epithelium.

to

cells—macrophage

epithelial in

squamous

transition

in

muscularis

third,

the

simple

like

antigen

externa

smooth

middle

the

muscle

the

lower

the

part

epithelium

presenting

of in

In columnar

cells—are

the

esophagus

distal

third,

consists and

of

a

third.

Microbiology

Copyright

McGraw

Figure II Figure

Hill Companies.

3 16.II

3 15. Esophagus

epithelium

The

Esophagus with

(arrow)

permission.Copyright McGraw

Companies.

upper half

half of

(ME) (ME)

Used

stratified epithelium

propria (arrowheads) with vessels

muscularis externa externa

from the upper

Hill

nonstratified keratinizing squamous

thin propria lamina with

underlying muscularis the

with

with keratinizing

non

andlamina a The

underlying

Used

permission.

squamous and (arrow)

vessels

isis skeletal skeletal

with

a thin

(arrowheads)

muscle muscle

from

of the esophagus the esophagus

Stomach The

stomach

The

mucosa

disappears

when

breakdown

of

juice

being

before

stomach

ingested

highly

is begins

food.

denatured acidic

full.

into The

digestion Proteins

hydrolyzed of

areas:

is thrown

stomach

consists fluid,

histological

stomach the

The

semi

3 distinct the

epithelium.

chyme

11

has of

to and medium.

polypeptide

cardia,

body,

(rugae)

surface by

are

partially

the folds

is lined

by

initiating

initially

the

empty, a

by by

up

food

simple

chemical

denatured

fragments broken

and

when

the

enzyme

antrum.

but columnar and

the

particles

pyloric

enzymatic

acidic

gastric pepsin.

suspended

The in

a

CHAPTER

Gastric

pits

the

stomach.

the

mucosa

form

by

composition

pyloric

regions

and

body lipase)

the

by

stomach,

cells

of

mucous

Copyright

McGraw

located

on

the

and of

also

the

Hill Companies.

major

Used

16.II 3Cardia 17.

pits protects

of

cells Stem

that cells

Oxyntic ions

or into

parietal

the

histamine,

cells

of part

lamina gastrin,

propria and

(a

surface

of

the

glands.

the

stomach,

type

in

the

0.1N byproduct

per

day.

Glands renin

the

pit

produce into

the In

and

in

cells

falling

is

about

stomach,

These

2

categories:

mucous

cardiac

and a

secreted and

pyloric

glands.

Companies.

Used

with gastric gastric with

pits

with

permission.

pits

and

cells cells are

are located

located

into of

These

the

the

stomach

acid

cells

lumen

and

production)

also

in

secrete

response

intrinsic

CLINICAL

bicarbonate to

factor

(a

CORRELATE

Acetylcholine

necessary

production of

peripheral

tion

in

Parietal base

for

of

and

Neuroscience

cells, and

functional

absorption

erythrocytes;

vitamin

central

nervous

B12). result

system

in

myelin

Vitamin

B12

pernicious (see

is required

anemia

subacute

and

in apex.

combined

disruption degenera

potentiates H2

Their

upper

regions structure

of varies

the

gastric greatly

glands, depending

have on

gastrin

parietal both

receptor.

inhibit

the

by

increase

cells.

HCL

Histamine

for a

section).

located

narrower

of deficiencies

and

glyco secretion

protein

PERINEUM

(arrowhead) (arrowhead)

HCl

acetylcholine.

are

AND

in

enzymes,

There

PELVIS,

of

glands

regions. and

ABDOMEN,

of

a change

cardiac

|

glands. glands.

all stomach stomach all

the at the isthmus isthmus

the

while

the of the stomach stomach

regenerate that regenerate

secrete

fluid

with permission.Copyright McGraw Hill

part Cardiac

at

of

glycoproteins.

coiled gastric and coiled gastric Stem

2 liters

and

by

body HCl

glycoproteins, acidic cell

in

lumen.

and

and

and

stomach

inner

neutral

coiled

fundus

surface

thickness

pits

lumen,

(containing

the

between

covers

are

the

some

is composed

are

II 3 Figure

to

the

inner the

between

of

juice

secreting

region

cells cells

Figure

are

there

is composed

mucous

mucous

gastric

from

which

mucous

neck

regions,

the

transitional

surface the

and

the

layer

the

in

deliver

in

the

into

transition

glands

straight

line

penetrate

narrowing The

and

that

they

The

is a

epithelium.

pit,

secreting neck,

the

spaced;

glands.

there

stomach

stomach

each

glands

Mucous

thick

the

to

5 million

in

of

the

invaginations

closely

gastric

where of

of

tubular

are

into

isthmus,

cellular

the

pits

extend

the

deep

gastric

and

marked

in

numerous

The

3

by

Cimetidine

binding and

to H2

the

histamine

antagonists

histamine.

a broader their

state.

11

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL

Chief

CORRELATE

or

peptic

secretory Infection

by Helicobacter

pylori

affects

HCl, Pharmacology

mucosal and

proteases

Hematemesis clinical

lining to

and

and

allows

erode

melena

secrete

pepsinogen,

granules

an

before

its

enzyme

induced

precursor

that

secretion.

is

stored

Pepsinogen

in

is inactive

the and

gastric

cells

(zymogen)

pepsin,

protects

the

converts

peptic

cells

pepsinogen

to

from

autodigestion.

Low

pH,

in

the

stomach

lumen,

pepsin.

the mucosa. Biochemistry

are

common

findings.

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Microbiology

Copyright

McGraw

Hill Companies.

Figure

II 3 Figure

Pale

The

stainingPale

are

tract.

more

are

dispersed

a

than

all

permission.Copyright McGraw

near near

or

APUD

cells

the

diffuse

GI

(amine

tract

precursor

and

are

the

GI

organs

tract

so

Used

in

found

that

that

the

they

permission.

shown.

and

in

the

decarbox respiratory

collectively

body.

can

with

glands

uptake

also

system

endocrine

throughout

Companies.

chief cells cells are chief (B) are (B)shown.

neuroendocrine

other

Hill

the basebase of gastric of gastric the glands

and parietal cells cells (A) (A) and

throughout

constitute cells

with

3 Stomach 18. Stomach

cells

present

They

for

17.II

parietal staining

enteroendocrine

ylation)

Used

accounts

Enteroendocrine

receive

and

cells

transmit

local

signals.

The

stem

cells

epithelium presence many

responsible

are of

gastrin

gastric

•

Although

and

the

stem

span

The effective plicae

11

>190

regeneration

of

Their

damage

is

types

4–7

capable

bile

cells

can salt

in

be

the

stomach

influenced

reflux).

by

Renewal

the of

days.

of

evidence

of

rate

alcohol,

every

are

all

mitotic

(aspirin,

occurs

there its

to

the isthmus.

cells

types,

environment,

Small

by

influences contrast

the

cells

cell

gland In

in

epithelial

stomach

•

for

located

differentiating

into

the

of

that

position

any the

of

the

cell

along

the

fate.

the

short

the

chief

life

span

(4–5

cells—deep

days) within

of the

the

cells

near

glands—may

the

acidic

have

a life

days.

Intestine small

intestine internal

circulares,

is tubular surface villi

area and

in

shape

of

the

microvilli.

and small

has intestine

a total is

length

of

about

greatly

increased

21

feet. by

the

The

CHAPTER

Plicae

circulares

surface

that

involve

surface

area

by

Villi

arise

(circular

of

Microvilli

of

20–30.

The

surface

the the

the

or

mucosa

a factor

above

epithelium

folds

both of

muscularis

mucosae Villi

absorptive

surface

Kerckring)

are

mucosa.

of

and

increase

epithelial

area

of sub

foldings

Plicae

of

circulares

the

|

ABDOMEN,

PELVIS,

AND

PERINEUM

inner

increase

the

3.

mucosa.

membrane

valves and

3

cells

microvilli

they

the

include

surface

increase

the

is increased

glycoproteins,

the

by

lamina

propria

a factor

surface

even

constituting

the

area

area

further

by

glycocalyx

to

of

10.

by

a

the

and

factor

of

presence

which

of

enzymes

are

bound.

The

luminal

ous

tubular

the

stomach.

surface

The

muscularis

The

small

completes

is is

small

secretions,

the

the

is of

perforated

by

Lieberkühn)

through

the

openings

analogous

the

digestion, fatty

proximal

jejunum,

intestine,

lamina

absorbs acids),

pyloric and

the

exocrine

Striated

to

propria

of the

and

numer

glands

reach

of

the

the and

digested

transports

food them

constituents into

blood

and

pancreatic

then

chyme

end the

from juice,

of

the

small

intestine.

Distal

to

the

ileum.

the and

stomach

is

mixed

with

mucosal

cell

bile.

border

Capillary

Lymphatic

penetrate

monosaccharides,

duodenum

with

crypts

intestine crypts

vessels.

duodenum

the

small (the

intestine acids,

lymphatic

In

the

mucosae.

(amino

The

of

invaginations

(shown red

blood

cell)

Villus

lacteal

Goblet

cells

Myofibroblast

Cryp

Enterocytes

Stem cells

Paneth

Smooth

Lamina

cells

muscle

propria Muscularis

Figure Figure

19. II II3 3 18.

Small Small

Intestine Intestine

Mucosal Mucosal Histology

mucosae

Histology

115

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL

Mucous

CORRELATE

production

Brunner Any

compromise

can

lead

of

the

mucous

occurs

glands

in

the

in

surface

duodenum

epithelial and

cells

goblet

throughout

cells

in

the

the

mucosa

GI

tract,

by

throughout

the

protection intestine.

of Pharmacology

the

to

significant

damage

gastrointestinal

gastritis,

and

tract,

duodenitis,

or

irritation

leading Biochemistryto

even

peptic

ulcer

disease.

Mucous

functions

trapping

immunoglobulins

The

rate

of

irritation, Physiology

of

where

mucous and

lubrication

secretion

physical

they

is

the

GI

have

increased

tract,

access

binding to

by

cholinergic

the

stomach

bacteria,

and

pathogens.

stimulation,

chemical

irritation.

Medical Genetics In

the

or

alkaline

duodenum,

The

pancreas Pathology

BehavioralScience/Social Sciences

CLINICAL

acidic

duodenum

and

of

also

bile

digestive

chyme

secretions

from

from glands

receives

the

liver

located digestive

(via

is

in

the

enzymes

gallbladder)

neutralized

by

submucosal and

through

or

the

bicarbonate the

neutral

Brunner’s from

bile

duct,

the

continuing

process.

CORRELATE

Peristalsis Microbiology

is activated

parasympathetic

manifesting

by

system.

decreased

diabetic

the

the

mucous

glands.

from

include

as

cholinergic

For

intestinal

agents

those

suffering

motility

constipation

gastroparesis),

the

(paralytic

ileus,

dopaminergic are

often

used

and (e.g.,

metoclopramide).

Copyright

McGraw

Figure

Hill Companies.

II

3

Used

19. Figure Duodenum II 3

with

permission.Copyright McGraw

with Duodenum

20.

Brunner submucosal

In

the

and

jejunum,

the

absorbs

ileum,

food

a major

with

of

and

fixed

the

Fc

adult, propria, direction

in

are time.

receptors only

In in

trace but into

the

jejunum.

patches)

not

process The

immune

and

duodenum

11

site

lymphocytes

(Peyer’s

digestion

products.

IgAs the

produced lumen.

and of

intact in

GALT

IgGs

produced

more

to

ileum

are provide

transferred are

enzymes here.

heavily than

ingested passive from transported

nodules their

are

the

the

lymphatic though

In

infiltrated

cells

secondary

that

are the

is

mucosa,

endocytosed

in

permission.

submucosal

developed

presenting

ileum’s

proteins

with

(arrowheads). propria (arrowheads).

best

mucosa

and

the

maternal

microvilli

amounts

the

in

and

enterocyte

are

antigen

present

propria

via

primary

infant,

lamina lamina

circulares

reactivity,

always the

in the in the

accompanying

Used

(arrow) (arrow) glands

continues

plicae

Numerous

Companies.

villiwith (curved villi (curved arrow) arrow) glands Brunner

Patches of lymphatic tissue are of lymphatic tissue are

Patches

Hill

location

is

recognized

by

immunity. lumen in

In to

the

lamina

opposite

the

CHAPTER

Throughout 5

the

types

of

small

intestine,

differentiated

the

cells,

simple

all

columnar

derived

intestinal

from

a

epithelium

common

pool

of

has

stem

3

|

ABDOMEN,

Goblet

cells

a viscous

secrete fluid

mucous

that

consisting

of

protects

the

glycoproteins

surface

(20%

of

the

peptides,

intestine

with

80%

have

digestion

steps

acids,

of

blood

the

absorb

are

in

against

pathogenic

the

cells

destroy

IIFigure 3 20. II 3Cells 21. cells Paneth adjacent an

organs.

detectable

by

the

cells

villi, The migrate undergo

based

located

lining completely newly

from

apoptosis

the

the

form

final

of it

is

of

carried

The

recognized

amino

glands

from

Brunner’s Peyer’s

nor

Peyer’s

glands,

patches

jejunum because

contains

in can

it has

be

and the

the

ileum

lamina

easily neither

Brunner’s

patches.

the

away

by

the

protect

small

span

is

about

Used

with

of

undergoing undergoing

mitosis.

and

large the the

mitosis.

intestine, function

lower

half

the

body defensins

20

of lysozyme, lysozyme, and

control in

the and

of Lieberkühninclude Lieberkühn

granules granules

(circle) (circle)

in granules

lysozyme

crypts of ofof crypts

crypts,

small itself

cells

(goblet, crypts,

and

cells

life

about

one

differentiates

renews

the

especially secretory

days.

permission.

include and

like

those

of

the

GI

of

the

crypts

of

the

of

the

tracts

and and

are

stains.

in

the

crypts,

These

apical apical

located

progeny

created up

atthe the base base

are

the

secreting

Their

that

They

Their

epithelial

it

withMcGraw permission.Copyright Hill Companies.

with (A) withlargelarge

of

of

cells.

adjacent stem stem cellcell

silver

are

bottom.

the

acidophilic

by

hormones

associated

Stem

the

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cells secrete

in

transporting

where

base

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11

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology accompany Other

cells

Paneth Gut Pharmacology

and

associated

these

epithelial

move

to

cells

the

base

enteroendocrine lymphatic

as

of

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11

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11

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology GASTROINTESTINAL

Salivary Pharmacology

Biochemistry

The

GLANDS

Glands major

acini

salivary

that

mucous,

or

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cells

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CHAPTER

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Figure II 3

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12

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Pharmacology

Biochemistry

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Microbiology

Copyright

McGraw

Hill Companies.

Figure

II Figure 3 24.

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portal

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CHAPTER

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

Hepatocyte Central

vein Bile

canaliculi

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cell

Sinusoid

Bile

flow

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12

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Pharmacology

Biochemistry

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Microbiology

Copyright

McGraw

Figure

II

lobule

and

Hill Companies.

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3

|

CLINICAL

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hypertension,

mucin

and

to

liver

type

contributing

kidney.

Gallbladder

wide

during

components

lead

The

AND

CORRELATE

stimulated

may

function.

and

PELVIS,

A. When

Bile

ABDOMEN,

the

has cystic

common

pancreatic

duct

a

hepatic at

CLINICAL

CORRELATE

duct

or

just

Disturbance

of

the

balance

components

of

bile

can

of

Vater.

one

or

more

resulting

in

lithiasis

in the

of

the

stone

in lead

bile

(or

the to

precipitation

components,

calculus)

gallbladder

formation and/or

or

bile

ducts.

NOTE Main

Functions

•

of

Absorption

of

Bile

fats

from

intestinal

lumen

Copyright

McGraw

Figure

Hill Companies.

II 3 Figure 28. Gallbladder II 3

Used

folds lined 27.with Gallbladder

columnar

The water. crine tion Oddi

gallbladder

stores

After

a

cells and in

of

meal, the

emptying the

ampulla

and

of

by a with simple

of to

lipid secrete

gallbladder. Vater.

bile into

This

no

by

the

Hill

Companies.

goblet

delivers

the

absorption

same a

bolus

with simple

of

which

of

it bile

no

electrolytes

stimulates

time,

with

Excretion

•

Transport

of

IgA

permission.

goblet

cells

cells

duodenum

cholecystokinin, At

Used

columnar lined epithelium folds by a

with

concentrates

duodenum the

permission.Copyright McGraw

epithelium

entrance

of

with

•

stimulates

relaxes into

and enteroendo

the the

contrac sphincter

of

duodenum.

12

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology ARTERIAL

The

SUPPLY

blood

supply

branches Pharmacology

of

through

Biochemistry

descends vertebral

to

3 groups

and

During

(c)

The

the

diaphragm

vertebra

(a)

several

short 3

and

aorta

just

its

branches:

VISCERA

viscera

aorta. of

lumbar

level.

ABDOMINAL

abdominal

hiatus

the

of

branches, Physiology

the

abdominal

aortic

on

L4

to

the

the

TO

to

body

enters at

the

the

the

left

course

unpaired

parietal

the

in

the

the

by

the

passing

and the

II

3

3

28).

bifurcates

aorta

(b)

body

by

(Figure

midline

branches, to

provided

vertebra

abdomen,

visceral branches

is

abdomen

T12 of

wall

at

gives

paired

It the

origin visceral

wall.

Medical Genetics

NOTE T12 Abdominal

Visceral Pathology

Aorta

Branches

branches

BehavioralScience/Social Sciences Inferior

Unpaired:

celiac

(foregut),

Celiac

L1 mesenteric

(midgut),

phrenic

superior

inferior

Middle

mesenteric

(hindgut)

Superior

suprarenal

mesenteric

Microbiology Paired:

middle

suprarenals,

renals,

gonadals L2

Parietal

Unpaired:

Paired:

Renal

branches

median

inferior

sacral

phrenics,

lumbars,

common

iliac

Gonadal

Lumbars

L3

Inferior L4

mesenteric

Median

sacral

Common

iliac

Internal and

iliac

External (to

Figure Figure

II

Three CLINICAL The

most

common is in and

abdominal

site

for

an

the

the

area

between

bifurcation

aorta.

circulation

126

to

Signs

the

radiating

down

The

common

aorta.

29.

Visceral

and

and

Visceral

Parietal

Branches

Parietal

of the

Branches

iliac

lower

limb)

Abdominal

of

the

Aorta

Abdominal

Aorta

Arteries

abdominal

of include

the

Artery

is at

the

lower the

the

The

celiac

artery

is

The

artery

arises

from

site bifurcation

of of

the

blood the

supply anterior

to

the

structures

surface

of

the

derived aorta

just

from inferior

the to

foregut. the

aortic

decreased

limbs

back

(Trunk)

renal

hiatus

plaque

II 3 Visceral

Unpaired

Celiac

most

28.

pelvis

CORRELATE

aneurysm arteries

3

(to

perineum)

and the

pain

lower

border

the

the

of

level

the

of

T12–L1

pancreas

and

vertebra. then

divides

The

celiac into

3

artery

passes

above

retroperitoneal

the

superior

branches.

limbs. The

atherosclerotic of

at

abdominal

left

curvature

gastric of

artery the

stomach.

courses

superiorly The

artery

and enters

upward the

lesser

to

the

omentum

left

to and

reach follows

the

lesser th

CHAPTER

lesser the

curvature

distally

to

the

pylorus.

The

distribution

of

the

left

gastric

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

includes

following:

•

Esophageal

branch

to

the

lesser

curvature

distal

one

branch

of

inch

of

the

esophagus

in

the

abdomen •

The

Most

of

splenic

the

artery

tortuous

is the

course

toneal

until

ligament

along

it to

reaches

enter

the

longest

the

superior

the

tail

border

of

hilum

of

the the

the of

celiac the

pancreas,

trunk

where

spleen.

The

and

pancreas.

runs

The

it

enters

the

distributions

a very

artery

is

retroperi

splenorenal

of

the

splenic

of

the

artery

include:

•

Direct

branches

to

the

spleen

•

Direct

branches

to

the

neck,

•

Left

gastroepiploic

curvature •

artery

of

Short

the

gastric

body, that

and

tail

supplies

of

the

pancreas

left

side

greater

stomach

branches

that

supply

passes

to

to

the

fundus

of

the

stomach CLINICAL

The

common

first

part

hepatic of

the

artery

duodenum,

where

it

the

right

divides

to

into

reach

its

the

superior

2 terminal

surface

of

the

•

CORRELATE

The

splenic

erosion •

Proper

hepatic

lesser

omentum

to

and

left

hepatic

the

liver,

with

to •

artery

the

reach

the

arteries. the

within porta

The

right

hepatoduodenal

hepatis,

right

hepatic

the

where

and

artery

left first

ligament it

divides

arteries

into

enter

giving

rise

of

the

to

2

the

the

the

right

lobes

of

cystic

artery

num

and of

the

divides greater

into

descends the

posterior

right

curvature

to

the

gastroepiploic of

the

first

part

artery

stomach)

and

moses mesenteric

arteries the

inferior artery).

(supplies pancreaticoduodenal

the

head

of

the

branches

be

subject

to

•

The

of

(supplies

the

superior

the

duode

the

pyloric

•

pancreas, of

where the

superior

of

the

ulcer

of

stomach

the

into

the

sac.

left

gastric

erosion

by

artery a

the

lesser

The

gastroduodenal

may

penetrating

curvature

be

subject

ulcer

of

the

artery

of

stomach.

may

be

pancreati subject

coduodenal

may

a penetrating wall

lesser

gallbladder. artery

by

posterior

to

Gastroduodenal

end

ascends

artery

branches:

it

to

erosion

by

a penetrating

anasto ulcer part

of of

the the

posterior

wall

of

the

first

duodenum.

12

PART

II

|

GROSS

Anatomy

ANATOMY

Immunology

Gastroduodenal

Proper hepatic

artery

artery

Common

Pharmacology

artery

Esophageal

Biochemistry Cystic

hepatic

branch

artery Left

gastric

artery Superior Physiology

duodenal

Celiac

Medical Genetics

pancreatico

Splenic

artery

Right Pathology

gastroepiploic

trunk

artery

Left

BehavioralScience/Social Sciences

gastroepiploic

artery

artery

Gastroepiploic Microbiology

Inferior

artery

pancreaticoduodenal artery

Superior

mesenteric

artery

Figure

II

3 29. II 3 30.

Figure

Superior The

superior

SMA the

Mesenteric

of

proper.

The

SMA

from at

the

aorta the

L1

pancreas

to

supplies

the

vertebral

and

superior

(SMA)

deep

neck

level.

the

third

mesenteric

It

part

vein

is

the

then of

to

the of

of

midgut.

the

the

to

to

of

The

below

anterior

duodenum

right

the

just

descends

the

the

viscera pancreas

enter

artery.

origin

the

uncinate

the

mesentery

Branches

of

the

include:

•

•

Inferior

pancreaticoduodenal

arteries

superior

pancreaticoduodenal

branches

the

of

head

Intestinal and

•

arise

•

Right

colic

•

Middle

colic proximal

is to

artery artery two

12–15

the

and

artery quadrant

as

supply

arcades

right

which

anastomose

of

gastroduodenal

the

with

the artery

in

the

SMA

pancreas

arteries

Ileocolic

the

the

segmentally

vascular

12

artery

the

artery

process

Artery Artery

Artery

mesenteric

arises celiac

Celiac Celiac

vasa

the

recta

most

supply passes

to

arteries

and of

the

at

the

enters transverse

to

and

side

wall

of

of

they the

form

gut.

descends

to

the

lower

cecum.

supply the

left

Distally,

which

ileum right

the

ileum.

branch

distal the

from

and

inferior the

ascends thirds

branches

jejunum

the transverse

colon.

ascending mesocolon

colon. to

supply

of

CHAPTER

Transverse

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

colon

Marginal artery Middle

colic

artery

Inferior Superior

pancreatico duodenal

mesenteric

artery

artery

Right

colic

First

artery

jejunal

artery

Ileocolic

Intestinal

artery

arteries (jejunal

and

ileal)

Ascending colon

Figure

Inferior

Mesenteric

The

inferior

aorta

that

line).

It

II

mesenteric

arises It

30. Figure

Distribution of II 3 31. Distribution

Superior of Superior

Mesenteric Mesenteric

Artery Artery

Artery

supplies

vertebra.

3

artery the

from

the

descends

(IMA)

hindgut

is

(distal

aorta

just

the

third

above

its

retroperitoneally

third of

the

unpaired

visceral

transverse

colon

bifurcation

and

at

inferiorly

to

the the

branch to

level left

of and

of

the the

gives

the

pectinate L3 rise

to

3

branches:

•

Left

colic

artery

descending •

Sigmoid

•

Superior

supplies

the

distal

third

of

the

transverse

colon

and

the

colon arteries

to

rectal

aspect

of

the

the

artery

sigmoid

colon

descends

rectum

and

into

anal

the

pelvis

and

supplies

the

superior

canal. CLINICAL

The parts

branches of

the

marginal

the

parts

SMA

and

of

the

the

large

the

and

intestines

artery. of

SMA

large

The

are

IMA

the

ascending,

interconnected

marginal

intestines

to

by

artery if

there

provides is

a

vascular

transverse a

continual a collateral obstruction

and arterial

arch

circulation in

CORRELATE

descending

some

Branches

called between part

of

mesenteric the

circulation

of

the

celiac

arteries within

and form

the

head

superior a

collateral of

the

pancreas.

IMA.

12

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL The of

CORRELATE

splenic

flexure

bowel

is the

most

common

site

ischemia.

Pharmacology

Biochemistry

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Inferior

mesenteric

artery

Descending

Left

colon

colic

artery

Microbiology Marginal

artery

Sigmoid

arteries

Sigmoid

colon

Superior Rectum

Figure

II

3

31.

Distribution Figure

Three CLINICAL

The an

CORRELATE

left

renal

aneurysm

artery

as

aorta.

Patients

renal

vein

the

may

compressed

anterior

the

renal left,

and and,

Middle

by •

to of

the

Visceral

and

mesenteric

compression

have

the

be

superior crosses

with

on on

•

the

vein

may

hypertension varicocele

vein of

Paired

the left

arteries

upper

border

medial are of

kidneys.

The

posterior

to

Mesenteric of

Artery

Inferior

Mesenteric

Artery

the

large

the

right

branch

parts

of

paired

L2

vertebra. artery vena

the

aorta

suprarenal

vessels

renal inferior

from

the

that

They is

arise

course

the

above

the

renal

arteries

gland. from

the

aorta

horizontally

longer

than

to

the

left

at the

and

the hila

of

passes

cava.

adrenal in

males,

•

a

Gonadal

left.

arteries

the

renal

arteries.

of

the

psoas

major

Vena inferior

level.

aorta The

inferior

through

the

inferior

vena

the

anterior

descend

surface

of

the

retroperitoneally

on

aorta

just

the

inferior

ventral

surface

muscle.

OF

ABDOMINAL

VISCERA

Cava vena

abdominal

from They

DRAINAGE

Inferior The

arise

to

VENOUS

13

arteries

the

Renal

Inferior

Distribution

Arteries

suprarenal supply

of

II 3 32.

rectal

artery

caval cava

cava by

the

forms

vena

cava

hiatus

of

receives

to

union

the

of

the

ascends the blood

right 2

of

to

the

diaphragm from

the

common

the

vertebrae

iliac right

at

lumbar

the

lower

of

veins the

T8 limbs,

at

and the

midline

vertebral pelvis

L5 and

level. and

the vertebral passes The

perineum,

the

CHAPTER

paired

abdominal

blood

viscera,

directly

The

right

from

tributaries

inferior

vena

drain

into

vein

crosses

But

left

renal

the

vein, to

body

tract,

wall.

the

Note

except

the

gonadal,

on

anterior

mesenteric

GI

(right

cava. the

and

the

left

right side,

which aorta,

the

then just

that

the

lower

vena

rectum

suprarenal)

drain

left

and

gonadal

drains

into

inferior

to

the

the

cava

and

not

ABDOMEN,

PELVIS,

AND

PERINEUM

receive

into

the

suprarenal cava.

of

|

canal.

separately left

vena

origin

does

anal

3

veins

The

the

left

renal

superior

artery.

Hepatic

veins Inferior phrenic

vein

T8 Aorta Left suprarenal Right

vein

Left

suprarenal

vein

renal

Right

vein

Left

renal

vein

gonadal

Right

vein

Superior

gonadal

vein

mesenteric artery L5 Common

iliac

Median

Figure II 3

Figure

Hepatic

Portal

The

hepatic

flow

from

liver

via

the

hepatic

the

right

The

the

veins,

Cava Cava and

vein

Tributaries and Tributaries

system tract

is

above portal

an

extensive

the

pectinate

vein

which

then

where drain

network line. it

into

of The

enters the

veins

venous

the

liver

inferior

that

receives

flow

is

sinusoids,

vena

cava

the

carried which

and

blood to

the

drain

ultimately

to into

atrium.

portal

midgut)

pancreas. splenic

GI hepatic

hepatic

(drains

Vena Vena

sacral

System

portal the

II 3 33. 32. InferiorInferior

vein

The

vein and

inferior

is formed splenic mesenteric

(drains

by

the

union

foregut) vein

of veins

(drains

the

superior

posterior hindgut)

mesenteric to usually

the

neck drains

of

the

into

vein.

13

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology

Hepatic

portal

Left Pharmacology

vein

gastric

vein

Biochemistry

Splenic

vein

(foregut) Physiology

Medical Genetics

Superior vein

mesenteric (midgut)

Inferior Pathology

BehavioralScience/Social Sciences

vein

mesenteric (hindgut)

Microbiology

Figure

II

3

33A.

Hepatic Figure II

portal

system

Portal System 3 34A. Hepatic Portal

System

Sinusoids Hepatic

Liver

Hepatic

veins

Heart

Inferior

Figure

II

If there

can

portal

system)

these

anastomoses

tric rhoids,

13

is an

blood

veins.

3 33B. Figure

in and

a

to

a caput

flow

retrograde pass

of

Normal of Normal

the of

medusae.

through

the

direction

through

include

Enlargement or

cava

Comparison II 3 34B. Comparison

obstruction

flow

vena

these

Caval Caval and

portal

(because

anastomoses esophageal veins

may

system of

to

and Portal

the

reach

veins,

rectal

result

in

Portal Blood

Blood Flow

(portal

hypertension),

absence the veins,

esophageal

Flow

of

caval

valves

system. and

in Sites

thoracoepigas

varices,

hemor

the for

CHAPTER

Azygos

vein

|

ABDOMEN,

PELVIS,

AND

PERINEUM

(caval)

Esophageal

A

3

vein

(caval)

Esophageal

varices

Esophageal vein

(portal)

Left Hepatic

gastric

vein

portal

vein Splenic

Paraumbilical vein

vein

(portal)

Superior mesenteric

vein Inferior

C

mesenteric

Caput

vein

Medusae

Superior Superficial

rectal

abdominal

vein

(portal)

veins

(caval) Inferior rectal

vein

(caval) B

Internal hemorrhoids

35. IIFigure 3 34. II 3 Chief

Figure

Table

II 3

Sites

6.

Sites

of

Portacaval

Chief Portacaval Portacaval

Anastomoses Anastomoses

Anastomoses

of Portal

Caval

Clinical

Signs

Anastomoses

Esophagus A

Esophageal gastric

veins

(left

veins)

Veins

of

the

thoracic

esophagus, drain

Esophageal

which into

the

varices

azygos

system

Rectum B

Superior (inferior

rectal

veins

mesenteric

Inferior

rectal

(internal

veins

iliac

Internal

vein)

hemorrhoids

vein)

Umbilicus C

Paraumbilical

veins

Superficial the

anterior

veins

of

Caput

medusa

abdominal

wall

13

PART

Anatomy

Pharmacology

II

|

GROSS

ANATOMY

Immunology

Biochemistry

URINARY

SYSTEM

Embryology

of

Renal

development

systems:

Physiology

kidneys

and

is

Ureter

characterized

pronephros,

by

mesonephros,

3

successive,

and

slightly

overlapping

kidney

metanephros.

Medical Genetics

Stomach

Midgut Pathology

BehavioralScience/Social Sciences Cecum

Pronephros

Allantois

Microbiology

Mesonephros

Cloaca

Mesonephric

Meta

duct

nephrogenic mass

Hindgu

Mesonephric

Figure

During

II 3

week

mesoderm

4, of

nephric the

In

week

derm

end

5, of

the

•

The

The

the

a

tuft

lateral

of

of

each

tubule

canalize last

does

not

in

to

ones

are

form formed.

function.

the

intermediate

meso

embryo.

to

form

glomerulus,

a

Bowman’s

capsule

into

invaginates.

opens

mesoderm

intermediate

and

tubules

the

enlarges

or

cervical

the

and

shaped of

tubule

capillaries,

intermediate

S

the

before

disappears

as

Metanephros Metanephros

laterally

regress

regions

each

in

grow

formed

lumbar

of

end

an

structures

appears

end

and and

appear

pronephros

and

medial

duct,

These tubules

mesonephros thoracic

which •

4,

Mesonephros, Mesonephros,

Pronephros,

nephrotomes

first

week

the

Pronephros, II 3 36.

embryo. The

of

the

35. Figure

segmented

tubules.

By

duct

into

the

mesonephric

derivative.

The

(Wolffian)

duct

drains

into

the

hindgut. •

Mesonephric ning

of

tubules month

3.

epididymis,

function The

temporarily

mesonephric

ductus

deferens,

and

duct and

the

degenerate

persists

in

ejaculatory

by

the

the

male

duct.

It

as

begin

the

ductus

disappears

in

the

female.

During

week

2 sources: metanephric sacral

The

major

134

the

metanephros,

ureteric mass

bud,

or

permanent

a diverticulum

(blastema),

from

kidney, of

the

develops

from

mesonephric

intermediate

mesoderm

duct,

and

the

lumbar

of

the and

regions.

ureteric

diverticulum pelvis,

5, the

bud to

which calyx

penetrates form

the

subsequently buds

into

the

splits the

metanephric

mass,

metanephrogenic

metanephric

into

cap. the

cranial tissue

which

The and

to

form

bud caudal the

condenses dilates

around to

major minor

form

the

calyces. calyces.

the renal Each

One

to

CHAPTER

3

million

renal

collecting

system

cap

to

tubule

gives

distal

convoluted

of

ureters

forms

or

excretory

tubules

nephrons, to

from

bud

the the

minor

calyces,

drainage

thus

forming

components

of

|

ABDOMEN,

PELVIS,

AND

PERINEUM

the the

urinary

cells

of

ureter).

collecting

form rise

kidneys

result

develop

ureteric

pelvis,

of

tissue

the

The

(calyces,

Penetration

The

tubules

pyramids.

3

the

into

proximal

the

metanephric

mass

units.

convoluted

induces

Lengthening

tubule,

the

of loop

of

the

the

excretory

Henle,

and

the

tubule.

develop fetal

in

growth

elongate,

of

and

abdominal

the

the

pelvis

the

lumbar

but

appear and

kidneys

to

sacral

become

ascend

into

regions.

the

With

vascularized

by

their arteries

abdomen

as

ascent,

the

which

arise

a

from

aorta.

Mesonephric

duct

Hindgut

Allantois

Paramesonephric

Mesonephric

tissue

duct

Allantois

Kidney

Bladder

Mesonephros Urorectal

septum Mesonephric Cloaca Ureteric

duct Ureter

bud Rectum

Metanephric blastema (mass)

End

of

Week

The

hindgut

The

urorectal

tal

sinus

of

Bladder

does

not

septum by

week

and rotate divides

Anal

membrane

membrane

End

5

Figure

Embryology

Urogenital

II 3 Figure

36. II 3

Development 37. Development

of the Urinary of the Urinary

Urorectal

of

Week

septum

8

System System

Urethra

but the

it

is divided cloaca

into

into the

2

parts

anorectal

by

the canal

urorectal and

septum. the

urogeni

7.

13

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology The

urogenital

•

sinus

The

upper the

and

urinary

The

lumen

the

urachus.

of

umbilicus.

3

parts:

largest

part

bladder,

of

which

the

is

urogenital

initially

sinus

(endoderm)

continuous

with

the

the

allantois

The

urachus

In

the

becomes

obliterated

connects

adult,

this

the

to

apex

structure

of

becomes

form

a fibrous

cord,

the

bladder

to

the

the

median

umbilical

ligament.

Medical Genetics –

The

trigone

of

mesonephric

Pathology

into

allantois.

Biochemistry

–

Physiology

divided

(cranial)

becomes Pharmacology

is

the

bladder

ducts

is

eventually

of

the

covered

bladder

is

into

is

the by

of

formed

by

dorsal

the

bladder

endodermal

incorporation wall.

epithelium

endodermal

origin.

the

caudal

mesodermal

so

The

of

This that

smooth

tissue

the

entire

muscle

of

lining the

BehavioralScience/Social Sciences bladder –

is

The

•

The

middle

spongy

The

the

of

mesoderm.

form

the

prostate

The

inferior

the

primordia

urogenital and

in

the

ejaculatory

ducts

as

they

enter

the

sinus

the

(endoderm)

prostatic,

will

membranous,

form and

all

of

the

proximal

male.

gland

prostatic

anorectal

also

the

female

urethra

the

•

ducts

part of

The

splanchnic

urethra.

urethra

–

from

mesonephric

prostatic

Microbiology

derived

in

the

male

is

formed

by

an

endodermal

outgrowth

of

urethra.

part

of

of

canal

the

the

sinus

penis

forms

forms or

the

the

lower

vagina

to

pectinate

and

contributes

to

clitoris.

hindgut

Urogenital

the

distally

the

line.

sinus

Allantois

Mesonephros Mesonephric

duct

Ureteric

bud

Urorectal

septum

Anorectal

canal

Cloacal

Figure

II Figure

Congenital agenesis

early

degeneration

Potter

13

37.

II

3

Abnormalities

Renal

bilateral

3

agenesis sequence:

results

from of

is

the

fatal

clubbed

Development Development

of

the

failure ureteric

of

Renal of

one

bud.

(associated feet,

of

38.

pulmonary

Bladder

Bladder

and

and

Urethra

Urethra

System or

both

Unilateral with

membrane

kidneys

to

agenesis

is

oligohydramnios, hypoplasia,

develop fairly

and and

because

of

common; the

craniofacial

fetus

may anomalies).

have

CHAPTER

Pelvic

kidney

(usually

is

caused

normal

kidneys

at

kidney

hooks

Double

their

ends

ureter

is of

of

male

the

older

with the

Postnatal

of

failure

caused

one

kidney

to

predisposition of

origin

of

by

2 separate

with

men

through

and the

the

the

to

fused

the

early

ascend.

Horseshoe

calculi)

kidney

is

to

inferior

mesenteric

splitting

of

a

ABDOMEN,

of

AND

PERINEUM

both

The

horseshoe

artery.

the

ureteric

bud

or

the

to

be

obliterated

congenital

enlarged

results

valvular

in

urachal

obstruction

prostates,

a patent

of

fistulas

the

urachus

or

prostatic

may

sinuses.

In

urethra

cause

or

drainage

in

of

urine

umbilicus.

Anatomy CLINICAL

The

PELVIS,

kidney

fusion

ascend.

|

buds.

allantois

children

a failure

function,

under

development

Failure

by

renal

3

kidneys

extend

are

from

right

kidney

liver.

Both

a pair

of

vertebral

level

is positioned kidneys

bean

shaped

T12

to

L3

slightly

are

in

organs when

lower

contact

approximately

with

the

than the

body the

12 is

left

in

the

long.

erect

because

diaphragm,

cm

of

psoas

position.

the

mass

major,

and

CORRELATE

They The

The of

most

common

constriction

the

renal

quadratus

sites

susceptible

of

ureteral

to

blockage

calculi

are:

•

Where

the

renal

•

Where

the

ureter

crosses

Where

the

ureter

enters

urinary

bladder

by

lumborum.

•

Right

•

Left

Ureters the

kidney: kidney:

are pelvis.

uterine

artery

run in

the

females.

ureter

lies

on

the the

structures

the

and

structures

that to

They

above above

tubes posterior

crossing

The

the

contacts

fibromuscular They

retroperitoneally, brim.

contacts

connect ductus

begin external

anterior

as

and

the

of

as the

they

psoas

the

12th

urinary and

renal pass

ribs

the

ureter

in to

pelves

and

the

the

pelvic

inlet

bladder

posterior

over

major

joins

rib and

the

males of

arteries

11th

to

in

continuations iliac

12th

the

kidneys

deferens

surface

the

pelvis

•

the

the

wall

of

the

run

pelvic

muscle.

Aorta Renal pelvis Inferior vena

cava

T12

Parietal

L1

Quadratus lumborum

pleural

reflection

L2 L3

Psoas

major

L4 Iliac

Iliacus

L5

crest

Ischial

Ureter

spine

Urinary bladder Course nerve pudendal

Figure

II 3

Figure 39A. Muscles Posterior

II 3 of

38A. Muscles of the Posterior Abdominal Abdominal

Wall

the Wall

Figure

II 3 Figure the

Posterior

38B. II 3

Bony 39B.

Landmarks Bony Landmarks

Abdominal

of of the

Posterior

of and

pudendal internal vessels

Abdominal

Wall

Wall

13

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology The

NOTE

urinary

bladder

muscular Parasympathetic

fibers

facilitate

and

fibers

inhibit

sympathetic

micturition. Biochemistry

•

The

•

The

neck

•

is

base

The

Medical Genetics

is of

base

a

the

of

ureters.

by

peritoneum.

The

body

is

a hollow

smooth,

the

urethra.

triangular

area

of

mucosa

located

internally

at

bladder.

the

The

with

triangle

apex

is

of

superior

the

trigone

supplied

by

and points

bounded

by

inferiorly

and

branches

of

internal

iliac

the

2

is

openings

the

of

opening

the

for

the

urethra. •

Blood –

Supply

The

bladder

arteries

is and

umbilical

vesicular

the

internal

iliac

arteries.

BehavioralScience/Social Sciences –

•

The

• bladder

Drain

results

from

lesions

of

to

drains

to

veins.

the

external

and

internal

iliac

nodes

spinal

cord

Innervation

above

the

sacral

Parasympathetic The

There

is

a

loss

of

nerve

inhibition fibers

of

that

the

muscle

during

detrusor

muscle

amount

of

minimum

the

from

sacral

segments

fibers

travel

S2, in

S3,

pelvic

and

S4.

splanchnic

the

filling

to

reach

the

detrusor

muscle.

Sympathetic

innervation

is

through

fibers

derived

supply

the

the

smooth

from

L1

through

L2

stage.

responds

stretch,

is

parasympathetic

innervate –

detrusor

innervation

preganglionic

nerves parasympathetic

Thus,

plexus

the –

cord

levels.

venous

CORRELATE

Spastic spinal

vesicular

Lymphatics –

CLINICAL Microbiology

the

superiorly

continuous

trigone

the

Pathology

covered

micturition

Pharmacology

Physiology

is

cavity.

to

causing

a

(lumbar

splanchnics).

internal

urethral

These

fibers

trigone

muscle

and

the

sphincter.

urge •

Muscles

incontinence. – Atonic

bladder

sacral

spinal

cord

spinal

nerve

roots.

motor the

results

innervation detrusor

with

a

from

segments Loss with

muscle

continuous

lesions or

to the

pelvic

loss

of

contraction

in

a full

dribble

of

of

–

from

the

internal

–

muscles

are

and

lumbar

Weakness

of

the

puborectalis

part

of

external muscle

urethra

and

ani

muscle

may

result

in

under

the

control

bladder

of

to

prevent

the

during

parasympa

are

urinary

smooth

neck

of

of

bladder. the

activated

lower

during

the

leakage. urethrae)

urogenital

is the

diaphragm

micturition

muscle the

fibers

and

(sphincter of

the

is

the

sympathetic L2)

the

4)

at

the

of

(micturition). of

vesicae)

(T11

sphincter

relaxed

3,

urethra

walls

bladder

control

(sphincter of

muscle

the

under (S2,

splanchnics

the

of

is

sphincter origin

component is

emptying

splanchnics

the

urethral

skeletal

voluntary

that

(voluntary

muscle

encloses of

the

micturi

the tion).

levator

of

of

muscles

pelvic

enclose

phase

most

during these

urethral

These

The

CORRELATE

the

that

filling

CLINICAL

of

fibers

thoracic

bladder.

of

fibers

The

forms

contracts

contraction

thetic

bladder

muscle

and

The

splanchnic

urine

detrusor

bladder

sacral

of

results

The

the

rectal

The

external

pudendal

sphincter

is

innervated

by

perineal

branches

of

the

nerve.

incontinence. The Weakness the

urogenital

urinary

13

of

the

sphincter

diaphragm

incontinence.

urethrae may

result

part in

of

in

male men

urethra) then

urethra

is

extends to to

the

from the

a muscular the

urogenital

external

tube

neck

of

diaphragm opening

of

the

approximately bladder of

the

glans

20 through

the

perineum

(penile

or

cm the

in

length.

prostate

(membranous spongy

urethra).

The gland

urethra (prostatic

urethra),

and

CHAPTER

The

male

and

spongy

urethra

is

ectodermal

cells

The

urethra

female

the

bladder

to

The of

the

divided

distal

into

spongy

glans

3 portions:

urethra

of

prostatic,

the

male

is

|

ABDOMEN,

PELVIS,

AND

PERINEUM

membranous, derived

from

the

penis.

is approximately

the

URINARY The

anatomically

(penile).

3

external

4 cm

urethral

in

orifice

of

length the

and

extends

from

the

neck

of

vulva.

HISTOLOGY

urinary

system

consists

of

2 kidneys,

2 ureters,

the

bladder,

and

the

urethra.

Cortex

Medulla

Renal pyramid

Minor

calyx

Major

calyx

Hilum

Renal Renal (of

pelvis

column Bertin) Ureter

Figure

II II

39. 3 40.

in

the

removal

balance,

salt

Figure

The

urinary

kidney

also

kidney

system

functions

functions

in

functions

leads

to

an

as

increase

erythropoiesis;

A

sagittal

section

tissue)

tip

of

of

the

and

urine

pyramid,

ureter.

The drains

of

medulla

called

the

collecting from

of the

presence

The

their

of

in

turn

papilla, ducts open

act

a

ends

as

and

glomeruli,

and an a

the

releases

a

wide

band

blood.

The

balance. renin,

The which

which

capsule of

stimulates

(connective cortex

a medulla

outer

and

space

invaginations into

base

vasodilators.

shows a

shows

from

acid

erythropoietin,

kidney

organ,

Kidney

products and

produces

borders are

waste

volume;

which

center

of the Kidney

of the

balance, it

fluid

protecting

the

Organization Organization

gland;

the

and

pyramid. the

endocrine extracellular

through

striations

inverted

an in

prostaglandins,

surrounding

radial

the

and

fluid

3

that of

the

in inner

showing the

shape

zone.

of The

is surrounded papilla’s

by epithelium

an

blunted calices and

calices.

13

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Table

II 3

Fluid

7.

Basic

Functions

balance

of

Maintain

Biochemistry

Electrolytes

fluid

(ECF)

and

intracel

with

intake

to

maintain

normal

concentrations

Excrete

metabolic

acids,

wastes

toxins,

(nitrogenous

products,

etc.)

Medical Genetics Fuels

Reabsorb

metabolic

acids,

Pathology

fluid

volumes

excretion

plasma

Physiology

extracellular

(ICF)

Balance

Wastes

kidneys

normal

lular Pharmacology

the

fuels

(glucose,

lactate,

amino

etc.)

Blood

Regulate

pressure

pressure

ECF

volume

for

the

long

term

control

of

blood

BehavioralScience/Social Sciences Acid−base

Regulate

absorption

control

and

acid−base

excretion

of

H+

and

−

HCO3

to

balance

Microbiology Organization The

of

cortex

is

vascular of

each

ous

with

is

lumen

are

The

1 located

medulla

cortex

is

to

The

cortex,

the

renal into

Along

edges

of

the

the

radially

divided

has

the of

are

each

the

center

parallel

to

each

other

rays

lobule and

with

At

medullary

arterioles

arranged

into

fewer

in

2 edges

and 2

contains

that

mixed tissue).

are

are

continu

glomeruli,

venules

with

a large

lobules.

elements,

is

tubules

oriented of

elements

connective

tubules

The

Radially

medulla

artery

enters

interlobar the

veins)

straight

stroma

zones.

(a A

profiles

profiles

of

of

Intralobular

the that

renal

kidneys

tubules small

wide

strip

tubules

similar

which

amount in

with

run

of

from

connective

proximity

to

different

the

appearances.

tubes.

and

forms

(the

efferent

efferent

bed.

This

a

sequence

in

near

the

the

branch

The in

ureter.

The

medulla–cortex

vessels

cortex.

the

cortex

total a

the

arcuate

branch

branch

at

the

off

the

branch

remaining

arteries

arteries

cortex

artery

border

into

arcuate

glomeruli,

cardiac renal tuft

carrying

at kidney

is divide

distal

high

has

into

in a

out

The the

complex

the

edges

of

(and into

inter

the

lobules.

interlobular

the

of

(the This

glomerulus

the

glomeruli

blood

pressure

arteriole body.

liters

in

vascular

corpuscle. in

lower

end.

unique

1,700 at

capillaries

the

blood bed

its

of

exits

remains

capillary

output,

corpuscle

convoluted

pressure

venules the

of

arteriole)

arterioles

to

upper

the

second

connects

hilum, to

tangentially

enters

arteriole

The

the

feeding

25%

arteriole

that

the

arterioles

corpuscle.

arteriole

fact

at travel The

of

travel

receive

intralobular

the

edge

arterioles,

each

kidney which

pyramids.

follow

arterioles

The

the

arteries,

medullary

that

lobular

14

the

medulla

medulla

outside

in

at

of

Circulation

The

the

rows.

vascular

outer

inner

Blood

medulla.

2

nephron

amount

containing

cortex.

comprised

papilla,

tissue).

The

the

the

contains

small

ray,

in

or

and (a

a medullary

in

along

lobules,

stroma

radially those

located

at

into and

lobule

oriented

kidney

divided

elements

and

es

the

capillary

efferent system

hours. as

glomerulus). is in

order

make than

second

situation to

allow

a second the

glomerulus

arteriole

capillary

arterioles in

Each

afferent A

a unique

capillary The

24

pole

the

from cortex.

due

to

filtration.

capillary and vein glomeruli

it

CHAPTER

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

NEPHRON

The

functional

unit

million

nephrons.

receive

urine

from

letting

the

to

and

form

the

The

nephron

end

with

capsule 2 the capsule

is

parietal

is the to

nephrons

urine

flow

of

55

mm

Each

collecting

and

out

nephron. ducts,

converge

the

and

with

kidney.

The

kidney

each

contains

collecting other

nephron

1–1.3 ducts

before

and

the

opening

collecting

duct

tubule.

a tube

been

about capsule,

is in

surrounds

an of

length

is the

by

layer

glomerulus

in

which

invaginated

visceral layer

and

kidney connect

several

Bowman’s

the

the

Nephrons

uriniferous

has

layers:

within

a

tuft

direct

of

approximately form

Proximal

Bowman's

tubule

capsule

the

human end

capillaries

contact

capillaries

in

enlarged

of

with

the

of the

It

nephron.

glomerulus

capillary

spherical a renal

kidney. the

urinary

starts

at

so

that

endothelium, space.

one

Bowman’s it

has

and Bowman’s

corpuscle.

Corte

Distal tubule

Outer

Collecting

zone

duct

Medulla Inner zone

Loop of

Henle

Figure Figure

II 3 II 3 41.

40. Nephron Nephron

141

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Renal The

Corpuscle parietal

layer

convoluted Pharmacology

complex

Biochemistry

which

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

of

tubule shape; surround

the the

lamina

that

is

almost

completely

Bowman’s

(PCT). cell

capsule The

body

has

blood

shared

by cover

vessels. capillary the

is

visceral

continuous

layer

extensive The

are

foot

and

processes cells.

surfaces,

walls

of

podocytes

the

foot

podocytes

podocyte small

proximal have processes

lie foot

slits

the and

secondary of

The

leaving

Afferent

the

called

primary

endothelial capillary

with

cells

in

a basal

processes between.

arteriole

Efferent arteriole

Microbiology Area of

Visceral

layer

Parietal

layer

Urinary

space

(podocytes)

detail

Fenestrated capillary Basal lamina

Urinary space

Podocyte

Foot processes

Figure

14

42. IIFigure 3 41. II 3Renal

RenalCorpuscle Corpuscle

and and

Bowman’s Bowman’s

Capsule

Capsule

a

CHAPTER

Copyright

McGraw

Figure

II

Hill Companies.

3 42. Figure

Used

IIRenal 3 43.

Renal corpusclecorpuscle

glomerulus glomerulus Simple cuboidal

Simple

From

Figure

II

the From IMC,

3

with permission. Copyright McGraw

cuboidal epithelium epithelium

© 2010 the IMC, DxR © 2010 Development DxR

43. Figure ScanningII 3

44.

electron Scanning

with podocytestheir

proximal proximal

(C), (C), andand

tubule tubule

urinary urinary

of the of the

Development Group,

Hill

(A),

Used

(A), vascular vascular pole

spacespace (D)

with

(B),

|

ABDOMEN,

PELVIS,

AND

PERINEUM

permission.

pole

(B),

(D)

distal tubule (arrowhead) distal tubule (arrowhead)

Inc. Group, All rights Inc.reserved. All rights

micrographmicrograph electron processes with their

Companies.

3

demonstrating demonstrating

reserved.

podocytes

processes (arrows) (arrows)

14

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Pharmacology

Biochemistry

Urinary (Bowman’s) Physiology

space

Medical Genetics

Podocyte foot Pathology

processes

BehavioralScience/Social Sciences

Podocyte

Capillary

Microbiology

endothelial

RBC From

the

IMC,

© 2010 DxR Development From the IMC, © 2010

Group, Inc. Development

DxR

All rights reserved. Group, Inc.

All Figure

II Figure

Blood the

plasma

Fenestrations

join

of

Podocyte

diaphragm

of

but

the

molecules

by complex and/or

and

experimental

free

of

in

of

the

varies

motile

plasma.

the

surface. The

coarser

shared

basal

filtration

the

podocyte

composed foot

20

foot of

process The and

elongated

cell

configuration. between

in

across

50

membranes

width nm,

of

the

possibly

as

glomerulus.

(they slit is

like

space

kD.

are

adjacent

a zipper

the

of

70

slits

urinary

capillary

first,

between The

podocytes

podocytes

the

the

flow

than

reserved.

Fenestrations of

the

openings filter.

surface slit,

the

20%

larger

slit

to

complex.

allow

podocytes

are

other

capillary

occupy

rights

demonstrating

demonstrating

constitutes

the

adjacent

processes each

composition human

cells,

selective

the

the

podocyte and

pressures

molecular in

of

of

nm)

of

from

perfusion

to

of

micrograph

micrograph

lumen

endothelium

passage

2

foot

connected

14

arise

function

exit

covering

center

the

the

a more

in

between

forms

the

which

electron

(50–100 the

constitute

junction

tions

from

diaphragms

processes proteins

Transmission

and

blocks

electron

endothelium

podocytes

it

thin

45.

large

block of

barrier;

and

3

Transmission

filtered

are

lamina

44.

capillary

endothelium

The

II

is

combined

3

contain

diaphragm associated

arrangement

with of

diseases.

actin and

these

to the

and the actin

complexes

myosin). basal

They

lamina.

cytoskeleton. are

are

The

slit

Altera found

in

many

a

CHAPTER

Proximal The

Convoluted

proximal The

connects

to

long

PCT

apical are

adjacent

cells

involved

in

microvilli

DCT

tall,

pole

with

a

they

have

and

of

the

to

a

the

which

the

a pink

they

is

mito

are

of

typical

of

clouded

cells

by

preparation

DCT

process.

collecting

its

far

end.

back

The

to

be

with as in

of

their

the

specific

medulla.

and

the

thick

the

PCT

loops

of

of

transport

“countercurrent

the

of

PCT

part

disposition

operate

tonicity

the

(constituting to

a

segments of

thought

special

have

convoluted

Henle

and

Henle

multipliers,” This

is

used

to

volume.

NOTE

make

are

or

loops less

these

only

in

its

urine

DCT,

more

general,

involved

with

receives

of

and In

contact

which

epithelium

microvilli. or

to

tubule,

thicknesses

PCT

of

now

descending

of

portions

coupled

them

final

and

loop are

has

loops

straight

The

fluid

and

Tubule

comes

the

the

branches, allow

and

PCT

straight

they

similar.

extracellular

tonicity

the

The

to but

more

properties,

to

of

well

own

Henle,

water

do

then

nephrons

and

much

Some

less

is

ducts

borders.

open

at

cortex

cells)

to

than

NOTE

lined

by

distinct

(also

under lamina and

mesangial

distorted

more

cells

capillaries,

of

to

an

by

inhibiting

increase

Na+ in

Na+

resorption, and

water

principal than

cells that

of

and the

intercalated PCT

or

cells.

the

DCT.

The

cell

Principal

outline cells

Cells

Mesangial

cytic

act

aldosterone.

Mesangial

basal

are

is

fibroblasts erythropoietin.

excretion.

ducts cells

produce

movements.

Ducts

Collecting

medullary

limited

transport

leading Collecting

and

(interstitial

have have

active

Renal

connects

and

collecting

cell

either

and

several

defined

tubes

passive

glomerulus,

from

Diuretics

respond

PERINEUM

that

borders

frequently

Some

The follow.

assigned

are

of

than

tubule.

(DCT)

ascending

Convoluted

these

AND

cytoplasm, large

lateral

histologic

directions.

limbs)

and

urine

diameter opposite

distal

been

gradient

modulate

of

PELVIS,

Bowman’s segment

characteristics

PCT

during

of

straight

Numerous The

These

well

in

descending

permeability

surface

urinary

invaginations.

lumen

smaller go

tubule

descending

variable

the ends

invaginations.

basal

The

a

traditionally and

creating

the

has

before

have

The

are

basal

the

preserve

which

convoluted

Distal

at and

interdigitated.

not

Henle

ascending

and

cells

extensive

transport.

limbs

Henle

opens path

PCT

extensively

do

segment

and

Henle. and

are

of

distal

DCT

ABDOMEN,

Henle

loop

the

(PCT)

circuitous

between

active

ascending wider

of

located

which

of

The

loop

a

microvilli,

chondria

Loop

tubule

follows

the

|

Tubule

convoluted

capsule.

3

the

known

as

basal

lamina

between may

be cells

Polkissen but

mesangial involved are

in detected

and the

or

Lacis

outside endothelial

maintenance in

several

the

are

located

capillary cells.

of diseases

cells)

the

Mesangial basal

resulting

between

lumen.

There cells

lamina. in

clogged

is are

no

phago

Abnormalities and/or

glomeruli.

14

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Proximal

Pharmacology

tubule

Biochemistry

Glomerular

basement

membrane Basement Physiology

Medical Genetics

of

Glomerular

membrane

Bowman’s

capsule

epithelium

Pathology

Epithelium

of

Bowman’s

capsule

BehavioralScience/Social Sciences

Polkissen

cell

Juxtaglomerular

Microbiology

Afferent Efferent

cells

arteriole

arteriole Macula Distal

tubule

Figure

II

densa

3Figure 45.

Renal II 3 46.

Juxtaglomerular juxtaglomerular

wall

of

and

a group

which

The detect

14

secrete

macula sodium

and and

Juxtaglomerular Juxtaglomerular

Apparatus Apparatus

Complex

The

the

CorpuscleCorpuscle Renal

(JG)

afferent

complex

arteriole),

of

mesangial

is

the cells.

a complex

macula The

JG

comprising

densa cells

(a

are

special

modified

JG

apparatus

domain

of

smooth

(in the

muscle

DCT), cells

renin.

densa levels

is

formed in

the

by tubular

tall

cuboidal fluid.

cells

in

the

wall

of

the

DCT

which

the

CHAPTER

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

PELVIS

Embryology

Table

of

II 3

8.

the

Reproductive

Embryology

of

System

Reproductive

System

Male

Adult

Adult

Female

and

Male

Reproductive

Female

Derived

Indifferent

follicles,

rete

Development

Structures

Female

Ovary,

and

ovarii

Embryo

tubes,

and

upper

Duct

of

uterus, part

of

Gonads

cervix,

ducts

Indifferent

Embryo

seminiferous

tubules,

rete

testes

Mesonephric

Appendix

of

testes

−

MIF

ducts

Testosterone

Genital

the

+

Paramesonephric

Clitoris

of

Male

Testes,

vagina

Gartner

Precursors

Adult

TDF

Uterine

From

Epididymis,

ductus

vesicle,

+

tubercle

deferens,

ejaculatory

Glans

and

body

seminal

duct

of

penis

Labia

minora

Urogenital

folds

Ventral

aspect

of

penis

Labia

majora

Abbreviations:

Labioscrotal DHT,

Congenital

dihydrotestosterone;

MIF,

Reproductive

Female

Müllerian

swellings inhibiting

Scrotum

factors;

TDF,

testes

determining

factor

Anomalies

Pseudointersexuality •

46,XX

•

Have

genotype ovarian

external •

Male

(but

no

testicular)

tissue

and

masculinization

of

the

female

genitalia

Most

common

which

the

cause fetus

is

produces

congenital excess

adrenal

hyperplasia,

a condition

in

androgens

Pseudointersexuality •

46,XY

genotype

•

Testicular external

•

Most to

a

(but

no

ovarian)

tissue

and

stunted

development

of

male

genitalia common 5α

reductase

cause

is

inadequate

production

of

dihydrotestosterone

due

deficiency

14

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology 5α

reductase •

2

Caused 5α

Pharmacology

deficiency

by

a mutation

reductase

2

testosterone

Biochemistry •

to

Clinical

findings:

•

At T:

2

in

catalyzing

underdevelopment

ductus

puberty,

of and

deferens,

these

DHT

Complete •

gene

that

renders

the

conversion

of

the

bifid

penis

and

scrotum)

seminal

emission

and

vesicle,

and

of

prostate.

sperm

The

ejaculatory

duct

are

androgen Occurs

are •

•

when

a

generally

Testes

may

be

Individuals

present is

of

to

an

increased

feminization

genotype

develops

syndrome) testes

the

and

uterus

and

female

uterine

tubes

AR

penis.

is

ventrally

appearing their

surgically

removed

to

females,

and

their

psychosocial

in

the

androgen

receptor

(AR)

gene

Testis

when

the

occurs

urethral

urethral

generally as

the

folds

orifice

associated

when of

are

genotype.

mutation

and

(known

surface

and

inactive.

external

It

Epispadias

a

Penis

the

majora

formation.

normal

is

occurs in

dorsal

testicular

vagina;

labia

despite

the

Hypospadias resulting

•

as

the

the tumor

cause

renders

curves

a 46,XY

in

female

common

the

or

a rudimentary

found

malignant

of

due

absent

Abnormalities •

with with

circumvent

that

virilization

(CAIS,

fetus

genitalia

Most

undergo

insensitivity

orientation •

patients

ratio.

external

Microbiology

reductase

normal

Medical Genetics

BehavioralScience/Social Sciences

5α

hypospadias,

epididymis,

Pathology

the

underactive

dihydrotestosterone

(microphallus,

Physiology

in

enzyme

fail

to

opening with

a

fuse

onto poorly

completely, the

ventral

developed

surface penis

that

chordee).

the

penis.

external It

is

urethral

orifice

generally

opens

associated

onto

with

the

exstrophy

of

bladder. •

Undescended descend The

(cryptorchidism) scrotum

canal. of

vaginalis

remains, The

may

Bilateral the

result

be

found

occurs that is

when

peritoneal

a fluid

when

occurs in

cryptorchidism

testes so

occurs

(typically

testes

Hydrocele

vaginalis.

14

the

undescended

inguinal •

testes into

filled

the

3

a small

cyst

in

near

flow the

fail after

cavity

of into testes.

to birth).

or

sterility.

patency can

testes

months

abdominal

results

fluid

the

within

the

processus

the

processus

in

the

the

CHAPTER

Pelvic

and

The

Urogenital

pelvic

and

phragms innervated

•

pelvic

rates

the

strong

support

branches

The

for

The

puborectalis

sling

around

rectum •

The to and

deep

the –

–

The

floor

of

AND

PERINEUM

dia They

the

pelvic

are

the

2 layers

the

pelvis

of

pelvis

to

fascia

and

each

sepa

diaphragm

transmits

from

by

of

anorectal

anal

the

junction,

canal,

and

is

and

is

ani

muscle

marks

the

boundary

in is

formed

perineus

levator

important

diaphragm It

transverse

is

distal

parts

the

perineum.

the

2

a of

the

muscles:

the

located

by

muscles)

fecal

2

a

muscular

between

the

continence. in

muscles

which

forms

the

perineum

inferior

(sphincter

extend

urethrae

horizontally

between

rami.

diaphragm and sphincter

(voluntary

is

and

penetrated

vagina

in

urethrae muscle

urethra

muscle

structures.

The and

tract

formed

diaphragm.

urethra

PELVIS,

coccygeus.

2 ischiopubic The

GI

urogenital

pelvic

muscular

component

and

skeletal

perineal

perineum.

organs

and

the

muscular the

ABDOMEN,

nerve.

the

pelvic

is and

and

the

from

2 important

pelvic

pudendal

the

diaphragm ani

are the

forms

cavity

system

levator –

the

diaphragm pelvic

support

The

of

of

genitourinary –

diaphragms

provide by

|

Diaphragms

urogenital

that

3

by

the muscle

of

the

serves

micturition)

maintains

urethra

in

the

male

and

the

female. as which

urinary

an

external

surrounds

urethral the

sphincter

membranous

continence.

Thorax

Thoracic

diaphragm

Abdomen

Iliac

crest Pelvic

brim

Pelvic

diaphragm

Pelvis Urinary

bladder

• Levator Ischial

ani

muscl

tuberosity Urogenital

diaphragm

Perineum Urethra

• Sphincter of

Figure

II

3

46.

Pelvic Figure

urethrae

micturition—external

muscle

(voluntary urethral

muscle

sphincter)

Diaphragm II 3

47.

Pelvic

Diaphragm

149

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology Male The

Pharmacology

Pelvic

Viscera

position

of

organs

and

peritoneum

in

the

male

pelvis

is

illustrated

below.

Biochemistry Detrusor

muscle

(pelvic

splanchnics) Trigone

Ductus

Ureter

deferens Physiology

Medical Genetics Parietal

peritoneum

Urinary

Fundus

of

bladder

bladder Rectovesical

Pathology

pouch

BehavioralScience/Social Sciences Internal

urethral

sphincter

(lumbar

Rectum

splanchnics)

Prostatic

Microbiology

M A

Urethra

Ductus

deferens

P

Membranous Seminal Penile

(spongy)

Corpora

cavernosa

Corpus

vesicle

Ejaculatory

duct

spongiosum (with

urethra)

Prostate Bulb

of

penis Median Urogenital (sphincter urethral

diaphragm urethrae

sphincter)

Anterior Bulbourethral external

pudendal

Figure

nerve

II Figure

CLINICAL Hyperplasia

of

An enlarged

prostate

urethra. to

Because dense will

The

urinate

starting

the

Prostate

gland

patient often

will and

will

compress

complain

has

of

difficulty

the

the

urge

with

urination.

the

prostate

connective compress

urethra.

15

CORRELATE

gland tissue

the

prostatic

is

enclosed

capsule, portion

in

hypertrophy of

the

a

gland

3

47. II 3 48.

Male Male

Pelvis Pelvis

Posterior

lobe lobe lobe

(M)

{Periurethral

zone}

(A) (P)

{Peripheral

zone}

CHAPTER

Female The

Pelvic position

Parietal

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

Viscera of

organs

and

peritoneum

in

the

female

pelvis

is

illustrated

below.

peritoneum Ureter

Suspensory of

ovary

ligament (ovarian

vessels)

Ovary

Uterine

tube

Round

ligament

of

Fundus

of

uterus

Uterus

(body)

Cervix

Rectouterine

uterus

(Pouch

pouch of

Douglas)

Vesicouterine pouch

Urinary

Posterior

fornix

bladder Rectum

Urogenital Vagina

diaphragm

Clitoris

Urethra

Vestibule

Figure

II

3

48.

Female Figure

Pelvis II 3 49.

Female

Pelvis CLINICAL The

ureter

suspensory be

protected

CORRELATE courses ligament when

just

medial of

ligating

the

to ovary the

the and

must

ovarian

vessels.

15

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL

CORRELATE

Support

for

pelvic

pelvic

and

viscera

urogenital

membrane, Pharmacology

cervical

ligaments.

Weakness

result

in

is provided

diaphragms,

perineal

(cardinal)

may

Uterus

body, and

by

the

A

and

posterior

prolapse

Ligament

view

of

the

female

reproductive

tract

is

shown

below.

perineal

and Biochemistry the transverse

uterosacral of

Broad

support of

uterus

into

Round

Mesovarium

ligament

structures

the

Mesosalpinx

Broad

ligaments of

Mesometrium

the

uterus

Ovarian Physiologyvagina

or

rectum

herniation

into

the

CLINICAL Pathology The

of

artery

vagina.

CORRELATE

ureter

Medical Genetics bladder or

the

passes

BehavioralScience/Social Sciences

inferior

to

the

uterine Suspensory

artery

1–2

(“water

centimeters

under

Microbiology avoided

the

during

from bridge”)

surgical

the

cervix

and

must

ligament

of

ovary

Ovarian

be

ligament

procedures.

Uterine

artery

(”water

under

bridge”)

Transverse

(cardinal)

cervical

ligament

Ureter Uterosacral

Figure

II

3 49. II 3 50.

Figure

Broad Broad

ligamen

Ligament Ligament

PERINEUM The

perineum

is

diaphragm. the

It

anal

and

•

The

the

is

and

•

blood internal

The

Anal CLINICAL

CORRELATE

A pudendal

nerve

to

anesthetize

nerve

is performed crosses

posterior

as

the

pudendal

to

the

ischial

located

the

below

ischial

the

pelvic

tuberosities

into

supply

3,

is

iliac

4)

of

to

the

provided

sacral

by

the

the

perineum

is

provided

by

the

plexus. internal

pudendal

artery,

a

branch

of

artery. nerve

and

vessels

cross

the

ischial

spine

posteriorly

to

enter

perineum.

anal

triangle

filled

is

anal spine.

ischioanal

sphincter

muscle

posterior

ischioanal

and

the

by

by

nerve

contains

and

the

anal

the

the

canal ANS

pudendal

internal

is

anal

canal

and

an

nerve.

pudendal

guarded

by

surrounded

external

The

a smooth

by

anal

pudendal

vessels

sphincter

canal

is found

on

muscle

the

the

internal of

skeletal

transmitting lateral

the aspect

of

fossa.

Triangle

urogenital

triangle

superficial

is divided

The

innervated

Urogenital The

fossa.

innervated

pudendal

152

pelvis

the fat

perineum

the

between

Triangle

The block

of

line

innervation

(S2,

pudendal

the

motor

nerve

the

outlet

a transverse

triangles.

sensory

The

shaped

by

urogenital

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diamond

divided

and into

root

superficial

forms

the

structures and

anterior of

deep

the perineal

aspect external

of

the

perineum

and

The

urogenital

genitalia. spaces

(pouches).

contains triangle

the

CHAPTER

The

superficial

perineal

urogenital It

pouch

diaphragm

and

is located

the

superficial

between

the

perineal

(Colles’)

perineal

membrane

of

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

the

fascia.

contains:

•

Crura

of

•

Bulb

•

Bulbs

•

Ischiocavernosus

of

penis

or

penis

of

(in

vestibule

clitoris: the

erectile

male):

(in

tissue

erectile

the

tissue;

contains

urethra

female):

erectile

tissue

in

lateral

muscle:

skeletal

muscle

that

covers

crura

muscle:

skeletal

muscle

that

covers

bulb

walls

of

of

penis

vestibule

or

clitoris •

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•

The

Greater

vestibular

Cowper

gland

deep

perineal

diaphragm.

•

of

penis

or

bulb

vestibule

It

Sphincter

(Bartholin)

pouch

gland

is formed

by

(in

the

female

fasciae

only):

and

homologous

muscles

of

to

the

NOTE

urogenital

contains:

The

urethrae

muscle—serves

as

voluntary

external

sphincter

of

bulbourethral

located

the

in

(Cowper)

the

deep

perineal

glands

are

pouch

of

the

male.

urethra •

Deep

transverse

•

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perineal

muscle

(Cowper)

gland

(in

the

male

only)—duct

enters

bulbar

urethra

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greater

vestibular

are

located

in

pouch

of

the

the

(Bartholin) superficial

glands perineal

female.

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Deep

perineal

(urogenital

internus

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urethrae

of

penis

membrane

perineal

(Cowper)

fascia

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space

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Bulbourethral

muscle

space diaphragm)

Buck

Superficial

muscle

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Crus Perineal

ani

Buck

gland Urethra

Figure

II

3

50.

II 3 51.

perineal

Superficial Superficial

(Colles’)

and and

Deep

Deep Perineal

penis

fascia

Bulbospongiosus

Superficial

Figure

of

muscle

muscle

fascia

Perineal Pouches

Pouches

of

Male

of Male

15

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology External

Genitalia

Male Pharmacology

Biochemistry

Crura

Bulb

of

of

Corpora Physiology

Pathology

penis

penis

are

is

continuous

with

continuous

cavernosa

with

and

corpus

the

corpus

spongiosis

corpora

cavernosa

spongiosis

form

of

the

of

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shaft

the

penis

of

penis.

(contains

the

penis.

Medical Genetics

In

the

male,

BehavioralScience/Social Sciences to the bulb of the

injury

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(blue

arrow)

extravasation urethra Microbiology

urethra).

of into

space.

the

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this

space,

the

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perineal urine

into

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into

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anterior the

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deferens

in

deep

to

arrows).

Urethra Urogenital diaphragm Penis Bulbourethral gland

Figure

15

II

3

51.

Male Figure

Reproductive II 3 52. Male

Urethra System

(P)

CHAPTER

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

Female Crura

of

Bulbs

of

Urethra

the

clitoris

vestibule

and

Duct

of

are

are

vagina

greater

continuous

with

separated

empty

from

into

vestibular

the

glands

the

the

corpora

cavernosa

vestibule

by

the

labia

the

clitoris.

minora.

vestibule.

enters

the

vestibule.

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of

symphysis

canal

• Pudendal

Urethra nerve

• Internal

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ramus

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triangle

pudendal

vessels

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Anal

Sacrotuberous

tuberosity

triangle

ligament Anal

canal Coccyx

Figure

Pelvic The

and pudendal

skeletal

the

and skin

in the that

II 3 52. Perineum

Perineum of Female

of

Female

Innervation

nerve

muscles

sphincter and

Perineal

Figure II 3 53.

(S2, the

S3,

pelvic

sphincter overlies

S4 and

ventral

urethrae, the

rami)

urogenital skeletal

and

its

branches

diaphragms, muscles

the in

both

innervate external perineal

the anal pouches,

perineum.

15

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology MALE

REPRODUCTIVE

HISTOLOGY

Testis Pharmacology

ISBN:

Biochemistry

The

testis

The

tunica

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into

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spermatogenic

cells,

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cells,

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lamina.

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cavernosum Prostate

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surrounded albuginea

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reproductive Male

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system System

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02

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A

in Initials

a

CHAPTER

Cross

section

seminiferous

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

of tubules

NOTE The

blood–testis

barrier

junctions

between

primary

spermatocytes

is formed

Sertoli

cells and

by and

their

tight protects

progeny.

*Area

of

detail

Spermatids Secondary spermatocyte* Primary

Spermatozoa

spermatocyte

Tight

junction

(blood–testis barrier)

Sertoli

cell

Spermatogonium

Basement

membrane

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tissue

Leydig

cell

*least

likely

to

be

Figure

seen

II 3 55. Figure

Seminiferous II 3 54.

Tubule Diagram Seminiferous

tubule

diagram

Spermatogenesis The

spermatogenic

occupy

the

erous

tubule.

membrane. the

cells space The As

(germinal

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the cells develop,

epithelium) basement

are

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stacked

membrane

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move

from

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basal

in the

4 lumen

to

8

layers of

the

to

the

basement

to

the

luminal

that seminif

side

of

tubule.

15

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology At

puberty

the

stem

differentiated B spermatogonia Primary Pharmacology

Biochemistry

Medical Genetics

weeks)

and

after The

in

produce

the

another

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form

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haploid).

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Physiology

cells

spermatogonia

to

to into

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mature

sperm.

Pathology

BehavioralScience/Social Sciences

Microbiology

Copyright

Figure

II 3

56.

Seminiferous

tubule

surrounded

Spermatogonia primary

(B)

inside Sertoli

15

lie

spermatocytes

cells

(arrow)

McGraw

by

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on

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Hill

blood

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membrane

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nuclei.

with

permission.

myoepithelial

cells

CHAPTER

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

Spermiogenesis Spermiogenesis

transforms

differentiation the

haploid

involves

nucleus;

spermatids

formation

development

of

of the

the

into

spermatozoa.

acrosome,

flagellum;

and

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condensation, loss

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process

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of

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cytoplasm.

Acrosome

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Figure

The

acrosome,

from

the

such

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of

hyaluronidase, cells

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56. Spermatozoan II 3 57. Spermatozoan

over

the

the

of

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corona

anterior

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and

neuraminidase,

structure the

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The

is

II 3 Figure

and

radiata

and

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of

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oocyte.

of

a flagellum among

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to

that ATP,

of and

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cilium.

Movement

is

a

dynein.

15

PART

Anatomy

Pharmacology

II

|

GROSS

ANATOMY

Immunology Sertoli

Cells

and

Sertoli

cells

are

Blood–Testis

tall

cells

in

but

only

10%

comprise

epithelial

the

cells.

seminiferous of

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during

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prior times

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cells

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maximal

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are

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spermatogenesis.

Biochemistry Irregular

in

extends

to

oriented Medical Genetics

•

shape; the

•

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stimulated

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BehavioralScience/Social Sciences

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lumen.

perpendicular

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Physiology

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The

follicle

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mechanism

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16

from the

network

spermatocytes)

found

protected

fetal

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during

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cells

synthesize

testoster

of

CHAPTER

Copyright

McGraw

Hill Companies.

Figure Figure II II3

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withCopyright permission. McGraw

Interstitium cells cells

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Companies.

between tubules between seminiferousseminiferous

(arrow) (arrow) and

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|

ABDOMEN,

PELVIS,

AND

PERINEUM

permission.

contains tubules (arrowhead)

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cellsand

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16

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology The

spermatozoa

function

pass

of

tion,

this

storage,

and

spermatozoa Pharmacology

Biochemistry

This

maturation

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

of The

which

contains

resorbs

to

epididymis. 5

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in

the

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Microbiology

Copyright

McGraw

Hill Companies.

Used

with Copyright permission.

3 60. Epididymis IIFigure 3 59. II Epididymis

Figure

epitheliumepithelium

The

ductus

(vas)

ejaculatory thick

16

duct walled, muscle

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Glands

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Used with permission. Copyright McGraw

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Companies.

3 61. Seminal vesicle showing mucosal Figure II 3 62. Seminal vesicle showing mucosal pseudostratified columnar epithelium with pseudostratified columnar epithelium

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permission.

with

16

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology The

prostate

empty

is a

into

rich

in

the

smooth

Biochemistry

glands

epithelium ous

is

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

30–50

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are

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of

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CHAPTER

Clinical

•

Injury

to

the

urethra

may

pass

the

bulb

into

abdominal •

penis

may

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ABDOMEN,

PELVIS,

AND

PERINEUM

Correlate

superficial

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FEMALE

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System

16

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology Folliculogenesis

and

Ovulation

14 Pharmacology

days

Biochemistry

Developing Primary Physiology

Medical Genetics

Secondary

follicles

oocyte Mature

follicle

(graafian) follicle

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Pathology

BehavioralScience/Social Sciences

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oocyte

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16

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology As

the

cans

follicle and

coalesce

and

present, Pharmacology

Biochemistry

it is

Medical Genetics

in

mature

and corona

where the

fluid

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the

has

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in

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16

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology The

wall

of

posed

of

the

numerous

Pharmacology

Biochemistry

cells

uterus, the

protective

or

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17

PART

II

|

GROSS

Anatomy

ANATOMY

Immunology Mammary CLINICAL

Breast Pharmacology born

cancer in

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PART

Anatomy

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GROSS

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Immunology Inferior Liver

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PART

Anatomy

II

|

GROSS

ANATOMY

Immunology

Ascending Colon

Pharmacology

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CT, CT, L2

L2

Superior Inferior Duodenum

Vena

Mesenteric Cava

Artery

Aorta

All From Inc.the rights Group, IMC, © reserved. Development 2010 DxR

DxR 2010

©

Development reserved

IMC, Group, the rights Inc. From All

Right

Kidney

Right

Ureter

Figure

II Figure

176

Left

3 79. Abdomen: II 3 80. Abdomen:

Psoas

Major

CT, CT, L3

L3

CHAPTER

Inferior Ureter

Vena

Left Cava

3

|

ABDOMEN,

PELVIS,

AND

PERINEUM

Common Iliac

Artery

All From Inc.the rights Group, IMC, © reserved. Development 2010 DxR DxR 2010

©

Development reserved

IMC, Group, the rights Inc. From All

Psoas

Right

Major

Common Iliac

Figure

Figure

II

3 II

Ureter

Artery

80. Abdomen: 3 81. Abdomen:

CT, CT, L4

L4

177

Upper

LEARNING

❏

Solve

❏

Answer

❏

Solve

problems

concerning

sensory

❏

Solve

problems

concerning

upper

❏

Use

knowledge

of

lesions

❏

Use

knowledge

of

arterial

❏

Solve

❏

Interpret

❏

Use

problems

brachial

and

is formed arise

•

concerning

questions

the

about

problems

muscle

of

knowledge

of

innervation

and

lower

branches

of

and

carpal

on

plexus

innervation

supply

concerning

scenarios

brachial

rotator

the

major

and

nerve

injuries

brachial

plexus

brachial

plexus

lesions

anastomoses

tunnel

cuff

radiology

PLEXUS

The

•

4#

OBJECTIVES

BRACHIAL

nerves

Limb

The

plexus by

provides the

from

the

fibers

forearm,

and axillary

innervate ments

brachial

of

and C5

and

innervate

function

and

spinal

radial

in that

nerves the mainly

ulnar

muscles

compartments

in

innervation T1

to nerves.

the

upper

Five

limb

major

plexus:

palmar and

sensory

through

median,

muscles that

motor

rami

musculocutaneous,

division

The

the

ventral

contain

posterior as

arm

nerves the

anterior

function posterior and

posterior

contain

anterior

arm, mainly division forearm

anterior as

flexors. fibers

and compart

extensors.

17

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Terminal

Mus,

Pharmacology

Branches:

Med,

(5)

Uln

Cords:

Lat

Rad, Axil Biochemistry

(3)

&

Divisions

Med

(6)

Trunks

(3)

Roots

(5)

Ant

Post

Post

C5 Suprascapular p e r io r S u

nerve Physiology

Medical Genetics

C6

M id d le

Pathology

BehavioralScience/Social Sciences

L

a t

e r

C7

a l

te o s

Musculocutaneous

ri

o r

In

C8

fe rio r

T1

nerve Microbiology Axillary

nerve M e

Radial

a d i

l

Long

nerve

thoracic

nerve Median

Ulnar

nerve

nerve

Figure II 4

Figure

MUSCLE

Terminal The below.

180

motor

II 4 1. Brachial 1. Brachial

Plexus Plexus

INNERVATION

Nerves innervation

of

Upper by

Limbs the

5

terminal

nerves

of

the

arm

muscles

is

summarized

CHAPTER

Table

II 4

Terminal

1.

Major

Nerve

Motor

Innervations

by

Muscles

All

nerve

compartment

Median

nerve

A.

C5–T1

the

Primary

muscles

of of

1.5

by

carpi

ulnar

of

C8–T1

B.

•

Thenar

•

Central

C5–6

Radial C5–T1

and

compartment

Flex

of

Digits

2

and

of

Flex 1

[1/2]

by

the

median

nerve

innervated

Hand

digits

wrist

Hypothenar

•

Central

compartment

Interossei

Lumbricals: Adductor

IP

Digits

4

&

5

Flex of

minor

compartment forearm

and

3

and

digits

Adduct

digits

Lumbricals

extension

4

digits

in digits

and

and

DIP)

and

2

5

(DAB)

2

5

(PAD)

MP

flexion

5

and

2–5

Dorsal

pollicis

and

2

Abduct –

Assist

muscles: and

–

Palmar

compartment

(PIP

(weak)

Dorsal

•

(MP)

interphalangeal

joints

3

thumb

metacarpophalangeal

extend

compartment

not

arm

digits

the

Compartment:

Posterior

all

Pronation

Deltoid

the

wrist

brachii)

digito

muscles

Teres

nerve

and flexor

Anterior

•

nerve

the

(biceps

nerve

Forearm

•

elbow

Opposition

Palmar

Axillary

except ulnar

Hand

–

LIMB

profundus)

Lumbricals:

A.

Flex

Supination

ulnaris

half

rum

nerve

anterior arm

compartment

(flexor

Ulnar

the the

muscles

UPPER

Actions

Flex

Anterior

|

Nerves

Forearm •

B.

5 Terminal

Innervated

Musculocutaneous C5–6

the

4

muscles

of

MP digits

and 4

extend and

PIP

Adduct

the

Abduct

shoulder—15°–110°

Lateral

rotation

Extend

MP,

Supination

&

DIP

joints

5

thumb

of

wrist, (supinator

shoulder

and

elbow muscle)

18

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Collateral In

addition

from Pharmacology

Biochemistry

Nerves to

the

trunks,

or

Table

II 4

2.

terminal

nerves, proximal

These

Table

II

The

4

nerves

2

are

the

terminal

innervate

summarizes

Collateral

there to

of

collateral nerves

proximal

the

Nerves

several

limb

collateral

the

nerves

(i.e.,

that

from

the

muscles

arise

rami,

(shoulder

girdle

nerves.

Brachial

Plexus

Medical Genetics Collateral

Nerve

Dorsal

Long Pathology

5

plexus

cords).

muscles).

Physiology

the

brachial

Muscles

scapular

nerve

thoracic

or

Skin

Innervated

Rhomboids

nerve

Serratus

anterior—protracts

and

rotates

BehavioralScience/Social Sciences scapula

Suprascapular

nerve

Supraspinatus—abduct

C5–6

Microbiology

superiorly

shoulder

Infraspinatus—laterally

0–15°

rotate

Lateral

pectoral

nerve

Pectoralis

major

Medial

pectoral

nerve

Pectoralis

major

Upper

subscapular

and

shoulder

minor

Subscapularis

nerve

Middle

subscapular

Latissimus

(thoracodorsal)

Lower

dorsi

nerve

subscapular

Subscapularis

and

teres

major

nerve

Medial ous

brachial

cutane

Medial

antebrachial

cutaneous

The

segmental

innervation i.e.,

to

the

more

arm

Skin

of

medial

forearm

the

muscles

(C5

and

C6)

and

segments

(C8

and

T1).

Therefore,

and

C6,

the

proximal

forearm

the

distal the

are

innervated

upper

are

C7

by

the

limbs

are

C6

the proximal–distal higher

innervated

by

by

a

by

by

muscles

innervated

and

has

innervated

shoulder

innervated

by

are

muscles

intrinsic

muscles

muscles

are

the

muscles

more

hand

forearm muscles

Sensory The

intrinsic

of

proximal

segments

and

and

C8

and

C7,

the

lower

are

innervated

T1,

the

and

the

by

distal

more

arm distal

C8.

Innervation skin

supplies thenar

of

the

the

palm

lateral

eminence.

hypothenar area

snuffbox.

18

medial

Innervation

gradient,

the

of

nerve

Segmental

C5

Skin

nerve

is supplied 31⁄2 The

eminence. of

the

first

digits ulnar The

dorsal

and

the

supplies radial web

the nerve

space,

median adjacent

and area

medial

11⁄2

supplies including

ulnar of

lateral

digits

and

skin the

nerves.

the

of skin

The

median

palm skin

the

dorsum

over

the

and of of

anatomic

the

the the

hand

in

CHAPTER

Palm

sensation

carpal

is

tunnel

not

affected

syndrome;

cutaneous

branch

passes

superficial

to

UPPER

LIMB

superficial

of

the

|

by

the

palmar

4

median

carpal

nerve

tunnel.

Anterior

Posterior

(palmar)

(dorsal) Musculocutaneous

nerve

(C5–C6)

lateral

(C8–T1)

forearm

medial Radial C6

nerve

forearm

dermatome C8

Ulnar Ulnar

31⁄2

Median

Figure Figure

On in

PLEXUS

the

exam,

follow

symptoms

distal

muscles,

assign

posterior

arm

11⁄2

List

the

arm

=

You

have

nerve

Upper

area

of

to

the

various

of

the

forearm

the

for

damage

Tip

the

location

injury.

of

the

Without

Innervation of the

injury.

Hand

An

specifically

of and

and

injury

the Hand Forearm

will

naming

compartments

those

limb, that

a

C6)

and

Forearm

of

all

the

limbs.

For

example,

manifest the

For

example,

shoulder.

muscles

or

that

area.

posterior

a function

of

the

muscles

within

that

area,

and

a

function.

nerve

and

Brachial

note

what

Plexus

function(s)

Lesion:

is

Erb

lost

or

weakened.

Duchenne

Palsy

Syndrome)

Usually

occurs

accident

or

•

Trauma

will

•

Primarily

the

to

innervate

of

and

(Waiter’s

nerves

site

that

can

(C5

•

4 2. Sensory 2. Sensory Innervation

nerve.

an

you

as

the

function

responsible

Now

II

clues

extension

nerve(s) radial

II 4

nerve

INJURIES

to

a =

nerve

31⁄2

nerve 11⁄2

BRACHIAL

dermatome

when birth damage

affects with

anterior

the

the

injury C5 the loss

head or and

axillary, of

and

shoulder

herniation

intrinsic

C6

of spinal

are

nerves

(roots)

suprascapular, muscles

forcibly

separated

(e.g.,

the

trunk.

disk)

and of

the

of

upper

musculocutaneous

shoulder

and

muscles

of

arm.

18

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology •

The

arm

and

suprascapular

major

is

medially

rotated

and

nerves.

muscles

pull

the

adducted

The limb

at

unopposed

into

the

shoulder:

latissimus

adduction

and

loss dorsi

medial

of

and

axillary

pectoralis

rotation

at

the

shoulder. Pharmacology

Biochemistry

Physiology

•

The

•

Sign

•

Sensory

is

is

extended

“waiter’s loss

and

pronated:

loss

of

musculocutaneous

nerve.

tip.” on

lateral

forearm

to

base

of

thumb:

loss

of

musculocutaneous

nerve

Medical Genetics

Lower

(C8 •

Pathology

forearm

and

Usually

T1)

Brachial

occurs

Plexus

when

the

Lesion:

upper

limb

klumpke’s

is

forcefully

Paralysis abducted

above

the

head

BehavioralScience/Social Sciences (e.g.,

grabbing

an

object

when

falling,

thoracic

outlet

syndrome

or

birth

of

trunk.

injury)

Microbiology

•

Trauma

will

•

Primarily

II 4

Lesioned

3.

Lesions

Root

of

Sign

is

•

May

include

•

Sensory

of

Brachial

the the

a on

C8

and

ulnar

Lateral of

Muscles

Deltoid

border

upper

arm

Rotator

cuff

Serratus anterior

spinal and

of

“claw

Horner

nerve

the

innervated

roots

intrinsic

muscles

muscles

hand”

and

of

“ape

inferior

the

hand”

of

hand

the

hand

(Figure

(median

II

medial

forearm

and

medial

11⁄2

digits

Plexus

C8

Lateral to

forearm

thumb

T1

Medial to

little

forearm

Medial

finger

elbow

Biceps

Finger

flexors

Brachioradialis

Wrist

flexors

Brachialis

Hand

muscles

Hand

arm

muscles

Supinator

Brachioradialis

Causes lesions

18

test

of

—

Upper compression

Biceps

trunk

1)

nerve).

Biceps

Reflex

with 4

syndrome.

C6

paresthesia

T1

nerve

median

combination

loss

C5

Dermatome

affected

of

•

Roots

the

affects

a weakness

Table

injure

Upper compression

tendon

trunk

—

Lower compression

—

trunk

Lower compression

trunk

to

CHAPTER

LESIONS

OF

•

Sensory

•

Proximal

deficits

Nerve

Axilla:

(Saturday •

Loss

•

Weakened

•

Sensory

•

Distal

head

loss

of

UPPER

LIMB

PLEXUS

weakness

the

using

crutches)

elbow,

wrist

and

MP

joints

supination on

sign

shaft

or

at

BRACHIAL

|

signs

palsy

extension

THE

motor

more

night

of

OF

precede

lesions:

Radial

Mid

BRANCHES

4

is

posterior

“wrist

humerus

arm,

forearm,

and

dorsum

or

elbow

of

thumb

drop.”

at

radial

groove

extensors

of

lateral

(lateral

epicondyle

or

radial

dislocation) •

Loss

•

Weakened

•

Sensory

•

Distal

Note:

of

forearm

wrist

and

MP

joints

and

dorsum

supination loss

on

sign

Lesions

Wrist:

the

is

of

the

posterior

“wrist

radial

forearm

of

thumb

drop.”

nerve

distal

to

axilla,

aspect

of

elbow

extension

are

spared.

laceration •

No

motor

•

Sensory

loss

loss

Median

Nerve

Elbow:

(Supracondylar

only

Weakened

•

Loss

of

pronation

•

Loss

wrist

of

digital

complete Loss

dorsal

fracture

•

•

on

flexion

thumb

of

first

sign

of is

ulnar

lateral

“hand

opposition

(first

dorsal

web

space)

humerus)

(with

flexion

fist; of

of

thumb

3 of

deviation)

digits

resulting

in

the

inability

to

make

a

benediction”

(opponens

pollicis

muscle);

sign

is

ape

(simian)

hand

Note: and

•

Loss

•

Thenar

•

Sensory

lumbricals

atrophy

of

the

A

lesion

“ape

2

loss lateral

of

(flattening on 31⁄2

median

palmar

of

thenar

surface

of

eminence) the

lateral

hand

and

the

palmar

surfaces

digits

nerve

at

elbow

results

in

the

“hand

of

benediction”

hand.”

18

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Wrist:

carpal •

tunnel

Loss

of

thumb

simian

Pharmacology

Biochemistry

Physiology

Loss

•

Thenar

•

Sensory

opposition

(opponens

pollicis

muscle);

sign

is

ape

or

of

first

2

lumbricals

atrophy

(flattening

loss

lateral

on

palm

of

the

palmar

may

be

thenar

eminence)

surfaces

of

lateral

31⁄2

digits.

Note

sensory

loss

spared.

Medical Genetics Note:

Lesions

and

Pathology

laceration

hand

•

on

or

BehavioralScience/Social Sciences

with

Ulnar

median

nerve

wrist

at

flexion,

the

wrist

digital

present

flexion,

without and

benediction

hand

pronation.

Nerve

Elbow

(medial •

Microbiology

of

normal

Loss

epicondyle), of

hypothenar

adductor •

wrist

(lacerations),

muscles,

or

third

and

fracture

fourth

of

hook

of

lumbricals,

hamate

all

interossei

and

pollicis

With

elbow

lesion

there

is

minimal

weakening

of

wrist

flexion

with

radial

deviation •

Loss

•

Weakened in

of

abduction

Loss

•

Atrophy

•

Sign

•

Sensory

4

of

of

Nerve

Fracture

of

•

Sensory

of

the

hypothenar hand.” on

surgical

lost

of

18

of

(interossei

digits

muscles)

2–5

(more

pronounced

of

is

greater

with

a

wrist

lesion.

digits

the

the

clawing

humerus

arm

to

deltoid

or

the

inferior

dislocation

of

the

shoulder

horizon

muscle

Nerve of

elbow

•

Loss

of

sensation

Thoracic

chest

the

that 11⁄2

neck

over

Loss

Often

Note

abduction

•

•

extension

2–5

eminence

medial

Musculocutaneous

Long

(IP)

digits

5)

“claw

the

of

adduction

loss

Axillary

Loss

and

thumb

is

•

adduction

interphalangeal

digits

•

and

flexion on

and

weakness

lateral

aspect

in of

supination the

forearm

Nerve damaged (nerve

during lies

on

a superficial

radical

mastectomy surface

or of

serratus

a

stab anterior

wound

to muscle).

the

lateral

CHAPTER

•

Loss

of

abduction

•

Sign

of

“winged

posterior

the

scapula”;

thoracic

Suprascapular •

of

arm

above

the

patient

horizon

unable

to

to

hold

above

the

the

4

|

UPPER

LIMB

head

scapula

against

the

wall

Nerve

Loss

of

shoulder

abduction

between

0 and

15

degrees

(supraspinatus

muscle) •

Table

Weakness

II 4

4.

of

Effects

lateral

of

rotation

Lesions

to

of

shoulder

Branches

of

(infraspinatus

the

Brachial

muscle)

Plexus

Musculo Lesioned

Axillary

Nerve

(C5,

Radial

Median

Ulnar

cutaneous C6)

(C5, (C5,

Altered

Lateral

arm

sensation

C6,

C6,

C7,

C8)

(C6,

Lateral

Dorsum

forearm

over

of first

hand

digits; and

anatomic

Abduction

weakness

shoulder

at

Flexion forearm Supination

C8,

of

Lateral

dorsal

interosseous

Motor

C7,

T1)

(C8,

T1)

C7)

Medial

11⁄2

medial

palm

digits;

palm

snuffbox

Wrist

extension

Wrist

Metacarpophalan geal

31⁄2 lateral

flexion

Finger

extension

Supination

Wrist

flexion

flexion

Finger

Pronation

Thumb

Thumb

Finger

spreading adduction extension

opposition

Common sign

—

—

Wrist

drop

Ape

of

hand

Hand

lesion

of

tion

lesions

of

Surgical

neck

Rarely

fracture

of

lesioned

humerus Dislocated humerus

Saturday Midshaft

night

palsy

fracture

humerus Subluxation

of

wrist

tunnel

compression

fracture

Pronator syndrome

Fracture

of

epicondyle

medial of

humerus of

humerus

humerus

deviation

wrist

devia at

Supracondylar

radius Dislocated

at

Carpal of

hand

Radial

benediction Ulnar

Causes

Claw

Fracture of

teres

of

hook

hamate

Fracture

of

clavicle

18

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology ARTERIAL

SUPPLY

Arterial Pharmacology

Supply

the

Upper

of

Limb

brachiocephalic

trunk

on

the

the

posterior

right

and

aortic

arch

on

the

left.

Medical Genetics Axillary

artery

•

From

the

•

Three

first

major

rib

to

edge

of

the

teres

major

muscle

branches:

BehavioralScience/Social Sciences –

Lateral

thoracic

thoracic –

–

Brachial

artery—supplies

Subscapular

Posterior

gland;

runs

with

long

artery—collateral

to

shoulder

with

suprascapular

branch

humeral

brachii

circumflex

artery

with

radial

humerus

artery

Deep

palmar

Ulnar

artery •

Common

•

Superficial

of

artery artery—at

surgical

neck

with

axillary

artery

Profunda

Radial

mammary

nerve

subclavian

Microbiology

18

ANASTOMOSES

artery

Branch

Pathology

to

MAJOR

Biochemistry

Subclavian

Physiology

AND

arch

interosseus palmar

artery arch

nerve

in

radial

groove—at

midshaft

of

nerve

CHAPTER

Suprascapular

4

|

UPPER

LIMB

artery

Subclavian

Brachiocephalic

artery

trunk

Clavicle

Axillary

1st

artery

rib

Aortic Anterior

humeral

circumflex

(landmark)

arch

artery Superior

Posterior

humeral

(surgical

Teres

neck

circumflex with

axillary

thoracic

artery Thoracoacromial

nerve)

(radial

brachii groove

Radial

with

radial

nerve)

Lateral

collateral

Subscapular

artery

Inferior

(courses

thoracic long

artery

thoracic

nerve)

artery

Superior

Radial

minor

artery

(with Brachial

artery

major Pectoralis

Profunda

artery

artery in

Common

ulnar

ulnar

collateral

collateral

interosseus

artery

artery

artery

artery

snuffbox)

Ulnar

Deep

Superficial

Figure

palmar

arch

palmar

artery

(radial)

arch

FigureII 4 II3. 4 3. Arterial Arterial

(ulnar)

Supply Supply

to the to

Upper the

Limb Upper

Limb

18

PART

II

|

Anatomy

GROSS

ANATOMY

Immunology Collateral

Circulation

Shoulder Pharmacology

Biochemistry

Subscapular

branch

of

axillary

and

suprascapular

branch

of

subclavian

arteries

Hand Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Superficial

and

CARPAL The

tunnel

The

orly

by

•

Microbiology

is

tunnel

the

tendons

of

the

There

Carpal

are

of tion

nerve

is also

digits.

The

through

CLINICAL Carpal median

is

the

tunnel

syndrome

compresses

the

vessels

median

nerve

reduces

the

the

only

or

and

tendon

any

nerve

aspect

of

and

the

posteri

the

radial 4

of

the

and

ulnar

tendons

flexor

of

bursae

the

pollicis

(4

flexor

longus)

and

branches

of

the

radial

or

ulnar

nerves

loss

on

the carpal

other

structures

results

affected

in

and and

in

carpal

the

patient

weakness

the

carpal

tunnel will

of

the

tunnel

due

syndrome.

in

present

with

thenar

to

The atrophy

muscles

(opposi

the

hand

and

numbness

lateral

side

of

branch

of

the

superficial

to

on the

the

palm

median the

palmar

nerve

flexor

surfaces

(thenar

of

eminence) which

retinaculum

the

lateral

is spared

supplies and

the does

31⁄2 because

lateral

not

course

tunnel.

nerve

and

artery

Pisiform

nerve.

Carpal

tunnel

Flexor

retinaculum

Median

nerve

Tubercle

Triquetrum

Lunate

Scaphoid

Figure Figure

Carpal Tunnel Tunnel II II4 44. 4. Carpal at Proximal at Row

190

ventral

hand).

sensory skin

and space

muscles

Ulnar

CORRELATE

tendons

the

the

retinaculum

superficialis,

and

blood

cutaneous

enters

9

on

flexor

(lunate).

digitorum

compartment

palmar

palm,

bones

transmits

thumb—ape

There

the

the that

thenar the

carpal

the

Syndrome of

of

located

by

tunnel.

condition

the

of

flexor

no

carpal

Entrapment

tunnel

nerve.

Tunnel

median

osseous anteriorly

profundus,

median

the

fibro

tunnel

digitorum

any

arches

bounded row

carpal

the

the

is

proximal

The

•

palmar

TUNNEL

carpal

wrist.

deep

of

Carpal

Bones

Proximal Row of Carpal

Bone

of

scaphoid

CHAPTER

ROTATOR

The the

CLINICAL

CUFF

tendons

of

rotator

of

the

supraspinatus,

cuff

muscles

strengthen

infraspinatus,

the

teres

minor,

rotator

cuff

glenohumeral

and

joint

subscapularis

and

(SITS)

Head

tendons

The

tendon

cuff

tears

muscles

of

the

may

become

torn

or

during

the

supraspinatus

experience

pain

is anteriorly

most and

commonly

affected.

superiorly

to

the

Patients

with

glenohumeral

rotator

the

joint

humeral

glenohumeral

portion

of

head

capsule

not

reinforced

Capsular

ligament

Synovial

membrane

tendon Glenoid

labrum

Glenoid

cavity

Axillary

recess

by

a rotator

cuff

II 4

After

is

inferior head

and

comes

injure

is to

glenohumeral

may

radial

5).

humeral

the

Dislocation

where and

superiorly to

capsule

inferior

slackest

the

anterior

or

joint

the

is the

(Figure

pulled

(cut)

joint

through

the

the

tendon

(cut)

Supraspinatus

the

occurs

dislocation, Acromion

Dislocation

of

typically

abduction

Clavicle

LIMB

inflamed. from

of

UPPER

muscles. Dislocation

The

|

CORRELATE

Humeral

include

4

lie

joint.

the

axillary

nerve.

Deltoid muscle

CLINICAL

CORRELATE

A rupture Axillary

cuff

nerve

or

follows

shoulder Radial

nerve

or

abducted

frequently rotator

Acromion

Coracoid

S

Superior

I

of

a

fall

upper

supraspinatus

Clavicle

tear chronic

rotator

use

of

with limb.

muscle damaged

the

the

an The is muscle

the

most of

the

cuff.

process

glenohumeral

ligament

Posterior SC

Anterior

Biceps

brachii

tendon

(cut)

Inferior

glenohumeral

T

Supraspinatus Rotator

Infraspinatus cuff

Teres Subscapularis

ligament

(S) (I) minor

(T) (SC) Inferior shoulder

Figure Figure

II II4 5. 4

Rotator 5. Rotator Cuff

and

anterior dislocation

Cuff

19

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL

CORRELATE

Humeral

The

Surgical

axillary

Pharmacology humeral

Neck

nerve

the

fracture

in

the

artery

Biochemistry it passes

surgical this

Fracture

accompanies

circumflex

around

RADIOLOGY

neck

area

as of

could

the

humerus.

lacerate

Glenoid

posterior

both

Clavicle

A

Coracoid

fossa

Humeral

Greater

head

tubercle

Acromion

All From

the

rightsthe artery

and

nerve.

Inc.

Physiology

Medical Genetics

Mid

Shaft

(Radial

Groove)

IMC, Group, © reserved.

Humeral

Fracture

The

Development 2010

radial

Pathology brachii result

nerve artery.

of

a

mid

accompanies Both shaft

the

profunda

DxR

BehavioralScience/Social Sciences could be damaged as a humeral

DxR

fracture.

2010Development reserved © IMC, Group,

Microbiology

Inc. the rights From All

Surgical

neck

humerus and

and

circumflex

humeral

shaft

of

groove

nerve

posterior

(radial humerus—radial nerve

profunda

brachii

II 4 6. Upper Extremities: Anteroposterior II 4 6. Upper Extremities: View

of

(External Shoulder

Rotation) (External

View of Shoulder Anteroposterior Rotation)

of

median

nerve Medial

Lateral

artery)

artery)

Figure Figure

Location

Mid

of

(axillary

epicondyle (location radial

of

of

humerus

of

ulnar

epicondyle (Location nerve)

nerve)

Capitulum of

humerus

Coronoid of

Radial

process

ulna

head

Radial Ulna

tuberosity

From Development From the the IMC, IMC,© 2010 © 2010DxRDxR Development Group, Inc. All rights reserved. Group, Inc. All rights reserved.

Figure

192

II

4 Figure 7. Upper II 4

7. Extremities: Upper Extremities:

Anteroposterior Anteroposterior

of View View of Elbow

Elbow

CHAPTER

Capitate

Trapezoid

CLINICAL

Trapezium

The

4

|

UPPER

LIMB

CORRELATE

scaphoid

fractured

is of

the

the

most

carpal

frequently bones.

This

fracture

From may

separate

the

proximal

head

of

the

the Hook

of

scaphoid

from

IMC, enters ©

Hamate

Hamate

2010

the

result

in

its

bone

blood at

the

avascular

supply

(which

distal

head)

necrosis

of

and

the

may

proximal

head. DxR Course Ulnar

of The

Nerve

lunate

carpal

is the

bone

(it

most

commonly

dislocates

dislocated

anteriorly

into

the

Triquetrum carpal Development Pisiform

tunnel

and

may

compress

the

median

results

from

nerve). Group,

Course

of

Median

Nerve

Inc. All

Ulna

CLINICAL

rights

•

CORRELATE

Carpal

tunnel

syndrome

compression reserved

Lunate From Figure

II

4

the 8.

IMC, Upper

© 2010

DxR

Scaphoid

Development

Extremities:

Radius

Group,

Inc.

Posteroanterior

All

rights View

within

• reserved. of

A fall

the

on

II 4 8.

Upper

Extremities:

Posteroanterior

View

the

median

nerve

tunnel.

the

outstretched

the

hook

fracture

hand

of

the

may

hamate,

Wrist which

Figure

of

may

damage

the

ulnar

nerve

as

of Wrist it

passes

into

the

hand.

193

Lower

LEARNING

❏

Explain

❏

Solve

❏

Demonstrate

❏

Use

❏

Demonstrate

❏

Explain

❏

Use

❏

Solve

information

and

The

major

The

concerning

knowledge

of

the

of

The deep

Obturator

•

Tibial

•

Common

•

Superior

•

Inferior

fibular

ankle

injuries

and

arterial

abnormalities

supply

and

of

major

gait

anastomoses

of

hip

to

knee

joint

joint

concerning

by

of

radiology

provides ventral

the

nerve:

nerve:

divisions

and

thigh

in

common

sensory

innervation

through

of

of

S3

spinal

L4

L2

to

the

lower

nerves.

divisions

nerve

connective

L4

through

L4

through

divisions

posterior

fibular

through

S3

divisions

posterior

a common

L2

of

posterior

nerve: nerve:

and L2

divisions

nerve:

gluteal

the

divisions

anterior

fibular

motor

of

are:

posterior

anterior

gluteal

the rami

plexus

nerve:

nerve

common

plexus

triangle

related

problems

nerves

•

sciatic

femoral

information

formed

Femoral

and

of

understanding

knowledge

lumbosacral

nerve

understanding

plexus

is

tibial

to

PLEXUS

•

region

related

problems

lumbosacral

limb

5#

OBJECTIVES

LUMBOSACRAL The

Limb

travel tissue

of

L4

of of

through

L4 L5

through through

together

through

sheath;

S2 S1 S2

the

together,

they

the

superficial

gluteal are

called

nerve.

fibular

nerve

divides

in

the

proximal

leg

into

and

nerve.

19

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology L2

L3 Pharmacology

Biochemistry L4

Femoral Physiology

L5

nerve

Medical Genetics Obturator

nerve

Superior

gluteal

Inferior Pathology

S1

nerve

gluteal

nerve S2

BehavioralScience/Social Sciences Common

fibular

Tibial

nerve

Sciatic

Microbiology

nerve S3

nerve

Figure Figure

Terminal The

Table

II 5

Terminal

1.

Terminal

Nerve

Femoral

nerve

Nerves

of

Lumbosacral

Origin

L2–L4

Obturator

L2–L4

nerve

divisions

posterior

nerve

L4–S3

anterior

Common fibular

L4–S2 nerve

Medial

Superficial fibular

Deep nerve

fibular

of

lumbosacral

thigh

plexus

are

described

below.

(quadriceps

femo

Primary

Actions

Extend

knee

Flex

of

adductor

thigh

brevis,

(gracilis,

anterior

adductor

portion

of

Adduct adduc

thigh

Medially

Posterior

compartment

of

semitendinosus,

posterior

portion

Posterior

compartment

of

flexor

longus,

tibialis

posterior)

Plantar

muscles

of

head

adductor

digitorum

of

biceps

(semimembrano

head

rotate

thigh

of

biceps

Flex femoris,

knee

Extend

thigh

(gastrocnemius,

Plantar

flex

flexor

(S1–2)

magnus)

of

soleus,

Short

thigh

long

leg

longus,

hallucis

Flex foot

foot

digits

Inversion

femoris

Flex

knee

divisions

compartment

fibularis

brevis)

Anterior

compartment

extensor

hallucis,

of

leg

of extensor

leg

(fibularis

longus,

Eversion

(tibialis

anterior,

Dorsiflex

digitorum,

fibularis

Extend

tertius) Inversion

19

hip

magnus)

Lateral nerve

the

Plexus

pectineus)

compartment

sus,

posterior

of

compartment

sartorius,

longus,

divisions

nerves

Lumbosacral

Innervated

Anterior ris,

anterior

of

Plexus

Plexus

tor

Tibial

terminal

Muscles

divisions

Nerves

II II 5 1.5 Lumbosacral 1. Lumbosacral Plexus

foot digits

(L4–5)

CHAPTER

Collateral The

Nerves

collateral

rized

below.

Table

II 5

of

nerves

2.

of

Collateral

Collateral

Lumbosacral the

of

Superior

plexus

Lumbosacral

Nerve

(to

the

lower

limb)

nerve

are

gluteal

Muscles

L4–S1

nerve

LIMB

summa

posterior

divisions

or

Gluteus

Skin

L5–S2

posterior

divisions

Innervated

medius,

minimus,

Inferior

LOWER

Plexus

Origin

gluteal

|

Plexus

lumbosacral

Nerves

5

gluteus

tensor

Gluteus

Primary

fasciae

maximus

Actions

Stabilize latae

Abduct

Extension Lateral

pelvis hip

of rotation

hip of

thigh

Segmental The

Innervation

segmental

gradient, and

•

innervation i.e.,

the

to

more

the distal

Muscles

more

Muscles to

the

proximal

muscles

of muscles

of

muscles are

Lower the

are

innervated

Limb lower

limb

innervated

has

by

by

the

lower

that

cross

the

anterior

side

of

the

hip

that

cross

the

anterior

side

of

the

knee

cross

the

anterior

side

of

the

ankle

that

cross

the

posterior

side

of

the

hip

that

cross

the

posterior

side

of

the

knee

the

posterior

side

of

the

ankle

the

a proximal–distal higher

segments

segments.

are

innervated

by

L2

and

L3 •

Muscles L3

•

Muscles L5

•

and

•

that

Muscles

and

Muscles and

by

are

innervated

by

L4

and

are

innervated

by

L4

L5

Muscles L5

innervated

(dorsiflexion)

and •

are

L4

innervated

by

S1 that

S2

are

(plantar

cross

are

innervated

by

S1

flexion)

19

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Pharmacology

NERVE

INJURIES

Superior

Gluteal

Biochemistry

•

Weakness

•

Impairment

AND

ABNORMALITIES

OF

GAIT

Nerve in

abduction of

of

gait;

the

patient

hip

cannot

keep

pelvis

level

when

standing

on

leg. • Physiology

Sign

is

“Trendelenburg

gait.”

Medical Genetics

Inferior

Pathology

Gluteal

Nerve

•

Weakened

hip

extension

•

Difficulty

rising

BehavioralScience/Social Sciences

Femoral

from

a

sitting

position

or

climbing

stairs

Nerve

Microbiology •

Weakened

hip

•

Weakened

extension

•

Sensory

loss

Obturator •

CLINICAL

common

fibular

nerve knee

aspect

of

fibula,

where

it is

damaged

nerve

present

ankle

the

The

common

on

of nerve.

motor

and

anterior

Loss

of

thigh,

medial

leg,

and

foot

adduction

of

the

thigh

as

well

as

sensory

loss

on

medial

thigh

lower

the

the

Patients

eversion,

and

surface

of

the

when

piriformis

muscle

with

the

results

to

the

lateral

of

the

leg.

extension

•

Loss

of

flexion

•

Loss

of

all

•

Sensory

of

of

the

functions

the

thigh

knee below

the

knee

loss

on

the

posterior

thigh,

leg

(except

medial

side),

and

foot

leg

be

syndrome loss

Weakened

the

muscle the

the

•

Tibial

may

through to

of

foot.

Piriformis sensory

limb.

piriformis

inferior

neck

at

nerve

the

the

dorsiflexion of

Nerve

nerve

only

•

Weakness

in

flexion

of

•

Weakness

in

plantar

flexion

•

Weakened

the

•

Sensory

knee

inversion

loss

on

the

leg

(except

medial)

and

plantar

foot

in

and Common

fibular

Produces

nerve

a combination

of

deficits

of

nerves

Deep

19

knee

the

frequently

lateral

fibular

compartments

at

of

loss

passes

tibial

the

the

crosses

most

loss

of

by

nerve

anterior

of

dorsum

compressed

the

drop),

loss

and

instead

the

with

(foot

sensory

the

the

the

CORRELATE

lateral

will

on

of

Nerve

Sciatic The

flexion

fibular •

Weakened

•

Loss

nerve inversion

of

extension

of

the

digits

lesions

of

the

deep

and

superficial

fibular

one

CHAPTER

•

Loss

of

•

Sensory

dorsiflexion loss

second

limited

fibular Loss

•

to

of

first

skin

of

the

first

web

space

between

the

great

CLINICAL

of

loss web

on

the

The

foot

anterolateral

leg

and

dorsum

of

the

foot,

except

for

the

thigh

The

of

lateral

leg

superficial which

of •

The

of

sciatic

The leg

the

nerve the

saphenous and

dorsum

by foot

with

the is

deep

supplied

Leg of

and

the

the

lesion

by

in and

is

results the all

often

dislocation.

posterior functions

in

damaged

following

A complete

sciatic

sensory

and

motor

compartment below

the

of

the

knee.

Foot

foot

are

supplied

exception

fibular

nerve hip

of

the

mainly first

by

dorsal

web

the space,

nerve. the

lateral

and

medial

plantar

branches

nerve.

sural

supplies •

the

tibial

Lower

nerve,

supplied

sole the

and

fibular is

The

the

CORRELATE

posterior nerve

space

Innervation

•

LIMB

and

deficits

•

LOWER

drop”)

nerve

eversion

Sensory

Sensory

|

toes

Superficial •

(“foot

5

medial

(a

combination

posterior nerve

of

leg

and

(a

branch

both

lateral of

peroneal side

the

of

and the

femoral

tibial

branches)

foot. nerve)

supplies

the

medial

foot.

Sural nerve

Superficial fibular

nerve

Saphenous nerve

Sural nerve

Sural Medial

nerve

plantar

nerve

Deep

Tibial

nerve

fibular Lateral nerve plantar

Figure

II

5

2.

Sensory II 5 2. Innervation Sensory

Innervation of

the of theLower Lower

nerve

Leg Leg and andFoot FootFigure

19

PART

Anatomy

Pharmacology

II

|

GROSS

ANATOMY

Immunology ARTERIAL

BLOOD

The

artery

obturator

•

External

iliac

•

Femoral

artery

Medical Genetics

medial

compartment

of

the

thigh.

BehavioralScience/Social Sciences

femoris

Medial

artery

circumflex

femoral

artery—supplies

circumflex

femoral

artery

head

of

femur

(avascular

necrosis)

•

o

Lateral

o

Perforating

Popliteal –

arteries—supplies

artery:

Anterior

tibial

compartment

o

Microbiology

–

Dorsalis

pedis

hallucis

longus tibial

of

leg

and

posterior

supplies

knee

artery:

courses

of

Posterior ment

20

the

artery

Profunda

o

Pathology

supplies

Biochemistry

–

Physiology

SUPPLY

compartment

of

thigh

joint with

deep

on

dorsum

fibular

nerve

in

anterior

leg

artery:

pulse

tendon; artery:

used courses

passes

o

Fibular

artery:

supplies

o

Plantar

arterial

arch

o

Lateral

plantar

artery

o

Medial

plantar

artery

to

note

with

posterior

lateral

of quality

tibial

to

the

nerve medial

compartment

foot

lateral of in

blood posterior

malleolus

of

leg

to supply

extensor to compart

foot

CHAPTER

External

iliac

artery

Lateral

circumflex

LOWER

LIMB

Inguinal

ligament

Femoral

triangle

artery

Deep

femoral

CLINICAL

artery Medial

circumflex

femoral

artery

Tibial

shaft

of

anterior

the

producing compartment

Popliteal

artery

Popliteal

tibial

Posterior Anterior

tibial

Dorsalis

fractures or either

can

cause

posterior anterior

tibial or

lacerations arteries,

posterior

syndromes.

artery

tibial

artery

artery

pedis

Fibular

artery

Medial

plantar

artery

artery Lateral

plantar

Plantar

arch

Arterial to Anterior

Figure

FEMORAL

FigureII

arter artery

supply

lower

limb

Posterior

Arterial 5 II 3.5 3.Arterial

Supply Supply

to

Lower Limb to Lower

Limb

TRIANGLE

femoral

adductor

CORRELATE

artery

Anterior

The

|

artery

Femoral

femoral

5

triangle

is

longus

the

femoral

artery

the

femoral

sheath).

Passing

under

femoral

artery,

femoral

canal,

femoral

canal

bounded

muscles. and

the

and is

the

and

canal)

vein

ligament vein,

inguinal site

an lymph

of

the

the

inguinal

femoral

by

Within

femoral

inguinal triangle and

the

(from empty

within

the

and femoral

femoral

lateral

space nodes

ligament, are

to

within

nerve

medial) the

the

the

are

is outside

the

femoral

sheath canal

and

(containing

(which

femoral

femoral

sartorius

sheath

called

(NAVEL).

of

nerve, the The

hernias.

201

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology HIP

Pharmacology

The

hip

joint

The

fibrous

is

formed

capsule

by

of

the

the

head

hip

joint

of

is

the

femur

and

reinforced

by

ligament,

and

the

acetabulum.

3 ligamentous

thickenings:

Biochemistry iliofemoral

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

ligament,

ischiofemoral

pubofemoral

ligament.

Ligamentum capitis

femorum

(round

ligament)

(cut)

Anterior iliac

superior spine

Microbiology Head

of

femur

Anterior iliac

Greater

trochanter

inferior spine

Iliopubic

eminence

Acetabular

Neck

of

femur

Transverse Iliofemoral and

ligament

joint

capsule

the

blood

femoral

circumflex

femoral

neck

the

20

of

head

acetabular

ligament

Figure

Most

labrum

of

artery) can

the

supply

compromise femur.

to

the

Figure

head

ascends this

of

II

5 4. II 5 4.

the

Hip Hip

femur

along

the

blood

supply

(arising

neck

of and

mostly

the

femur.

lead

to

from Fracture

avascular

the

medial of

necrosis

the of

CHAPTER

kNEE

The

|

LOWER

LIMB

JOINT

knee

lateral

joint

is

femoral

The

primary

The

knee

a synovial

joint

is and

several

joint

condyles,

the

movement

(quadriceps by

5

sets

at

a weight

by

medial

the

and

knee

bearing

hamstring of

formed

articulations

lateral

joint

is

joint,

muscles)

the

tibial

flexion

and that

of

its

the

medial

condyles,

and

and

extension

stability

cross

the

of

depends

joint.

The

the the

on knee

and patella. leg.

the

muscles

is strengthened

ligaments.

Posterior Anterior

cruciate Anterior

cruciate

ligament

cruciate

ligament

ligament

Lateral

condyle Medial

Lateral

condyle

Lateral

meniscus

condyle Lateral

meniscus

Medial Popliteus

ligament

meniscus Popliteus

ligament

Transverse Fibular collateral

Fibular

ligament

(lateral)

collateral

ligament

Tibial

ligament

(medial)

collateral

Fibula

ligament

Tibial tuberosity

Anterior

Posterior

Figure

Tibial

(Medial)

Tibial

collateral

inferiorly

and ligament

to

capsule

and

attach

to

medial

(abduction)

Fibular

of

(Lateral) extends

the

meniscus.

the

tibia

under

5 5. Figure

Structures II 5 5. Structures

Collateral

from

medial

II

aspect

the of

The

tibial

the

femur.

the of the

Knee Knee

Ligaments

medial the

of

CLINICAL

epicondyle

tibia.

ligament

It

is

of

firmly

prevents

the

femur

attached

lateral

to

The the

collateral

inferiorly

to

meniscus.

ligament attach

The

tibia

under

The

collateral

the

fibular

to

the

extends head

of

ligament

from the

prevents

the

fibula

and medial

lateral is

condyle not

attached

displacement

of

collateral

frequently

torn

commonly

seen

ligament ligament

at

is the the

most

knee,

displacement

the Fibular

tibial

CORRELATE

the to

following

lateral

trauma

to

knee.

femur the

(adduction)

lateral of

the

femur.

ligaments

are

taut

with

extension

of

the

knee.

20

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL The

tests

posterior

CORRELATE for

the

Anterior

integrity

cruciate

of

ligaments

the

anterior

are

the

and

These

are

posterior

•

Tearing

drawer

of

ligaments

the allows

signs.

Biochemistry

anterior

tibia

Anterior and

lateral

pulled

forward

to

(anterior

be

easily

Tearing ligament pulled

Pathology

drawer

sign).

of

the allows

posteriorly

posterior the

(posterior

to

cruciate

ligament

courses

superiorly,

condyle

of

the

of

the

the

cruciate tibial

but

are

located

outside

the

synovial

membrane.

knee

attaches

to

posteriorly,

femur.

the

is

(ACL)

The

tibia

anterior

under

extended

and

the

and

the

anterior

laterally

ligament

femur.

resists

aspect

to

to

prevents

Tension

on

It

the

the

anterior

the

hyperextension.

of

attach

ACL is

is

greatest

weaker

than

sign).

Medical Genetics •

Ligaments

ligaments

displacement when

Physiology

Cruciate

intracapsular

tibia

cruciate

the

Posterior

anterior •

and Pharmacology

and

• be

easily

posterior

Posterior tibia

cruciate and

medial

drawer

tibia

(PCL)

superiorly, of

under

ligament. ligament

courses condyle

the

BehavioralScience/Social Sciences

cruciate

the

the

attaches

anteriorly,

femur.

The

femur.

PCL

Tension

to and

the

prevents

on

the

posterior

medially

to

aspect attach

posterior

PCL

is

of

to

the

the

displacement

greatest

when

of

the

knee

is

flexed.

Microbiology Femur

Anterior

Femur

cruciate Posterior

ligament

cruciate ligament

Anterior

cruciate

ligament

(cut) Posterior

Anterior

Posterior

Tibia Tibia

Figure Figure

Medial

and

These

are

condyles shock

wedges

help

⯑igaments

Menisci

intracapsular that

⯑ruciate Ligaments

an⯑ Posterior Posterior Cruciate

and

(cut)

make

of

the

fibrocartilage

articulating

located surfaces

between

more

the

congruent

articulating

and

also

serve

absorbers.

•

Medial

meniscus

ligament. the •

Lateral fibular

20

Lateral

II 5 6. Anterior II 5 6. Anterior

cruciate

ligament

lateral

is

Therefore,

C it

shaped is

less

and

is

mobile

firmly and

attached is

more

to

the

frequently

tibial

collateral

injured

than

meniscus. meniscus collateral

is

circular

ligament.

and

more

mobile.

It

is

not

attached

to

the

as

CHAPTER

Common The

knee

3

most

ligament, jury

usually

the

|

LOWER

LIMB

Injuries

commonly the

5

injured

medial results

structures

meniscus, from

a

and blow

to

the the

at ACL

the (the

lateral

knee

are

terrible

aspect

the or

of

tibial

collateral

unhappy

the

knee

the

leg

triad)—in

with

the

foot

on

ground.

Patients the

with

a medial

meniscus

tear

have

pain

when

is

medially

rotated

at

knee.

ANkLE

JOINT

Tibia

Lateral

Fibula

(collateral)

Posterior

talofibular

Calcaneofibular Anterior

ligament

of

ankle

ligament ligament

talofibular

ligament

Tibia

Medial

(deltoid)

Posterior

ligament

tibiotalar

Tibiocalcaneal

ankle

part part

Tibionavicular Anterior

of

part tibiotalar

part

CLINICAL

Figure

II

5

7.

Structures II 5 7. Structures of the

ofAnkleFigure the Ankle

CORRELATE

•

Inversion

sprains

•

Anterior

talofibular

frequently

are

most

ligament

common.

is

damaged.

20

gure

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology RADIOLOGY

Pharmacology

Biochemistry

Physiology

Medical Genetics Lateral Femoral Condyle

Pathology

Lateral

BehavioralScience/Social Sciences

Medial

Patella

Femoral

femoral Medial

condyle

Condyle

femoral

condyle

Lateral tibial

Microbiology

Fibular condyle

Medial

Head

tibial

condyle Fibular

head

Fibular

neck

Intercondylar eminence

From the IMC, © 2010 DxR Development the IMC, © 2010 DxR Development rightsAll rights reserved. reserved. Group, All Inc. From

Figure

II

5 Figure 9. Lower II 5 8. Extremities: Lower Extremities:

Anteroposterior Anteroposterior

Group,

Inc.

View View of Knee of

Knee

Femoral Condyle

Medial

Patella

Patella

Femoral

femoral Medial

condyle

Condyle

femoral

condyle Fibular

Lateral tibial

condyle

Medial

Head

tibial

condyle Fibular

head

Fibular

neck

Intercondylar eminence

From Group,

II

5

9.

20

Lower

the

IMC,

Inc.

© 2010

All rights

Extremities:

DxR

From From

Development

Anteroposterior

the

IMC,

©© 2010 2010 DxR DxR Development Development

Group, All rights All rights Inc. reserved.

reserved.

View

of

Knee

Figure

FigureII

5 II 10. 5 9. Lower Lower

Group,

Inc.

reserved.

Extremities: Extremities:

Lateral

Lateral Knee

th

Group,

Lateral

Lateral

From

Knee

Figure

II

5

1

Head

LEARNING

and

6#

Neck

OBJECTIVES

❏

Explain

information

❏

Answer

questions

❏

Demonstrate

❏

Solve

❏

Answer

❏

Use

❏

Interpret

related

about

to

carotid

and

understanding

problems

of

concerning

questions

of

arteries

embryology

cranial

of

meninges

intracranial

scenarios

subclavian

the

head

and

neck

cranium

about

knowledge

neck

on

and

dural

venous

sinuses

hemorrhage

orbital

muscles

and

their

innervation

NECk The

thoracic

outlet

vertebra. first

The rib

upper

(scalene limb

plexus

the

Thoracic

outlet

brachial

plexus of

lung),

these a

brachial include

subclavian

The

and

rib

plexus

(C8,

by

the

anterior

and

the

structures

triangle

manubrium,

the

middle

scalene coursing

contains

the

first

rib,

muscles between

trunks

of

and and

the

the

T1 the

thorax,

brachial

artery.

syndrome

results

the

or

from

subclavian can

result

from

hypertrophy

T1)

is

the

compression

artery

of

usually

the

within tumors

the

of

the

scalene

first

to

of the

neck

affected.

trunks

of

triangle. (Pancoast

muscles.

be

the

scalene

The

on

lower

Clinical

the

NOTE

Compres apex

trunk

of of

the

and

•

Weakness

of

•

Decreased

blood

can

subclavian

(C 3,

4,

pain the

also laryngeal

on

medial

muscles flow

affect

into

the nerves

aspect

of

supplied

by

upper

limb,

cervical

the

ulnar

forearm nerve

in

indicated

sympathetic

and

by

trunk

the

and

anterior

scalene

Numbness

recurrent

The

the

symptoms

following:

•

the

bounded the

neck.

structures

Compression and

space

transmits

lower

cervical

the

the between

triangle)

and

and

sion

is

interval

vein 5)

are

scalene

and on

phrenic the

muscle,

nerve

anterior and

surface not

in

of the

triangle.

hand hand

weakened

(Horner’s

(claw radial

hand) pulse

syndrome)

(hoarseness).

20

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology Sternocleidomastoid

Anterior

Pharmacology

scalene

Middle

scalene

Phrenic

nerve

Biochemistry

Brachial

plexus

Trapezius Physiology

Medical Genetics

Subclavian Clavicle

1st Deltoid

BehavioralScience/Social Sciences

Figure

Microbiology

20

rib

Subclavian

2nd Pathology

vein

(cut)

II 6 1. IIScalene Figure 6 1.

ScaleneTriangle Triangle

of of the the

Neck Neck

rib

artery

CHAPTER

CAROTID

AND

SUBCLAVIAN

6

|

HEAD

AND

NECk

ARTERIES

Common

A.

Carotid

Internal

Artery

carotid artery

B.

External

carotid

1.

Superior

2.

Ascending (not

7

6 8 5

A

pharyngeal shown)

Lingual

4.

Facial

5.

Occipital

6.

Posterior

7.

Superficial

8.

Maxillary—deep

auricular temporal

middle

B

artery thyroid

3.

4

artery—ophthalmic and brain

face;

meningeal

Subclavian

3

artery

Artery

Common 9.

1

carotid

Internal bypass thoracic—cardiac

10.

Vertebral—brain

11.

Costocervical

15

12.

Thyrocervical

10

13.

Transverse

13

14

Subclavian

12

14.

11

Suprascapular—collaterals to 15.

9

Figure Figure

IIII 66

2. Arteries Arteries 2.

to

the theto Head

Head Neck and and

cervical

Inferior

shoulder

thyroid

Neck

CLINICAL The

CORRELATE

most

carotid artery. the

significant system

It

is the

arises

from

infratemporal

through

the

skull

and

result

in

foramen

of

the

external

meningeal

maxillary and

enters

spinosum

Lacerations

epidural

the

middle

fossa

dura. an

artery

of

artery

in

the

skull

to

supply

this

vessel

hematoma.

20

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology EMBRYOLOGY

OF

Pharyngeal Pharmacology

Biochemistry

The

THE

HEAD

AND

NECk

Apparatus

pharyngeal

•

apparatus

Pharyngeal

consists

arches

(1,

of

2,

3,

the

4,

following:

and

6)

composed

of

mesoderm

and

neural

crest

Physiology

Medical Genetics

•

Pharyngeal

pouches

•

Pharyngeal

grooves

The

anatomic

2,

or

associations

summarized Pathology

(1,

3,

4)

clefts

lined

(1,

relating

to

with

2,

3,

these

endoderm

and

4)

lined

structures

with

in

ectoderm

the

fetus

and

adult

are

below.

BehavioralScience/Social Sciences

Section

level

in

Figure

II

6

4

Microbiology Mandibular and

swelling

maxillary

4

swelling

6

3 2 1 Upper

limb

Somites

Lower

Figure

II

6

3.

The

Fetal

Pharyngeal

Figure

II 6

Apparatus

3. Fetal

Pharyngeal

Pharyngeal

Pharyngeal

Apparatus

arch

(mesoderm

groove

Pharyngeal

and

neural

groove

crest)

1

1 Pharyngeal

1

1 2

1

pouch 2

3

3 3

3

4

4 4

4

Figure

II 6 Figure

210

2 3 Ectoderm

Endoder

3

Developing

4.

4

6

Section

II 6 4.

1 2

2

2

pharynx

limb

Section

6

through through

the the

4

Developing

Developing

Pharynx

Pharynx

bud

bud

CHAPTER

The

components

Table

II 6

1.

of

the

Components

Nerve*

pharyngeal

of

the

arches

are

Pharyngeal

(Neural

summarized

Artery

(Aortic

Arch

AND

but

from

NECk

Skeletal/Cartilage (Mesoderm)

Mesoderm)

(Neural

Trigeminal:

Four

mandibular

HEAD

Arches

Muscle

1

|

below.

Arch Ectoderm)

6

nerve

muscles

of

mastication:

Crest)

Maxilla

•

Masseter

Mandible

•

Temporalis

Incus

•

Lateral

pterygoid

•

Medial

pterygoid

•

Digastric

•

Mylohyoid

•

Tensor

tympani

•

Tensor

veli

Malleus

Plus:

2

VII

Muscles

of

(anterior

belly)

palatini

facial

expres

Stapes

sion:

Styloid

Plus:

Lesser •

Digastric

(posterior

IX

Right

and

left

common

horn

upper

belly)

3

process and

body

of

hyoid

bone

•

Stylohyoid

•

Stapedius

Stylopharyngeus

muscle

Greater

carotid

horn

lower

arteries

body

and of

hyoid

bone

Right

and

left

internal

carotid

arteries

4

X –

–

Superior

Right

subclavian

artery

(right

laryngeal

Arch

nerve

arch)

of

Cricothyroid arch)

aorta

Soft

(left

muscle

Thyroid

cartilage

palate

Pharynx

(5

muscles)

Pharyngeal branches

6

X

Right

Recurrent

and

laryngeal

nerve

Note: mesoderm

are

The

not

ocular of

arteries

Ductus

the

derived

from

pharyngeal

muscles

(III,

occipital

somites

IV,

muscles

(except

cricothyroid

of

larynx

All

muscle)

cartilages

other

laryngeal

arch) arch;

VI)

Intrinsic

arteriosus

(left *Nerves

left

pulmonary

and

they

the

grow

tongue

into

the

muscles

arch.

(XII)

do

not

derive

from

pharyngeal

arch

mesoderm

(somitomeres).

21

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology The

anatomic

structures

relating

to

the

pharyngeal

pouches

are

summarized

below.

Pharmacology

Biochemistry Auditory

tube

middle

and

ear

cavity

(pharyngeal

pouch

Foregut

1)

Foramen Physiology

Medical Genetics

External

auditory

meatus

(pharyngeal

groove

1

cecum Site

1)

2

of

thyroid

gland

development Tympanic Pathology

BehavioralScience/Social Sciences

3

membrane

(pharyngeal

membrane

Path

1) 4

SP

of

thyroglossal duct Thyroid

C

Gland

IP IP:

Microbiology

SP:

inferior

parathyroid

superior

T:

thymus

C:

c cells

gland

parathyroid

gland T

of

thyroid

Figure

The

adult

structures

II 6 5. Figure

derived

Fetal II 6 5.

from

Pharyngeal Fetal Pharyngeal

the

fetal

Pouches Pouches

pharyngeal

pouches

are

summarized

below.

CLINICAL

CORRELATE

Normally,

the

pharyngeal

grooves

overgrowth

of

Failure

of

a

obliterated lateral

Table

second, are

the

cleft

to

be in

and

fourth

obliterated

second

results cervical

third,

arch.

completely branchial

2.

Adult

Structures

1

Epithelial

lining

of

auditory

2

Epithelial

lining

of

crypts

of

3

Inferior

(IP)

gland

cyst

or

may

abnormal

21

C cells

sequence

presents

problems be

Pharyngeal

Pouches

Derivatives

parathyroid

tube

and

palatine

middle

ear

cavity

tonsil

combined

(persistent ears,

and

and

*Neural

crest

cells

parathyroid of migrate

(SP)

gland

thyroid to

form

parafollicular

C

cells

of

the

thyroid.

hypocalcemia,

with truncus

with

(T)

Superior

CORRELATE

DiGeorge

defects

Fetal

cyst.

immunologic and

the

Adult

4

The

From

Pouch

Thymus

CLINICAL

Derived

by

pharyngeal

a

II 6

cardiovascular arteriosus),

micrognathia.

Pharyngeal meatus.

groove All

other

1 gives grooves

rise are

to

the

obliterated.

epithelial

lining

of

external

auditory

CHAPTER

Thyroid

6

|

HEAD

AND

NECk

Gland

The

thyroid

thyroid

gland

does

not

diverticulum,

develop

which

from

forms

a pharyngeal

from

the

pouch.

midline

It

develops

endoderm

in

from

the

floor

the of

the

pharynx.

•

The

thyroid

in

the

duct, •

The

diverticulum

neck

but

which

is

former

remains later

site

foramen

migrates

caudally

connected

to

to

the

its

adult

foregut

via

anatomic the

position

thyroglossal

obliterated.

of

the

thyroglossal

duct

is

indicated

in

the

adult

by

the

cecum.

Tongue The 2.

anterior

two

General

(cranial

The

sensation nerve

[CN]

posterior

General

Most

one

sensation

of

thirds

the

of is

carried

V).

Taste

third and

muscles

of taste

of

the

the

tongue by

the

sensation

is

associated

lingual

carried

associated

tongue

is

are

carried

by

are

branch

is

the

tongue

with

CN

innervated

of by

pharyngeal the

mandibular

chorda

with

arches

tympani

pharyngeal

1

and

nerve of

CN

arch

VII.

3.

IX.

by

CN

XII.

Circumvallate papillae Sensory Posterior

General

1/3

Post Ant

sensation

1/3 2/3

IX

V Lingual of

Foramen

Taste

IX

VII

branch

Chorda

mandibular

tympani branch VII

cecum

of nerve

Foliate papillae Anterior

Somatic

Filiform

2/3

papillae Fungiform

CN extrinsic

papillae

tongue

Figure Figure

II

6 II6. 6Tongue 6.

XII

innervates skeletal except

Motor the muscles palatoglossus

intrinsic

and of

the muscle.

Tongue

21

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology CLINICAL

Cleft

lip

CORRELATE

occurs

prominence nasal Pharmacology

Cleft

Face

when fails

to

the

maxillary

fuse

with

prominence.

palate

shelves

fail

the

The

to

when

fuse

the

with

each

medial

face

and

• or

develops

the

The of

the

from

arch:

nences,

palatine other

Palate

pharyngeal

Biochemistry

occurs

and

pair

primordia

the

of

forms

prominences lip

(neural the

crest) pair

of

of

the

first

maxillary

promi

prominences.

segment

the

mesoderm

prominence,

mandibular

frontonasal of

of

frontonasal

intermaxillary

philtrum primary

5

a single

and

fuse the

primary

when

the

2

together

at

medial

nasal

the

prominences

midline

and

form

the

palate.

palate.

Physiology

Medical Genetics

•

The

secondary

nence), •

Pathology

which

The

primary

the

definitive

palate fuse and

forms in

the

from midline,

secondary

hard

palates

palatine

shelves

posterior

to

fuse

at

the

(maxillary the

promi

incisive

incisive

foramen. foramen

to

form

palate.

BehavioralScience/Social Sciences

Frontonasal Medial

nasal

prominence

nasal

prominence

prominence

Microbiology

Lateral

Maxillary

Maxillary

prominence

prominence

Philtrum

Mandibular

Primary

Four

palate Intermaxillary primary

Secondary (maxillary

incisor

teeth of

lip

segment palate

Incisive

foramen

palate Fused

prominence)

(secondary

Figure

21

Philtrum

prominence

IIFigure 6 7. IIFace 6 7.

and Face

andPalate Palate

Development Development

palatine

shelves palate)

CHAPTER

CLINICAL

CLINICAL

CORRELATE

Robin First

arch

syndrome

because well

of

faulty

Pharyngeal

generally

Pharyngeal

cyst

obliterated

persist,

Ectopic

thyroid,

of

glands

these

be

Thyroglossal

the

DiGeorge

an

cyst

cyst in

base

into

tissue

of

or

midline

the

tongue

occurs the

located

thymus

results

parathyroid

position

is

generally

issue

during

when

neck

persist,

sequence

presents

mandibular

growth,

posteriorly

Robin

at

are

the

the

NECk

with

a

placed

muscle.

cleft

triad

of

palate,

and

a

tongue.

Collins

syndrome

mandibular

also

hypoplasia,

hypoplasia,

down

colobomas,

and

presents

zygomatic

slanted

palpebral

malformed

fissures,

ears.

normally

angle

of

from

abnormal

their

adult

midline

along

with

thereby of

AND

mandible.

CLINICAL

migration anatomic

of

the

the

the

Cribriform neck.

lateral

CORRELATE

Ectopic

aspect

of

plate

dysosmia

and

fractures

may

rhinorrhea

result

in

(CSF).

the

surgery.

when

parts

of

hyoid

bone.

The

the

thyroglossal cyst

may

duct also

be

cyst).

pharyngeal glands

that

the

found

the

(lingual

2 border

to

along

occurs near

poor

Two

Pierre

HEAD

1

anomalies.

and

groove

grooves

found

facial

arch

|

CORRELATE

Treacher

anterior

usually

fistula

the

causing

pharyngeal

syndrome

2 and the

embryonic is

of

cells.

pharyngeal

tissue

important

sequence

differentiate

along

or

their

thymus

generally at

pouch

a

thyroid

duct

persist, found

from

crest

found

parathyroid,

or May

neural

when

cells,

Collins

when

forming

Ectopic

parathyroid neck.

occurs

formation

crest

Treacher

involve

occurs

fistula

abnormal

neural

are

defects

fistula a

position.

of

syndromes Both

forming

from

migration

described

sequence.

results

6

pouches and

thymus.

3

and

Neural

4

fail

crest

to cells

are

involved.

CRANIUM

Cranial

Cribriform

Fossae

Optic

plate

canal

Superior

Anterior

and

Middle

Posterior

6

Figure II 6 8. 8. Foramina:

Foramina: Cranial

and

orbital

ophthalmic

fissure

artery)

(III,

IV,

VI,

V1

veins)

Foramen

rotundum

Foramen

ovale

Foramen

spinosum

Foramen

lacerum

(maxillary

nerve/V2

(mandibular

auditory

meatus

Jugular

foramen

(IX,

canal

magnum

meningeal

(VII

X,

)

nerve/V3

(middle

Internal

Foramen

II

(II

ophthalmic

Hypoglossal

Figure

(I)

and

and

artery)

VIII)

XI)

(XII)

(XI,

spinal

cord,

vertebral

arteries)

Cranial Fossae Fossae

215

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology

Pharmacology

Biochemistry

Foramen

magnum

vertebral

arteries)

Stylomastoid Physiology

foramen

foramen

Carotid BehavioralScience/Social Sciences

cord,

(VII)

Figure

II 6 Figure

9.

Foramina: II 6 9. Foramina:

Base Base

ovale

Foramen

lacerum

foramen

(II

II

6

10.

Foramina:

Figure

II 6

10.

Front

artery)

(mandibular

nerve)

(supraorbital

ophthalmic

fissure

orbital

VAN)

artery)

(III,

IV,

VI,

ophthalmic

fissure

foramen

foramen

Foramina:

artery,

veins)

Infraorbital

Figure

and

orbital and

Mental

carotid nerve)

of Skull of Skull

Superior

Inferior

XI)

spinosum

Foramen

canal

nerve

(internal

meningeal

Supraorbital

Optic

X,

sympathetic

(middle

Microbiology

(IX,

canal

carotid

Foramen

21

spinal

Medical Genetics Jugular

Pathology

(XI,

of Front

(infraorbital

(mental

Skull of Skull

VAN)

VAN)

CHAPTER

CRANIAL

MENINGES

AND

DURAL

VENOUS

SINUSES

CLINICAL

Jugular Cranial

by

Meninges

The

brain

is

covered

magnum

with

between

spinal

by

the

3

spinal

and

meninges

that

meninges.

cranial

are

There

continuous are

through

several

the

similarities

a tumor

(CN

differences

meninges.

•

•

Pia

mater

tightly

invests

away,

having

the

Dura

mater

(thickest)

teal

and

the

cranial

–

surfaces

of

relationship

with

unlike

meningeal)

that

the are

the

brain

and

the

brain

as

spinal

fused

dura,

cannot pia

consists

together

be

spinal of

during

2

most

AND

NECk

with

X),

loss

and (CN

may CN

be

IX, X, and

hoarseness, of

third

trapezius

XI.

dysphagia

sensation

posterior

IX), and

caused

over of

the

the

and

dissected sternocleidomastoid

mater. layers

of

on

present

oropharynx

the

same

HEAD

syndrome

pressing

IX and

tongue

|

CORRELATE

foramen

Patients

foramen

and

6

weakness

nearby

CN

tongue

deviation

XII may

be

involved,

(CN

XI).

The

producing

(perios

their

course

in

to

the

lesioned

side.

cavity.

Periosteal

layer:

and

as

serves

outer their

layer

lines

the

periosteum;

inner

can

surfaces

easily

be

peeled

layer

that

of

the

flat

away

bones

from

the

bones –

Meningeal the

(true

periosteal

points

in

teal

rium of •

inner

is

superior

CSF

returns

the

meningeal

dural

separate

and

connective sellae

and

fused At

from

diaphragma

duplications

mostly

cavity.

separates

sinuses

cerebri,

is

cranial

layer

venous

falx

These

the

support

with

certain the

perios tissue

and

tento

different

parts

CNS. the

surface

arachnoid

the

forms

innermost

throughout

duplications:

cerebelli. the

layer:

mater

cranium,

and or

Arachnoid

the

the

layer

foldings

dura) dura

thin,

of

the

delicate

granulations sagittal to

the

membrane

meningeal

dura.

penetrate dural

venous

systemic

which Projections

through sinus.

venous

the Arachnoid

dura

and

follows

arachnoid mater

the

called and

extend

granulations

are

into where

circulation.

Deep Arachnoid

lines of

of

vein Emissary

scalp

vein

granulations Diploic

vein

Skin

Galea

aponeurotica

Pericranium

Skull

Superior

sagittal

(diploic

Periosteal

bone)

dura

mater

sinus Meningeal Falx

dura

mater Cranial

cerebri

meninge Arachnoid Subarachnoid space Pia

Inferior

mater

sagittal Bridging

sinus

Figure

II 6 Figure 11.

II 6 11. Coronal

Coronal Section Section

of ofthethe

Dural Dural

veins

Sinuses Sinuses

217

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology There

are

•

several

Epidural

Biochemistry

•

of

the

Subdural

a

to

is

Subarachnoid of

cranial

meninges:

space

of

the

between

epidural

site

space of

lies

periosteal

the

hematomas the

arachnoid

hemorrhage

dura

(described

between

subdural

between

subarachnoid

the

hematomas

potential

space

site

the

potential site

membrane:

CSF: Physiology

is skull:

space

arachnoid •

related

space

bones Pharmacology

spaces

meningeal

dura

(described

later).

and

(described

and

the

later).

pia

mater

and

the

containing

later).

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Dural

Venous

Dural

venous

sinuses

periosteal

and

channels

called

drainage

from

internal

jugular

the Microbiology

Sinuses

dural

mater

The

•

•

venous

vein,

are

and

and

cerebelli

subdural

space

to

veins

skull

and

flow

•

Diploic

veins

•

Arachnoid

granulations

•

Meningeal

veins

into

into

the

the

form

to

are the

the

major

They

the

where

lined

jugular

the

venous

venous

drain

mostly

into

foramen.

duplications

sinuses

are

bridging

the

of

the

Most

of

meningeal

dura

the

following:

veins,

which

pass

across

the

sinuses. that

course

communicate

spongy

drain

2 largest

channels

sinuses

drain

at

cavity

cerebelli).

valveless

dural

cranial

endothelial

cavity.

floor

the

the

form provide

cranial

cranial in

veins

drain

are

allow

the

in

to

sinuses

the

tentorium

that

Cerebral

The

located

the

points

separate

within exits

sinuses

different

sinuses.

which

tributaries

Emissary

at layers

structures

cerebri

primary

formed dural

dural most

venous (falx

are

meningeal

(diploe) where

CSF

through with

core returns

of

the

bones

extracranial the

to

flat the

of

the

veins.

bones. venous

circulation.

meninges.

1 A Names

of

1.

Superior

2.

Inferior

3.

Straight*

4.

Transverse*

5.

Sigmoid

6.

Cavernous

7.

Superior

* Drain

Major

Dural

Sinuses

2

6

sagittal*

Orbit

sagittal

3 B

B.

Tentorium

6

(2)

face

veins

Confluence

the

confluence

the

inion.

5

of

of

Dura

of

sinuses

5

(2) sinuses

Jugular

foramen

Internal

jugular

Mater

cerebri cerebelli

Figure Figure

218

Deep

4

(2) petrosal

(Duplications)

Falx

veins)

(2)

at

A.

(ophthalmic

7

4

into

located

Folds

the

II 6

II 6 Dural 12. 12.

Dural Venous

Venous Sinuses

Sinuse

vein

CHAPTER

Major

dural

The

venous

major

•

venous

superior

of •

•

aspect

the

cerebral

vein

•

The

straight

of

(or

NECk

the

midsagittal

drains

plane

primarily

into

along

the

the

confluence

sinus cerebelli.

confluence

of

laterally

into

the

The

2

transverse

sinuses

The

the

sigmoid the

The

paired

sinus via

is

sinus

of

at

with

the

the the

junction

inferior

great

of

sagittal

draining

in

the

into

posterior

confluence by

of

the

posteriorly

transverse

the by

found the

formed

sinuses

the

sinus the

and

conflu

union

at

of

the

border

of

the

sinuses. the

superior

occipital

sagittal,

bone.

It

drains

sinuses. are

paired

bone

sinuses

that

in

drain

the

tentorium

venous

cerebelli

blood

from

the

and confluence

sinuses. paired

and

fossa.

The

form

a S

sigmoid

shaped

sinus

channel

drains

in

into

the

the

floor

internal

foramen.

sinuses

receives

are

located

on

of

the

from

either

the

drains

located

in

lateral

located

centrally

face

via sinus

are

side

of

the

wall in

of the

most to

and

sinus.

(ophthalmic venous

into

drain

and

body

of

the

cranial

divisions VI

of and

angle

cavernous

respectively. dural

nerves. the internal

of sinus.

petrosal

vein,

significant of

veins) plexus).

medial the

inferior

jugular

clinically

CN

the into

superior internal

a number

maxillary the

the

orbit

(pterygoid

drain and

and

the

the

face

veins,

relationship

ophthalmic

deep

maxillary

sigmoid sinuses

their

from

the

ophthalmic sinus

the

cavernous of

primarily

veins

enter

into

the

blood

emissary

cavernous

because and

near

joining

sinus).

sinus

jugular

veins

eye,

sinuses The

union

plane

by

terminates

into

sinuses

are

Superficial

Each

small

sinuses

the

midsagittal

bone.

Each

the

drains

cavernous

sphenoid

and

a

It

sigmoid

at

the

transverse

is

cranial

vein

straight

usually

the

the

posterior

the

terminates

the

by

It

occipital

into

in It

form

formed

sinuses

to

located

cerebelli.

into

occipital

–

in It

cerebri.

to

is

and

–

AND

following:

located

is

falx

vein.

straight,

–

cerebri.

tentorium

sinuses

jugular •

is

falx

Galen)

sinus

occipital

The

of

sinus

the

cerebral

attached

•

(of and

great

The

of

the

sinus

of

cerebri

tentorium •

are

the

sagittal margin

ence •

of

inferior

inferior

the

HEAD

sinuses.

The

falx

sinuses

sagittal

superior

|

sinuses

dural

The

6

CN

trigeminal carotid

sinuses III

and nerve artery

IV are are

sinus.

21

PART

Anatomy

II

|

GROSS

ANATOMY

Immunology

Cavernous

sinus

Oculomotor Pharmacology

Optic

nerve

chiasm

(III) Internal

Biochemistry Trochlear

nerve

(IV)

Abducent

nerve

(VI)

carotid

Pituitary

Ophthalmic Physiology

nerve

(V1)

gland

Internal

carotid

artery

Medical Genetics Sphenoidal Maxillary

Pathology

artery

nerve

sinus

(V2)

BehavioralScience/Social Sciences Nasopharynx

Microbiology

Figure

II 6

13.

Coronal

Figure Section II 6 13.

Through Coronal

SectionPituitary Through

CLINICAL

Cavernous

Sinus

Infection

the

spread

CN

III

a

and

IV

CN

VI

in

and

that

the

the

lateral

internal

with

the

An

is

the of

cavernous

sinus

and

damage

sinus.

maxillary

with

will

be

divisions

its

of

periarterial

CN

plexus

compressed

affected

in first

affected

deviated with

into

V

will

be

sinus.

being

along

face swelling

cavernous

typically

nerves

in

in

later.

eyeball)

(CN

altered

the a

of

central

VI in

patients

lesion).

have

Later,

the

of

sinus

Initially,

sensation

part

cavernous

skin

of

all the

eye upper

HEMORRHAGE

Hematoma

epidural

hematoma

lacerates

the

in

the

epidural

space

•

Epidural lateral

22

Sinuses Sinuses

scalp.

which

•

other

affected,

INTRACRANIAL

Epidural

the

fibers VI

the

artery

(medially

are

and

of

deep

result

and

wall

CN

strabismus

to

carotid

sinus.

movements face

related

sympathetic

cavernous

and

may

ophthalmic

internal

postganglionic

thrombosis

Cavernous and Cavernous

CORRELATE

superficial that

are

and

the

the

thrombosis

nerves

compressed

the

from

producing cranial

and Gland

Thrombosis

can

sinus,

Gland Pituitary

results middle

from

meningeal

between

the

hemorrhage

trauma

to

artery. periosteal

forms

a lens

the

lateral

Arterial dura

shaped

aspect

of

hemorrhage and

the

the

skull

occurs

rapidly

skull.

(biconvex)

hematoma

at

hemisphere.

Epidural

hematoma

followed

by

a

lucid

is

associated

(asymptomatic)

with period

a

momentary of

up

loss to

48

of

hours.

consciousness

the

an

CHAPTER

•

Patients

then

headache,

develop

symptoms

nausea,

and

of

vomiting,

elevated

intracranial

combined

with

pressure

neurological

such

6

|

HEAD

AND

NECk

as

signs

such

rapidly

if

as

hemiparesis. •

Herniation

of

arterial

Subdural A

the

blood

temporal

is

not

lobe,

coma,

and

death

may

occur

the

evacuated.

Hematoma

subdural

hematoma

cerebral

veins

at

hemorrhage

results

the

point

occurs

•

Subdural

from

where

between

the

hemorrhage

head

they

trauma

enter

meningeal

forms

that

the

tears

superior

dura

a crescent

superficial

sagittal

and

the

shaped

(“bridging”)

sinus.

A

subdural

arachnoid.

hematoma

at

the

lateral

hemisphere. •

Large

subdural

such •

as

Small

hematoma

headache

or

results

and

chronic

in

signs

of

elevated

intracranial

pressure

nausea.

hematoma

is

often

seen

in

elderly

or

chronic

death

alcoholic

patients. •

Over

time,

the

herniation

venous

Subarachnoid A

subarachnoid

at

branch

Willis.

The

of sites

of

the is

ORBITAL

MUSCLES orbit,

muscle,

there

the

•

the

Four

of

rectus,

The

•

•

(CN lateral

(CN

VI).

The

levator the

6

coma,

and

rupture

of

a berry

may

result

if

the

superior

part

anterior of

the

aneurysm of

the

in

circle

of

communicating middle

arteries.

cerebral

communicating

the Willis

artery

arteries.

or

at

the

Typical

THEIR

INNERVATION

muscles

that

muscles

(the

oblique,

nerve is

the

the

the

the

levator

(CN

III).

only

eyeball.

upper

superior,

plus

oculomotor muscle

move

elevates

A

inferior,

and

palpebrae

muscle

seventh

eyelid.

medial superioris)

innervated

by

the

are

trochlear

IV). rectus

is

the

palpebrae

fibers

by reach

postganglionic cervical

only

muscle

superioris nerve

innervated

of

part

superioris,

oblique

anterior

headache.

extraocular

inferior

the

posterior

severe

extraocular

the

Sympathetic artery

6

oculomotor

muscle)

a

palpebrae

by

The

by

•

lobe,

and

proximal and

of

a

is in

cerebral

the

AND

superior

nerve

anterior in

onset

are

the and

innervated •

the

site

carotid

levator

from

common

are

internal

presentation

the

temporal

evacuated.

results

most

point

common

junction

In

the

not

hemorrhage

of

the

is

Hemorrhage

circle

Other

of

blood

(CN

innervated

is III)

sympathetic the axons

composed and

by

of

smooth

the

abducens

skeletal

nerve

muscle

muscle

(the

innervated

superior

tarsal

fibers. orbit that

from originate

a plexus

on from

the cell

internal bodies

carotid in

the

ganglion.

22

PART

II

|

GROSS

ANATOMY

Anatomy

Immunology Right

Eye

Trochlea Superior

Levator

oblique

(pulley)

palpebrae

superioris

Pharmacology

SR

Biochemistry

Superior

LR

Physiology

rectus

MR

Arrows

tendon Medical Genetics

movement

BehavioralScience/Social Sciences

Microbiology rectus

nerve

Inferior

rectus

Inferior

oblique

(II)

Figure

II Figure

22

(III)

SO

(IV)

(cut)

annular

Pathology

Optic

(III)

rectus

Common

Medial

IO

(VI)

IR Lateral

(III)

(cut)

6

15. II 6

Muscles 14.

Muscles

of of

the the

Eye Eye

show

direction produced

of by

eye each

muscle.

(III)

PART

NEUROSCIENC

III

Nervous

System

Organization 1

and

LEARNING

OBJECTIVES

❏

Explain

❏

Use

information

of

to

general

autonomic

nervous

system

organization

SYSTEM The

central

which •

related

knowledge

NERVOUS •

Development

nervous

develop

The

peripheral consist

of

neural

tube,

and

the

and

system

(PNS)

that

neurons of

contains

the

brain

and

spinal

and

spinal

cord,

tube. contains

give

rise

derived

to

from

preganglionic

cranial

axons,

which

neural

grow

crest

autonomic

nerves,

out

cells.

of

the

Skeletal

neurons

are

motor

derived

from

tube.

Neural

crest

neurons.

cells

The

ganglia. or

(CNS)

neural

neurons

axons

neural

–

the

nervous

which

neurons

system

from

form

sensory

neuronal

Therefore,

all

postganglionic

neurons

cell

bodies

ganglia

and

of

found

autonomic

postganglionic

these in

neurons

neurons

the

PNS

and

are

autonomic are

found

contain

in

either

derived

from

migrate

into

sensory neural

crest

cells. –

Chromaffin

cells

medulla

to

Development

of

Neurulation

the

begins

toderm.

The

to

form

neural

Nervous in

By

cells,

the

third

end

of

which

sympathetic

the

adrenal

neurons.

NOTE

System week;

induces

neural

crest

postganglionic

notochord

(neuroectoderm). fuse

are

form

the the

both

CNS

overlying

third

and

PNS

ectoderm

week,

neural

derived to

folds

from

form grow

the over

Alpha

neuroec

neural

plate

midline

and

tube.

•

During

closure,

•

Neural

tube

AFP

levels

syndrome neural

3

fetoprotein

elevated

crest

primary

cells

vesicles

also

form

from

→ 5 secondary

in

(AFP)

gastroschisis

are

low

in

levels and

pregnancy

may

also

be

omphalocele. of

Down

fetus.

neuroectoderm.

vesicles

→ brain

(sensory)

and

and

spinal

cord •

Brain

stem

(motor); •

Neural non

•

Peripheral

and plates

crest

spinal are

cord separated

→ sensory

neuronal

cell NS

have

an

by and

the

alar sulcus

postganglionic

plate

a basal

plate

limitans. autonomic

neurons,

and

other

types.

(PNS):

cranial

nerves

(12

pairs)

and

spinal

nerves

(31

pairs)

22

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Neural

Neuroectoderm

plate

Neural groove

Pharmacology

Ectoderm

Biochemistry

A Neural

fold

Mesoderm A Endoderm Physiology

Notochord of

Medical Genetics

the

(induces nervous

formation system)

Notochordal Neural

process

groove

Pathology

B

BehavioralScience/Social Sciences

Day

crest

Somite

18

Neural

Microbiology

Neural

fold Neural Rostral

neuropore

(closes

at

day

Failure

to

close

tube Neural

25)

crest

C Alar

in

B

anencephaly,

causing

polyhydramnios C

and

increased

D

results

Basal

alpha

fetoprotein

and

plate

(motor)

AChE Neural

Caudal

neuropore

(closes

at

crest

27D) D

Day

22

Failure

to

results

in

and

increased

fetoprotein

Figure

22

close spina

bifida alpha

and

Figure III

AChE

1. Development 1 III1. 1 Development

of Nervous of NervousSystem

System

plate

(sensory)

CHAPTER

Central

Nervous

|

NERVOUS

SYSTEM

ORGANIZATION

CLINICAL

CORRELATE

AND

DEVELOPMENT

System

Adult 5

Derivatives

secondary CNS

Telencephalon primary

Ventricles

Axonal

polyneuropathies

Cerebral

Lateral

“glove

and

hemispheres

ventricles

deficits,

Third

failure.

ventricle

with

vesicles

3

1

vesicles Diencephalon

and Diabetes

are

weakness related mellitus

to

distal or

axonal patients

sensory transport present

Thalamus

Forebrain

Midbrain

produce

stocking”

sensory

neuropathies.

Cerebral

Mesencephalon

Midbrain aqueduct

Hindbrain

Pons

and

Metencephalon cerebellum

Fourth ventricle

Medulla

Myelencephalon Spinal

cord

Central Spinal

cord canal

Neural

Figure

Table

III

1 1.

Adult

tube

III 1 Figure

2. III

Adult Derivatives 1 2. Adult Derivatives

Derivatives

of

Secondary

of Secondary of Secondary Brain

Brain

Vesicles

Vesicles

Vesicles

Structures

Telencephalon

Brain

Neural

Cerebral

hemispheres,

most

of

basal

Lateral

Canal

Remnant

ventricles

ganglia

Diencephalon

Thalamus,

hypothalamus,

epithalamus optic

Mesencephalon

Midbrain

Metencephalon

Pons,

Myelencephalon

Medulla Spinal

(pineal

subthalamus, gland),

retina

Third

ventricle

and

nerve

Cerebral

cerebellum

aqueduct

Fourth

ventricle

Central

canal

cord

22

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Table

III

1

2.

Congenital

Malformations

of

the

Nervous

System

Condition

Types

Description

Anencephaly

—

Failure

Pharmacology

Biochemistry

of

Brain

anterior

does

not

Incompatible

Spina

bifida

Spina bifida Medical Genetics occulta

AFP

Failure

(Figure

A)

to

Mildest

No BehavioralScience/Social Sciences

Spina

bifida

Microbiology

fail

bifida

with

in

(Figure

bifida

(Figure

with

Most

Spinal Vertebral

Type

I

malformation

spinal

can

be

in

AFP

and

and

defect

protrude

Type

through

vertebral

defect;

II

seen

externally

AChE

II

C

space

cord body

Most

common asymptomatic

in

displacement

More

often

children of

association

with

displacement of

Frequent

tonsils

through

foramen

magnum

syringomyelia

of

of

IV

lumbar

Failure

cerebellar

symptomatic

Compression

ventricle

cerebellar →

vermis

obstructive

hydrocephaly

meningomyelocele

foramina

of

Luschka

and

Magendie

to

open

→

dilation

ventricle Agenesis

Hydrocephalus

of

Most CSF

often

Holoprosencephaly

cerebellar

Seen AFP,

alpha

fetoprotein

by

accumulates

in head

Incomplete One

vermis

caused

Increased

228

vertebral

arachnoid

Downward

Walker

defect.

B

Frequent

malformation

over

cord

Chiari

AFP

Downward

Abbreviation:

hair

through

in

cord

Mostly

Type

cord

laminae

Subarachnoid

Dandy

of

A

Dura

Chiari

spinal

severe

Spinal

Unfused

Arnold

cord

D)

Skin

vertebral

spinal

AFP

Arnold

Increase

symptomatic

the

AFP

and with

Increase

myeloschisis

occulta:

AChE

around

around

protrude in

seen

C)

Spina

the

growth

form

tuft

Meninges

meningomyelocele

bifida

and

B)

Spina

Muscle

bone

to

increase

Meninges

with

pregnancy

form

Increase

(Figure

during

Asymptomatic;

meningocele

close

life

induce

Vertebrae

Pathology

to

develop with

Increased

Physiology

neuropore

stenosis

in

trisomy

of

ventricles

and

splenium

cerebral subarachnoid

circumference

separation

ventricle

and

in

of telencephalon 13

(Patau)

cerebral

hemispheres

of

the

corpus

aqueduct space

callosum

of

IV

CHAPTER

Table

III

1

3.

Germ

Layer

|

NERVOUS

ectoderm

Mesoderm

Endoderm

Muscle

Forms

epithelial

Epidermis

Smooth

Tonsils

Hair

Cardiac

Thymus

Nails

Skeletal

Pharynx

Inner

ear,

external

Enamel

of

Lens

of

ear

Connective

teeth

All

eye

Anterior Parotid

(Rathke’s

pouch)

and

Blood,

Neuroectoderm tube nervous

Larynx

membranes

Trachea

lymph,

ORGANIZATION

AND

DEVELOPMENT

Adrenal

cortex

Gonads

and

parts

of:

Bronchi cardio

organs

reproductive Central

tissue

cartilage

vascular

gland

Neural

serous

Bone

pituitary

SYSTEM

Derivatives

Ectoderm

Surface

1

Lungs Urinary

bladder

Urethra internal

Tympanic

cavity

organs

system

Auditory

tube

Spleen Retina

and

optic

nerve

GI Kidney

Pineal

and

tract

ureter

gland Dura

mater

Neurohypophysis Astrocytes Oligodendrocytes

(CNS

myelin)

Ectoderm

Mesoderm

Neural

crest

Adrenal

Endoderm

Forms medulla

parenchyma

of:

Liver

Ganglia

Pancreas

Sensory

(unipolar)

Autonomic Pigment

Tonsils

(postganglionic) cells

Schwann

Thyroid

(melanocytes)

cells

(PNS

Parathyroid myelin)

Glands

Meninges

glands of

the

Submandibular

Pia

and

Pharyngeal arch

gland

arachnoid arch

mater cartilage

Sublingual

GI

tract gland

gland

(first

syndromes)

Odontoblasts Aorticopulmonary ogy

of

Endocardial

septum

(tetral

Fallot) cushions

(Down

syndrome)

22

PART

III

|

NEUROSCIENCE

Anatomy

Immunology AUTONOMIC

The

autonomic

smooth Pharmacology

NERVOUS

nervous

muscle,

in

the

peripheral

with

cell

(ANS)

cardiac

muscle,

and

and

sympathetic

in

in the

the

of

CNS,

is

responsible

glands

of

nervous

distribution

body

ganglion

Physiology

system

parasympathetic

Biochemistry

SYSTEM

and

the

for

the

body.

systems.

motor

the It

is

Both

innervation:

postganglionic

motor

innervation

divided

into

systems

with

the

have

preganglionic

neuron

of

2

neurons

neuron

cell

body

in

a

PNS.

Medical Genetics Central

nervous

system

Ganglion

(CNS) Preganglionic

Pathology

Postganglionic

nerve

BehavioralScience/Social Sciences

fiber

nerve

fiber Target

Microbiology

Figure

III

1

3.

Figure

Autonomic III

1 3.

Nervous

Autonomic

Nervous

System System

CNS Postganglionic neuron

Preganglionic

various

neuron

PAN

ACh

Craniosacral

NN

ACh

M

organs

heart,

smooth

muscle,

SANS

α

Thoracolumbar

ACh

NN

NE

glands

various

organs

or

heart,

smooth

β

muscle,

sweat ACh NN:

neuronal

nicotinic

NM:

muscle

NE:

norepinephrine

nicotinic

NN

ACh

M

receptor

Neurohumoral

receptor

ACh

α

NN

Epi

or β

ACh:

muscarinic

glands

piloerector muscles

transmission

M:

receptor

Adrenal

various

organs

transported via

blood

medulla

SOMATIC

acetylcholine

Motor

neuron ACh

NM

skeletal

Neuromuscular junction

Figure

III

1

4.

Autonomic Figure

and III

1 4.

Somatic Autonomic

Nervous and

Neurotransmitters/Receptors

230

glands

Somatic

System Nervous

Neurotransmitters/Receptors System

muscle

CHAPTER

•

Somatic

•

ANS:

nervous 2

system:

neurons

–

Preganglionic

–

Postganglionic

–

Parasympathetic:

–

Sympathetic: (except

1

(from

neuron

CNS

neuron: neuron:

short adrenal

Parasympathetic

in

body

in

ganglia

in

short

preganglionic,

long

CLINICAL

CORRELATE

AND

DEVELOPMENT

organ)

PNS

postganglionic

postganglionic

System

ganglion III

m.

VI Submandibular

Midbrain

IV

gland

V

gland

Pons

VII

Pterygopalatine Lacrimal

Submandibular

ganglion

gland

Sublingual

a

ganglion

VIII

mucosa mucosa

IX Otic

Parotid

ORGANIZATION

sphincter

Ciliary

Oral

SYSTEM

CNS

preganglionic,

Ciliary

Nasal

NERVOUS

organ)

body

cell

→ effector

|

medulla)

Nervous

Pupillary

CNS

→ effector

cell

long

(from

1

Medulla

ganglion X

gland

XI C1

Viscera thorax (foregut

of

the

and

Terminal

abdomen

and

ganglia

midgut)

T1

Hirschsprung’s terminal Infants

disease ganglia

cannot

in pass

results the

wall

from of

the

missing rectum.

meconium.

Preganglionic Postganglionic

L1

Terminal ganglia Hindgut pelvic (including

and viscera

the

bladder,

erectile

tissue,

and

S2

rectum)

S3 S

Pelvic splanchnic

Figure

III

1 5. Figure

Overview III 1 5.

Overview

of

nerves

Parasympathetic of Parasympathetic

Outflow

Outflow

231

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Table

III

1

4.

Parasympathetic

=

Craniosacral

Origin

Site

Cranial Pharmacology

nerves

Cranial

III,

nerve

VII,

IX Biochemistry

X

of

Four

(S2,

splanchnic S3,

nerves

S4)

Innervation

cranial

ganglia ganglia

the

walls

the

walls

Terminal near

Physiology

Synapse

Terminal near

Pelvic

Outflow

ganglia

ptosis,

or

Viscera

of

smooth the

muscle

neck,

of

thorax,

the

head

foregut,

and

midgut

viscera) (in

of

and

or

viscera)

Hindgut

and

erectile

tissue)

pelvic

viscera

(including

bladder

and

Medical Genetics

NOTE

Horner’s Pathology

(in of

Glands

Sympathetic syndrome miosis,

results

Nervous

System

in ipsilateral BehavioralScience/Social Sciences

anhydrosis. Horner’s

Syndrome

Lesion

Sites

Hypothalamus III Microbiology

IV

Head

V

pupillae

m.,

Internal

carotid

(sweat

glands,

dilator

superior

tarsal

m.)

VI VII VIII

External

IX

a.

carotid

a.

X

XI Descending

Superior

hypothalamic fibers

(drive

cervical

ganglion

all

preganglionic

Middle

sympathetic

Vertebral

cervical

ganglion

ganglion

neurons) Cervicothoracic T1

Heart, lungs

ganglion trachea,

bronchi,

(Thorax) Smooth and

muscle glands

foregut Gray

rami

*Rejoin of

spinal

of and

* branches

Prevertebral

*

ganglia

nerve *

Thoracic

splanchnic

Prevertebral

ganglia

muscle

glands L2

and

Lumbar nerves

Sympathetic chain

Figure

III

nerves

Smooth

L1

1

6.

Overview

Figure

23

the

midgut

III

of 1

6. Overview

Sympathetic of Sympathetic

Outflow System

of pelvic

splanchnic

the

and hindgut

viscera

CHAPTER

Table

III

1

5.

Sympathetic

=

Origin

Thoracolumbar

Site

of

1

|

NERVOUS

Outflow

SYSTEM

cord

levels

T1–L2

Synapse

Sympathetic

Gray

Innervation

chain

(paravertebral

AND

DEVELOPMENT

NOTE

rejoin Spinal

ORGANIZATION

ganglia

Smooth

ganglia)

muscle

glands

of

limbs;

head

rami spinal

are

postganglionics nerves

to

go

that to

the

and

body

wall and

body

and

wall.

thoracic

viscera

Thoracic

Prevertebral

splanchnic

(collateral;

nerves

aorticorenal

T5–T12

mesenteric

Lumbar

Prevertebral

splanchnic

(collateral;

nerves

L1,

L2

mesenteric

ganglia e.g.,

Smooth celiac,

muscle

glands

superior

of

and

the

foregut

and

midgut

ganglia)

ganglia e.g., and

Smooth inferior

glands

pelvic

viscera

muscle of

and

the

pelvic

and

hindgut

ganglia)

Lateral

horn

(T1–L2)

Dorsal

ramus

Ventral

Spinal

ramus

nerve White

Gray

ramus

communicans

1Figure 7.

Cross III

1 7. Section Cross

glands

wall

and

muscle of in

body

limbs

ramus

(preganglionic)

Sympathetic

III

smooth

and

communicans

(postganglionic)

Figure

To

of Section

Spinal of Spinal CordCord

ganglion

Showing Showing

Sympathetic Sympathetic

Outflow

Outflow

23

Histology

LEARNING

of

the

Nervous

System

2

OBJECTIVES

❏

Explain

❏

Solve

information

related

problems

to

concerning

neurons

disorders

of

myelination

NEURONS Neurons

are

information by

the

form

body

of

elles

cells

which

may

pass

and

the

typical

apparatus,

number

neuron of

are

morphologically

from

one of

end

their

contains

cell,

mitochondria,

and

the

cell

processes

the

a eukaryotic

and of

nucleus

as and

including

to

functionally the

bipolar, membrane

The

Neurons

unipolar,

endoplasmic

lysosomes.

polarized

other.

or

bound

and

that be

classified

multipolar.

The

cytoplasmic

reticulum

nucleus

so may

organ

(ER),

nucleolus

cell

Golgi are

prominent

in

neurons.

The

cytoplasm

somes. the

The Nissl

contains

Nissl

cytoplasm

substance

also are

sites

substance, contains of

protein

clumps free

polysomes;

of

rough free

ER and

with bound

bound

poly

polysomes

in

synthesis.

23

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Multipolar

Pharmacology

Biochemistry

Physiology

Medical Genetics

Neuron

Dendrites

Mitochondria

Pathology

Cytoskeleton

BehavioralScience/Social Sciences Nucleolus

Perikaryon Pe Nissl

Microbiology

Initial of

segment

(SOMA)

body

ent

axon

Golgi

Node

Schwann Schwa

of

Ranvier R

cell

Axon

Myelin M

FigureFigure

23

IIIIII 22

1. 1. Neuron Neuron

Structure Structure

sheath

apparatus

CHAPTER

Copyright

McGraw

Figure III 2

Figure ER

in

III 2.

cell body

cell

The

Copyright Used with

Hill Companies.

axon

2 2. Neural Neural

Tissue Tissue

body (arrowhead) (arrowhead)

The

axon (A)

adjacent

Hill

with Nissl stain with Nissl

Companies.

that stain

and proximal parts and proximal

(A) lacks Nissl lacks Nissl

neuron neuron

McGraw permission.

substance. substance.

has a prominent has a prominent

stains that

with

(B) dendrites

nucleus of an The nucleus

(arrow). nucleolus

HISTOLOGY

CLINICAL

(B)

adjacent of

|

CNS in

an

(arrow).

Disease

and

bodies

nigra,

the

neuron

consists

of

neurofilaments,

microfilaments,

neurons

Neurofilaments numerous

provide in

the

structural

axon

and

the

support proximal

for

the

parts

of

neuron,

and

are

most

Negri

Microfilaments

matrix

and

to

A

functions

in

matrix

specializations

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a

used

found in

axonal

near

prominent the

also

synaptic in

the in

motility

is at

are

matrix

is

aid

microfilament

tural •

form

microfilament

of

periphery growth

of

in

neuron.

of

cones

during

growth

prominent

the

cones

dendrites

neuronal

and

Inclusions

cytoplasmic

neurons

in

inclusions

of

compacta,

and seen

bodies

inclusions

dendrites.

the •

SYSTEM

the

evident

cortical

and

of

substantia in brain

Parkinson’s stem

and

microtubules.

•

Cytoplasmic

are

pars

disease of

NERVOUS

Neurons

Lewy

Cytoskeleton cytoskeleton

THE

CORRELATE

degenerating

The

OF

permission.

rough ER in stains rough

of dendrites parts of

The nucleolus

Used

2

in

certain

are seen

forms

eosinophilic in

hippocampus

degenerating and

cerebellar

of

dementia.

cytoplasmic neurons cortex

in in

A processes

patients

with

rabies.

development. forms

struc

membranes. all

parts

of

the

neuron,

and

are

the

cytoplasmic

transport.

23

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

Pharmacology

Biochemistry

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Microbiology

Copyright

McGraw

Figure III Figure

Hill Companies. with permission. Copyright Used McGraw Hill Companies.

2 III 3.

Neuron

2EM 3. of EM of Neuropil

with Surrounding and

CLINICAL

CORRELATE

Dendrites

taper

contacts In

degenerative

neuronal

diseases

of

a

tau

protein

becomes

phosphorylated,

which

of

The

microtubules.

form

helical

excessively

prevents affected

filaments

and

cytoplasmic

dendrites.

crosslinking

and

senile

be

used

The

axon

to

has

dendrites

tangles degenerating amyotrophic syndrome.

are

of

in

neurons.

prominent neurons

the

cell

lateral

features

and

provide

the

Dendrites

that

a

be

dramatically

highly

branched;

particular

a uniform

major

ER

for

synaptic

surface

may

contain

increase

the

the

neuronal

diameter

the

part

sion

of

and

disease,

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initial

Down

the

of

cell

length

the

cell

and

of

axon

body

the

spines,

which

surface

branching

area

are

pattern

of

of

dendrites

type.

may

branch

in

particular

axon,

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that

segment

segment

contains

segment

is

an

action

If the

lacks

marked

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axon

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apparatus

but

the

the

at

right near

angles

into

distal

end.

its

by

an

axon

hillock,

a

The

tapered

exten

substance.

•

body

Fast motor

the

axon

voltage of

hillock.

sensitive

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axon

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sodium

where

membrane ion

of

channels.

conduction

of

the

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electrical

initial initial

activity

as

is initiated.

myelinated, the

the

entire

cell

anterograde molecule.

neurotransmitters

free

moves

through

axon

is

the a

begins

rapid

at

polysomes, and

transport

body

the

sheath

lacks

mitochondria

there to

myelin

axon

contains

transport, cell

to

zone”

axonal

in

grade

adjacent

“trigger

potential

cytoplasm

sized

is numerous

the

Anterograde

23

of a Rough

(arrows)

of

Alzheimer’s

sclerosis,

Body with

Golgi

body

Neurofibrillary

in

body neurons.

may define

along

proximal and

Cell Neuron

microtubules neurofibrillary

plaques

cell

other

extensions

Dendrites

may

collaterals tangles

of

of thea

and (arrows)

permission.

neuropil has myelinated axons(M) Surrounding neuropil has myelinated axons(M) unmyelinated bare axons (box). and unmyelinated bare axons (box).

the

axons

including Cell Body

(arrowheads) and Golgi

with

the small

CNS,

from

with

Neuropil including

Rough(arrowheads) ER

Used

smooth

axon

to

and

the

initial

segment.

substance,

The

and

Golgi

ER.

proteins

(100–400

the

Nissl

membranes

synaptic

mm/day)

that

terminal.

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movement

of

are fast

synthe antero

materials

from

terminal.

transport Fast to

is anterograde synaptic

dependent transport terminals.

on

kinesin, delivers

which precursors

acts

as

the

of

peptide

CHAPTER

•

In

slow

anterograde

movement

of

enzymes,

soluble

and

ported is

transport,

to

not

there

cytoplasmic

precursors

synaptic on

small

•

and

Axonal

Disruption

of

by

slow

microtubules

fast

•

In

may

with

diabetes,

axonal

“glove

and

then

in

are

transport

molecules.

result

in

(which

an

axonal

affects

agents

hyperglycemia

e.g.,

results

may

polyneuropathies

mitochondrial

colchicine

and

disrupt in

pattern

of

in

long

alteration

of

transport.

axons

altered

an

axonal in

nerves,

sensation

and

proteins

Patients

may

producing pain

in

a

the

feet

and

hands.

axonal

terminal

to

the

transport

cell

returns

body

to

be

intracellular

recycled

or

material

digested

by

from

the

The

synaptic

polio,

tetanus

lysosomes.

CORRELATE herpes, toxins

transport

(60–100

mm/day).

retrograde the

from

Glial

and

The

supporting

•

neurons,

they

readily

primary

tumor

of

are of

the

They

and They forming •

They

surround

the

are

and

acts

permits

as

skeletal

and by

axons

that

muscle.

the Herpes

trophic

extracellular

transported

innervate

communication

transporting

up

and

factors

is

taken

transported

space.

dormant

in in

up

and

sensory

sensory

retrogradely fibers

and

remains

ganglia

PNS

small

process

cells

and

do

proliferate;

cells

that not

differ form

glioma

in

glial

from

neurons.

chemical

is the

synapses.

most

common

the

CNS,

and

they

have

large

and

contributing the

capillaries

left

scaffolding

for

filaments

that

the

CNS

consist

of

and glial

(GFAP). which

remove

extracellular

the

neurotransmitter

glutamate

space.

which

limiting

space

or

intermediate

processes

hypertrophy

Also

the

and

support

of

systems

from

extracellular scar.

CNS of

glial

protein

foot a

the

kind

structural

uptake

ions

have

in

by

which

transport

taken

viruses

CNS.

bundles

acidic have

or

anterograde

ATPase, also

body

CNS

numerous

the

large

K+

cell

the

divide the

an

than

rabies

processes.

provide

They

of

one

most

radiating

fibrillary

•

cells only

contain

•

glial)

have

numbers

the

in

slower

dynein,

target

Cells

is

transport

and

postsynaptic

(or

Astrocytes

on

Retrograde

terminal the

cells

and

is dependent

Supporting

Supporting

of

microtubules

molecule.

synaptic

emanating

Unlike

It

motor

between

type

uses

and are

retrogradely Retrograde

SYSTEM

trans

Slow

CLINICAL

Retrograde

NERVOUS

microtubules).

which

stocking”

the

may anoxia

anticancer

depolymerize

microtubules,

develop

THE

CORRELATE

be

or

(which

form

OF

proteins,

transport. motor

HISTOLOGY

anterograde

Cytoskeletal

ATPase

transport

cause

phosphorylation)

patients

that

mm/day)

neurotransmitters

anterograde

or

anterograde The

vinblastine

(1–2

|

Transport

polyneuropathy. oxidative

slow

molecule

CLINICAL

Neuropathies

a

components.

of

terminals

dependent

is

2

contribute

to

the

blood–brain

barrier

by

membrane. proliferate by

after

an

degenerating

to

the in

the

blood

injury

neurons brain

barrier

to by are

the

CNS,

filling

forming

an

the

pericytes

up

the

astroglial that

brain.

239

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Radial

glia

CNS

are

Microglia Pharmacology

Biochemistry

cells

neurons

and

from

Physiology

precursors

are

bone

marrow

that

glial

are

guide

provide

a

•

They

proliferate

cells

derived

monocytes

They

neuroblast

migration

during

and

link and

migrate injury.

the

cells

of

to

the

CNS.

Unlike

the

neuroectoderm,

enter

between

after

in

from

CNS

the

the

after

CNS

site

of

rest

of

microglia

CNS

derived

birth.

and

a

the

are

the

CNS

immune

injury

system.

and

phagocytose

Medical Genetics debris

They

determine

cells

in

The

the

the

CNS

affected

chances

that

of

are

microglia

survival

targeted may

of

by

the

produce

a CNS

HIV

tissue

1 virus

cytokines

in

that

are

graft,

and

those

with

toxic

to

are

the

AIDS.

neurons.

BehavioralScience/Social Sciences CNS

microglia

secrete

that

toxic

lead

to

free

become

disruption

of

Oligodendrocytes

axons

Schwann are

and

processes

are

cytes

and

region

the

from

increases

axons, node

the

DISORDERS

myelin.

node

generally

a single

diseases called

cell

in

the

PNS

Ranvier

(saltatory velocity

CNS.

nervous

myelin axons

sites

of

impulses

may may

processes

of

the

Unmyelinated

in

system

the

myelin

for

only

the

injury. axons

that

in

the

permit

myelinated

node CNS

axons

a single are

cells A

(PNS), for

PNS

Schwann

Saltatory in

the

axons.

form

cell.

conduction).

damage

superoxide,

cytoplasm.

forms

of

are

of

many

cells

after

as

Each of

peripheral

a Schwann

segments

of

the

Unmyelinated of

myelinated

nodes

the

tissue

such

neurons.

Schwann

Schwann axon.

neuronal

oligodendrocyte

of

cells.

debris

conduction

diseases Other

are

to

OF

Demyelinating

Each

to radicals,

segments

cells

processes

adjacent

in

by

crest

neuronal

myelinated

axons

ensheathed

PNS. of

remove

for

supporting

cytoplasmic

between

jump

and

the

free of

individual

neural

segment by

all

the

from in

myelin

not

response of

homeostasis

myelinate

are

derived

internodal

In

CNS

cells

and

oped

calcium

form

the

in

Accumulation

the

can

in

phagocytic

radicals.

oligodendrocyte

24

astrocytes

smallest

which

•

•

Microbiology

the

glia,

neuronal

Pathology

of

development.

act of

envel as

phago

Ranvier

and

action

the

is

potentials

conduction

to

dramatically

axons.

MYELINATION are (e.g.,

acquired infectious,

leukodystrophies.

conditions metabolic,

involving inherited)

selective can

damage also

affect

the

PNS.

to myelin

CHAPTER

Table

III

2

1.

Conditions

of

Impaired

Disease

Multiple

(MS)

|

HISTOLOGY

OF

THE

NERVOUS

SYSTEM

Myelination

Symptoms

sclerosis

2

Notes

Symptoms

separated

in

space

and

time Vision

loss

(optic

Internuclear

neuritis)

longitudinal

2x

Onset

often

Higher

ophthalmoplegia

(medial

Occurs

and

often

in

in

decades

prevalence

women 3

in

Relapsing–remitting

or

4

temperate course

zones is

most

common

fasciculus) Well

Motor

more

sensory

deficits

in

Vertigo

circumscribed

Chronic

Neuropsychiatric

demyelinated

periventricular inflammation;

Increased

plaques

often

areas

IgG

Treatment:

axons (oligoclonal

high

dose

initially bands)

steroids,

preserved in

CSF

interferon

beta,

glatiramer

Guillain

Barré

syndrome

Acute

symmetric

ascending

inflammatory

Onset

neuropathy

of

PNS

often

myelin

Elevated

Weakness

begins

and

ascends;

can

occur

in

lower

limbs

respiratory in

Autonomic

preceded

respiratory

(albuminocytologic

or CSF

GI

1–3

weeks

by

normal

cell

illness

protein

with

count

dissociation)

failure

severe

cases

dysfunction

may

be

prominent Cranial

nerve

involvement

is

common Sensory

loss,

pain,

paresthesias

rarely

Reflexes

invariably

and occur decreased

or

absent

Copyright

McGraw

Hill Companies.

Figure ⯑⯑⯑⯑⯑⯑⯑⯑⯑⯑⯑ ⯑⯑⯑

Figure III

Note

Used

2

with McGraw permission.Copyright Hill Companies.

III 2 4. Section 4. ⯑⯑⯑⯑⯑⯑⯑

⯑⯑⯑⯑⯑⯑ endoneurial

⯑⯑⯑ ⯑⯑⯑⯑⯑⯑⯑ (arrowhead) and

⯑⯑ border

of

⯑⯑ of

Used

a Peripheral Nerve ⯑⯑⯑⯑⯑⯑⯑⯑⯑⯑⯑⯑ ⯑ ⯑⯑⯑⯑⯑⯑⯑⯑⯑⯑ an individual axon

⯑⯑⯑⯑ ⯑⯑⯑⯑⯑⯑ ⯑⯑⯑⯑⯑⯑⯑⯑ ⯑⯑⯑ 2 Schwann cell nuclei (arrows)

with

permission.

⯑⯑⯑⯑⯑ ⯑⯑⯑⯑

⯑⯑⯑⯑⯑⯑⯑⯑⯑⯑⯑

⯑⯑⯑⯑⯑⯑

⯑ 24

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Myelin

Pharmacology

Biochemistry

Physiology

Medical Genetics

Schwann cell

Pathology

nuclei

BehavioralScience/Social Sciences

Microbiology From

the

IMC, From © 2010the DxR IMC, Development ® 2010

Figure

Ependymal

cells

line

differentiate

into

choroid

produces

circulate

are with

blood

specialized

of

readily barrier.

diffuse

lipid across

ethanol,

soluble the

compounds

and

•

The

most

24

Some

ependymal

of

choroid

are

the ciliated;

cells plexus,

ciliary

which

action

that

have

basal

cytoplasmic

transport

processes

substances

in

between

a

cells pericytes

and

via

readily

vitamins

K

Sodium

and

and

D

potassium

and

to

blood–brain ion

channels.

diffuse

across

are

the

organisms,

proteins,

endothelial

the

at

cells,

cells,

the

capillary

into and

an

and

underlying

CNS

carbon

across blood–brain

outside

that

cover

the >95%

of

cells.

by

diffusion,

dioxide

the

cerebral

junctions.

feet”

endothelial

the

the

barrier

“end

barrier.

the

are

blood–brain

blood–brain

across

barrier tight

with

transported move

brain

intercellular

processes

Oxygen the

blood

found

barrier

selectively ions

micro capillary

their

have

adjacent

the

of

are

Astrocytes lamina

of of

pericytes.

endothelial

cross

that

consists

elements

and

basal

transport,

channels.

part

may

access It

and

lamina.

Substances

gases

brain.

cells

processes

important

Astrocytes

the

blood–brain

adult forming

cells

these

system.

astrocytes,

basal

that

in Cross Section ⯑⯑⯑⯑⯑⯑Sec⯑i⯑n

Ependymal

restricts

nervous

capillary

addiction—heroin,

nicotine—are

the

reserved.

ventricle.

barrier

the

lamina,

CORRELATE

(CSF).

Cut in

rights

Barrier

to

•

Drugs

a

blood–brain

basal

in cells,

ependymal

vessels;

and

Blood–Brain

drugs

ventricles epithelial fluid

blood

vessel

The

III 2 5. Axons ⯑⯑⯑n⯑ ⯑u⯑

All

CSF.

Tanycytes contact

Figure 2 5.

the

cerebrospinal

helps

CLINICAL

III

Inc. All rights DxR Group, Development Group, reserved. Inc.

are

Glucose, blood–brain barrier

by lipid

selective soluble

amino

acids,

barrier. through

ion

and

CHAPTER

Chromatolysis Nissl

(dispersion

substance of

the

neuron

2

|

HISTOLOGY

OF

THE

NERVOUS

SYSTEM

of

and

swelling

cell

body)

Anterograde

Retrograde Site

degeneration

(Wallerian)

of

degeneration

injury

Schwann cell

Distal Proximal

stump

stump

Degenerating nerve

terminal

A

Schwann the Aberrant sprouts

degenerate

Distal completely

6.Figure Neuron III

2 6. Undergoing Neuron

UndergoingAxotomy, Axotomy,

Chromatolysis, Chromatolysis,

rate

mm

Axonal

B

2

axon;

per

day

of

Ranvier

III

the

regeneration 1–3

Figure

guide

of

regenerating

axonal

Node

cells

growth

and

sprout

axon

and

terminals

degenerate

and Regeneration Regeneration in the

PNS

in

the

PNS

24

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Response

of

Axotomy)

Axons

or or

severed

Biochemistry

in

neuronal

cell

of

the axons

and

or more

is

PNS.

cell

the

neuron

that

scaffold

the

to

after

envelops

for

an cut

die.

occurs

a

In

the

degenerating

an

is to

PNS,

weeks.

and

or

when

lesion

several

regeneration

Axon

Axon)

destructive is

complete

sheath a

to

closer

the

and

an

of distal

The

likely

rapid

provides

(Severing

(Compression

degeneration

CNS

Schwann

degenerate Physiology

the body,

degeneration

Lesions

Lesions

Wallerian

either

endoneurial

Destructive

Irritative

Anterograde Pharmacology

to

axon

anterograde

In

the

axon

PNS,

does

remyelination

the

not of

the

axon.

Medical Genetics

CLINICAL

Neurons

CORRELATE

with

tion. Schwannomas

typically

affect

seen

in

sprouts

axons

in

from

the

the

PNS

cut

are

axon

capable

grow

of

into

complete

and

axonal

through

regenera

endoneurial

VIII nerve

neurofibromatosis

Pathology

severed

Successful

sheaths fibers

type

2.

and

proceeds

BehavioralScience/Social Sciences

are

at

grade

the

guided rate

of

by

Schwann

1–2

mm/day,

cells

back

which

to

their

targets.

corresponds

to

Regeneration the

rate

and

B

of

slow

antero

transport.

Half

of

brain

and

spinal

cord

tumors

are

metastatic.

Microbiology Table

III

2 2.

Primary

Tumors

Tumor

Features

Schwannoma

•

Pathology

Third

most

common

primary

brain

•

tumor •

•

Most

frequent

Hearing VII

•

Antoni

A

(hypercellular)

(hypocellular)

areas location:

cerebellopontine

CN

VIII

at

•

angle loss,

tinnitus,

CN

V

Bilateral

acoustic

nomonic

for

schwannomas—pathog

neurofibromatosis

type

2

+

signs

Good

prognosis

after

surgical

resection

Craniopharyngioma

•

Derived

from

(remnants •

Usually

•

Often

•

Symptoms pituitary

•

24

is

the

Benign

oral of

epithelium

Rathke

children

•

pouch)

and

young

adults

calcified due stalk but

to or

may

encroachment optic

recur

chiasm

Histology common

on

resembles tumor

ameloblastoma of

tooth)

(most

Ventricular

LEARNING

3

System

OBJECTIVES

❏

Demonstrate

❏

Explain

understanding

of

information

related

to

within

a

ventricular

CSF

system

and

distribution,

venous

drainage

secretion,

and

circulation

The

brain

and

(CSF), of

spinal

which

the

is

cord

produced

protective

continuously

by

bath

the

of

choroid

cerebrospinal

plexus

fluid

within

the

ventricles

brain.

Each

part

of

the

CNS

interconnected fourth

contains

ventricles

a component in

the

brain:

of

the

2 lateral

ventricular

ventricles,

system. a third

There

are

ventricle,

and

4 a

ventricle.

•

A

ventricle

third

The

which

upper

medulla

and

is

continuous

brain the

ventricles

Choroid

found the

the

the

third

in

the

fourth

midline

hemisphere.

ventricle

via

within

ventricle the

located

via

an

of

Each

CSF

CSF granulations

into

all are

sites

resorption.

interven

ventral

the

surface the

the

the

diencephalon

cerebral

aqueduct

and (of

midbrain.

between

with

cerebral

secretes

Arachnoid

Monro).

through is

each

plexus

of

central

dorsal the

surfaces

of

cerebellum.

canal

of

The

the

lower

the

pons

and

fourth

medulla

and

cord.

VENTRICULAR The

within with

of

passes

ventricle

ventricle spinal

is with

fourth

deep

(foramen

ventricle

communicates Sylvius),

located

communicates

foramen

The

•

is

ventricle

tricular •

NOTE

ventricles.

lateral

lateral

by

float

SYSTEM and

lining

spinal of

and

the then

cord

AND float

ventricles, enters

within the

the

choroid

subarachnoid

VENOUS a

protective plexus. space

DRAINAGE bath CSF to

of

CSF,

which

circulation surround

the

is produced

begins

in

brain

and

the spinal

cord.

24

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

Foramen Pharmacology

of

Monro

Biochemistry

Third

ventricle

Body

of

lateral

ventricle Anterior of

the

horn lateral

Posterior

ventricle Physiology

horn

ventricle

of

lateral

(occipital)

Medical Genetics

Inferior

horn

ventricle Cerebral BehavioralScience/Social Sciences

Pathology

(of

of

lateral

(temporal)

aqueduct

Sylvius)

Fourth

ventricle

Central

canal

Microbiology Figure

III

3

1. Ventricles Figure III

3

1.

and CSF Ventricles and

Circulation CSF Circulation

Superior sagittal

Arachnoid

NOTE

sinus

granulation A total

of

400–500

is produced and

cc day;

subarachnoid

90–150 over

per

cc, 2–3

so

times

all per

of

CSF

(CSF

return)

ventricles

space

contain

of

is

CSF

turned

Lateral Choroid

ventricle

plexus

day.

Interventricular foramen

Third

of

Monro

ventricle

Cerebral

Foramen (lateral

aqueduct

of

Luschka

aperture)

Foramen of

Fourth

Magendie

(median

aperture)

Subarachnoid

Figure Figure

interventricular Lateral

foramen

ventricles

→ (via

24

third

foramina

Sagittal III III 3 3 2.2. Sagittal

of

Monro

ventricle of

Luschka

Section Section

cerebral →

fourth and

of theof Brain the

ventricle

space

Brain

aqueduct ventricle foramen

→ of

subarachnoid

Magendie)

space

CHAPTER

CSF

Production

Choroid

and

ventricles.

Blood

brain

astrocyte

Once

CSF

enters

the

dural

choroid Secretes

CSF.

by

processes

is

in

the

cells

junctions

and

form

capillary

VENTRICULAR

SYSTEM

is

in

the

blood

endothelium

lateral,

CSF

with

third,

and

barrier.

tight

junctions;

contribute.

subarachnoid

venous

venous

epithelial Tight

barrier—formed foot

|

Barriers

plexus—contains

fourth

3

space,

circulation

by

it

passing

goes

up

over

through

convexity

arachnoid

of

the

brain

granulations

and into

sinuses.

Deep Arachnoid

vein

of

Emissary

scalp

vein

granulations Diploic

vein Skin

Galea

aponeurotica

Pericranium

Skull

(diploic

Dura

mater

bone)

Cranial Arachnoid

Pia

mater

meninges

mater

Superior

Falx

sagittal

sinus

cerebri

Subarachnoid

space

Inferior

Figure Figure

IIIIII 33

3. 3.

Coronal Coronal

SectionSectionof the

sagittal

of the Sinuses Dural Dural

sinus

Sinuses

Sinuses Superior 2

sagittal

transverse

into the

sigmoid

and

the

great

internal transverse the

sinus

sinus—a

sinus inferior

these

margin

of

drains

sigmoid

falx

blood

sinus

cerebri)—drains from

exits

the

the

skull

into

confluence (via

of

jugular

sinuses

foramen)

as

veins.

(in

plexus

petrosal

of

margin Galen

junction.

artery (via

inferior

vein

cerebelli

carotid

superior of

Each

cerebral

tentorium

Cavernous

(via

jugular

sagittal

with

(in Each

sinuses.

internal

Inferior

sinus

sinuses.

and the

of cranial superior

to This

veins

of form drains

on nerves petrosal

falx the

cerebri)—terminates straight

into

either III,

the

side IV, sinus)

at

confluence

of V,

by

sinus

and and

the

of

sella VI.

the

the

falx sinuses.

turcica. It

drains

internal

joining cerebri

Surrounds into jugular

the vein

sinus).

24

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Superior sagittal Falx

sinus Inferior

cerebri

sagittal Pharmacology

sinus

Biochemistry Tentorium

Cavernous

cerebelli

sinus

Sigmoid Physiology

sinus

Medical Genetics Superior

Pathology

petrosal

sinus

BehavioralScience/Social Sciences Straight sinus

Transverse

sinus

Microbiology Tentorium

cerebelli

Occipital

sinus

Figure

III 3 Figure

4.III

Dural 3 4. Dural Venous Venous

Sinuses Sinuses

Hydrocephalus Excess

Table

Type

III

of

3 1.

Types

and

Features

Hydrocephalus

of

volume

Obstruction

Communicating

of

foramen

Impaired

(chronic)

flow of

CSF

subarachnoid

CSF,

leading

to

dilated

ventricles

within

Monro,

ventricles;

most

cerebral

reabsorption

aqueduct

in

commonly and/or

arachnoid

occurs openings

granulations

or

at of

narrow

points,

fourth

obstruction

ventricle

of

flow

in

space

CSF

is

not

absorbed

CSF

pressure

is

dementia,

24

of

Hydrocephalus

e.g.,

pressure

pressure

Description

Noncommunicating

Normal

or

apraxic

by usually (magnetic)

arachnoid normal.

villi

(a

Ventricles gait,

and

form

of

chronically urinary

communicating dilated. incontinence.

hydrocephalus). Produces Peritoneal

triad shunt.

of

CHAPTER

CSF

DISTRIBUTION,

CSF

fills

has

90–150

of

the

CSF

SECRETION,

subarachnoid mL

is found

Approximately

space

of

total

CSF,

in

the

ventricles

70%

glomerular

tufts

ventricles

of

(the

choroid

of

and

the

although

the

is

capillaries

secreted

in

mL

by

covered 30%

is located

of

the

is

produced

brain.

The

average

daily.

Only

fourth

mL

by

choroid

ependymal

represents parts

the

cells

metabolic

of

each

plexus, that

water

lateral

which

consists

project

into

production).

ventricle,

the

of

the

The

The

third

CLINICAL

concentration

Monro

the into

Sylvius enter

lateral the

into

fourth

the the

ventricles

third

passes

ventricle.

fourth

2

ventricle.

the

there,

The space

lateral

through

From

subarachnoid

ventricle,

ventricle,

protein

(including

is much

lower

in

all the

CSF

and

CSF

only

of

flows

sites

outside

foramina

interventricular through

where

the

the

CSF

can

CNS

are

through

and

the

median

Luschka

foramina

of

aqueduct

of

compared

with

leave 3

the

serum.

openings

in of

the

Ma

the

lymphocytes

the

subarachnoid

around

the

draining

space,

spinal

through

cord.

CSF

Almost

arachnoid

also all

flows CSF

granulations

up

over

returns into

the

to

the

convexity

the

of

venous

superior

system

sagittal

the

brain

•

by

dural

0–4 per

is

of

normal,

in

in

the

the

few

monocytes

presence

bacterial

blood

cells

CSF

or

of

is always meningitis.

are

but

or

millimeter.

a

leukocytes

as

Red

lymphocytes

cubic

presence

polymorphonuclear abnormal,

Within

contains cells

Although

ventricles

foramen

CSF

mononuclear

gendie.

and

of

ventricle.

from

and

CORRELATE

immunoglobulins)

Normal CSF

SYSTEM

adult 25

as the

VENTRICULAR

CIRCULATION

ventricles

400–500

|

themselves.

CSF

remaining

plexus

AND

3

not

may

be

normally present

found after

venous traumatic

spinal

tap

or

subarachnoid

sinus. hemorrhage. •

Normal

•

The

•

Sodium

CSF

is

a

clear

fluid,

isotonic

with

serum

(290–295

mOsm/L). •

pH

of

CSF

ion

(≈138

is

7.33

(Na+)

(arterial

blood

concentration

is

pH,

7.40;

equal

in

venous serum

blood and

pH,

7.36).

Increased a

•

mEq/L).

•

CSF

has

ions

than

CSF

has

bicarbonate

The the

blood–CSF brain.

form

the

those

of

does

not

a

higher does

a

concentration

lower

concentration −)

(HCO3

is

junctions

blood–CSF

a

as

(Cl−)

mechanism

will

gain

as

and

the

magnesium

access

of to

the

a

calcium

than

protects epithelial

systems ability

(K+),

glucose,

which along

The

potassium

well

Transport

barrier. it

of

ions,

located barrier.

blood–brain guarantee

chloride

may

indicate

tumor.

Tumor cases

cells with

may

be

meningeal

present

in

the

CSF

involvement.

(Mg2+)

serum.

barrier Tight

of

levels

CSF

in •

CNS

protein

are substance

(Ca2+),

does

the cells similar

chemical of but

(drug)

and

serum.

the

integrity choroid

not to

identical enter

of

plexus

the

to

the

CSF

brain.

24

The

LEARNING

❏

Solve

❏

Interpret

spinal

problems

from

are

are

neural

features

systems

are (L2

are

sacral

level

is

spinal

bundles

of

descend

in

the

cord,

neuronal matter

of

cell

functionally the

spinal

pairs

the

medulla

medullaris

of

spinal

gray bodies, the similar

(T1

at nerves

(L1

through

that

the arise

cervical

form

the

brachial

the

the

T12).

L5).

form

Spinal

nerves

trunk.

the

The

lumbar

lumbar

and

enlarge sacral

limbs.

nerves

(S1

lower

spinal

nerves.

matter

and

The and

is

their

through

limbs

sacral,

gray

The

that

through of

rootlets

lower

spinal

of

C8).

rootlets

most

nerves to

lumbar,

surrounds

31

with

conus

through

the

nerves

spinal

of

to

innervate

the

part

of

continuous the

limbs.

spinal

rise

pair

roots

the

of

gives

innervate

1 coccygeal

ventral

of

pairs

innervate

of

(C1

rise

upper

levels

pairs

is as

roots

nerves

gives

pairs

5 sacral

The

spinal

the

S3)

which

There

of

thoracic

5 lumbar

It

terminates

adult.

T1)

thoracic

canal.

and

cord.

pairs

through

plexuses,

vertebral

the

through

from

ment

the

spinal

innervates

12

emanating

in

of

8 cervical

which

There

housed

the

(C5

plexus,

White

on

vertebra

enlargement

contains

general

decussation

lumbar

There

Inside

is

pyramidal

segmentally

and

concerning

scenarios

cord

the

second

There

4

FEATURES

below

There

Cord

OBJECTIVES

GENERAL The

Spinal

axons

the

centrally

cauda

on called

equina

all tracts

nerves

consists

spinal

located and

Spinal

at

the

pelvis.

coccygeal

dendrites, matter

S5).

and the

sides. or

shaped

like

proximal White fasciculi,

of

the

dorsal

nerves.

parts matter which

a butterfly. of

It

axons.

contains ascend

or

cord.

25

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

Pharmacology

Biochemistry

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Supplies: • White

matter:

tracts

and

fasciculi Dorsal

Microbiology

•

ramus

Skin

of

back

dorsal

neck

Deep

intrinsic

muscles

(mixed) Arachnoid

and

back

(Erector

spinae) Dura

White

mater

matter

Gray

Pia

matter

mater Dorsal

root

(sensory)

Dorsal

root

ganglion

Gray

Ventral

matter

root

(motor)

Spinal Gray Dorsal Ventral

Ventral

horn

(sensory)

horn

neurons Clarke’s

ramus

•

(mixed) •

zone T1 -L2 nucleus

(autonomic S2 -S4 (T1

Figure

-L2

III

of

Skeletal anterolateral

)

Sympathetic

limbs

ganglion

)

4Figure 1.

Skin trunk

(motor)

Intermediate

25

Supplies:

nerve

matter:

III 4 Cross

1. Section Cross

Section of

of Spinal Spinal

Cord Cord

andand Parts Partsof Spinalof

Nerve Spinal

Nerve

anterolateral and

limbs muscles

of trunk

and

CHAPTER

Table

III

Conus

4

1.

General

Spinal

Cord

medullaris

Caudal

equina

|

THE

SPINAL

CORD

Features

L2

Cauda

4

end

of

the

spinal

cord

(S3–S5)

(in

adults,

ends

at

the

vertebra)

Nerve

roots

of

the

lumbar,

sacral,

and

coccygeal

spinal

nerves

Filum

terminale

Slender

pial

bottom

Doral

root

ganglia

Dorsal

and

Dorsal

horn

Ventral

Spinal

ventral

roots

Sensory

Motor

nerve

enlargement

enlargement

Posterior

(dorsal)

Lateral

that

vertebral

of

primary

segment

tethers

the

spinal

cord

to

the

column

sensory

has

a

neurons

pair

neurons

neurons

Formed

from

dorsal

(C5–T1)

→

branchial

(L2–S3)

→

lumbar

and

ventral

plexus

and

sacral

roots

→

(mixed

upper

nerve)

limbs

plexuses

→

Posterior

funiculus

Posterior

median

Posterior

intermediate

lower

limbs

horn sulcus

funiculus

Anterior gray

gray

extension the

bodies

Each

horn

Cervical

Lumbar

Cell

of

(ventral)

sulcus

horn Dorsal

Anterior

root

entry

zone

funiculus Intermediate

(lateral)

gray

horn

Dorsal

Root

filaments

Ventral

Dorsal Anterior

Anterolateral

median

root

ganglion

fissure

sulcus

Spinal

FigureFigureIII

4 2. 4 2. IIIGeneral

General Spinal

Cord

Spinal Features

Cord

nerve

Features

25

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Dorsal

Horn

The

dorsal

horn

incoming Pharmacology

Biochemistry

adjacent

to

higher

Dorsal

horn:

rexed

laminae

Ventral

horn:

rexed

laminae

zone:

lamina

spinal

to

carry

horn

the

in

CNS dorsal

a

horn

neurons

VIII–IX

that

nerves

respond

enter

dorsal

the

root.

to

neurons

to

in

the

brain

participate

in

root

sensory

stimulation.

dorsolateral

Neurons

sensations

Dorsal

part

the

dorsal

stem,

All

the

horn

cord project

cerebral

to

cortex,

or

reflexes.

ganglion

cell

division

Ib

Collaterals

fibers)

VII

BehavioralScience/Social Sciences

of

Proprioception

dorsal Touch

(II,

Lateral

A

beta

enter columns

fibers)

division

Sharp

Microbiology

by in

Medical Genetics I–VI

(Ia, Pathology

dorsal of

Other

Medial

Intermediate

dominated fibers

the

levels

cerebellum.

Physiology

is

sensory

I

pain,

cold

(III,

Dull

pain,

A

warmth

delta

(IV,

fibers)

C

II

III

fiber) IV

Contribute to

V

reflexes

VII

IX X VIII VIII

IX

IX

Figure Figure

III III4 43.3. Dorsal Dorsal in

Ventral

the

Roots and Roots

Spinal Spinal

and Sites

Sites of Termination of Termination in the

CordCord Gray Gray Matter

Matter

Horn

The

ventral

•

•

horn

The

alpha

way

of

The

gamma

fibers •

contains

motoneurons

the

muscle

•

to

of

alpha

nomic

neurons

those

a

muscle

(extrafusal

neuromuscular the

alpha

and leave

distal

and

that

innervate

the

Axons

skeletal

at

fibers)

by

junction. contractile

intrafusal

muscle

spindle.

that

innervate

motoneurons.

innervate

horn,

dorsal

motoneurons

gamma

innervate

ventral

are

and

synapse

motoneurons the

Within

that

alpha

a specialized

of

flexors

25

IX

gamma

innervate the

motoneurons extensors.

proximal

that Alpha

musculature

and are

medial

innervate gamma to

those

musculature.

gamma the

motoneurons cord

by

way

and of

a ventral

axons

of root.

preganglionic

auto

CHAPTER

Corticospinal

4

|

THE

SPINAL

CORD

tract

NOTE C5–T1 large

ventral

TRUN

E X T

N S

E

O R

motor

skeletal

muscles

Gamma

motor muscle

sensitive

and

motor

gamma

Alpha

and

in

motor

axons

contract.

to

neurons spindles

more

stretch.

lamina

IX

neurons

cervical

cord

gamma from in

ventral

Renshaw

Figure

III

4 4.

Topographic

Organization

Motoneurons

Intermediate

(LMNs)

of Alpha in Lamina

and

root

cells

Gamma

IX

Zone

intermediate

zone

sympathetic

of

neuron

proprioception

the

cell

to

NEURAL

the

spinal

bodies

cord

and

from

Clarke

T1

to

nucleus,

L2

contains

which

preganglionic

send

unconscious

cerebellum.

SYSTEMS

There

are

matter

3 major

and

neural

tracts

or

components

cortex

to

essential and

make

organization

alpha

have

neurons

S

make

The

horn.

NOTE Alpha

of

have

O

HAND ARM

Topographic

L2–S3

R S SHOULDER FOREARM

E

L

F

X

and

at

fasciculi

which

the for

systems

tip

of

can

the

higher

levels

the

spinal

of

axons

in

the

found

at

all

cord. the

of

the

be

spinal

understanding

in

A

effects

cord white

use

matter.

levels

of

knowledge of

that

of

lesions

in

the these the

neurons These

in neural

CNS,

from

cerebral

systems

cord

gray

systems the

3 neural spinal

the

and

is brain

stem,

CNS.

NOTE Motor

System

Voluntary

Upper Two form muscle ventral

innervation

and

Lower

of

an

basic

neural

everywhere horn

motoneuron

Lower

motoneuron

muscle

Motoneurons

motoneurons, the

skeletal

Upper

in of

the

upper

motoneuron

circuit the

spinal

and

involved body. cord

in

The

lower

and

in

the

a

lower

voluntary

motoneuron,

motoneurons cranial

nerve

together

contraction

of

are nuclei

found in

the

Motor

end

plate

of

skeletal

muscles

skeletal

in brain

the stem.

255

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Axons join

of the

lower

directly

at

neurons Pharmacology

motoneurons

spinal

nerve

a

in

of

to

course

neuromuscular the

spinal

in

nerves

one

of

junction

brain

stem

exit

in

in

a

exit

its

skeletal

cranial

in

a

branches

to

ventral

root,

reach

muscle.

then

and

Axons

synapse

of

lower

moto

nerve.

Biochemistry To

initiate

a

innervated

Physiology

Medical Genetics

found

in

spinal

cord

rons,

an

the

contraction upper

brain in

which

initiate

stem

then

must the

lower

The

cell

bodies

and

to

skeletal The

cerebral

reach

synapse

and

on

involved. motoneuron

bodies

on

lower

cortex,

their

motoneuron

upper axons

skeletal

are

found

into or

on

the

interneu

therefore,

motoneurons,

an

innervates

the

be are

descend

a minimum,

2

must

motoneurons

motoneurons,

muscle,

motoneuron

innervates

of

At

skeletal

upper

a lower

and

motoneurons. of

The

muscle, cell

synapse

lower

contraction

be

and

of

motoneuron.

a tract

a voluntary

lower,

Pathology

voluntary by

the

lower

to

upper

and

motoneuron,

muscle.

BehavioralScience/Social Sciences

formation,

of

and

location

of

neurons

upper

lateral

upper

course

motoneurons vestibular

nuclei

motoneurons in

the

is

of

in

corticospinal

the

the

in

the

brain

cerebral

red

stem,

nucleus, but

cortex.

reticular

the

most

Axons

of

important these

cortical

tract.

Microbiology

NOTE Right UMNs stretch

have

net

inhibitory

effect

on

Left

muscle

reflexes. Upper

motor

neuron

(UMN)

Cerebral

Frontal

cortex

Brodmann

lobe

Areas

4&6

Precentral

NOTE

gyrus Voluntary

contraction:

Reflect

contraction:

neuron

→

UMN

muscle

→

(primary

motor

cortex)

LMN

sensory

Caudal medulla

LMN

spinal

cord

junction

Brain stem Pyramidal decussation

Spinal Lateral

cord

corticospinal tract

Function: refined

voluntary movements

Muscle

spindle

afferent

from

muscle

spindle

of Muscle

the

distal

(Ia)

stretch

reflex

extremities

Lower

Muscle

motor

neuron

spindle

(LMN) (Alpha)

Skeletal muscle

Figure

25

IIIFigure 4 5.

III Voluntary 4 5. Voluntary Contraction Contraction

of of Skeletal Skeletal

Muscle: Muscle: UMN

and UMN LMNsand

LMNs

a

CHAPTER

Corticospinal The the

Tract

primary

motor

premotor

area,

rise

to

about

and

secondary

located

of

of

the

Fibers

in

which

carries

all

the

length

the

in

the

fibers

of

of

the

corticospinal

the

in

out

brain

of

located

the

frontal

primary (Figure

in

the

lobe,

motor III

4

parietal

and

cortex, 4).

lobe

cerebral

the

stem

cortex

cortex.

in

the

in

the

internal

Corticospinal

ventral

of

the

The

Primary give

then

of

the

rise

to

Corticospinal

or

SPINAL

CORD

Tract

decussation

corticospinal

tract

cord

has

junction

at

of

the

axons

of

the

medulla/spinal

significant

clinical

implications.

descend

midbrain,

crossing

•

pons,

If lesions occur

of the above

the

corticospinal

tract

pyramidal

decussation,

medulla. a

In

THE

CORRELATE

Lesions

capsule,

fibers

portion

|

give

tract.

the

of

the tract

areas

leave

and

the

gyrus to

corticospinal

corticospinal

tract

of

precentral anterior

cortical

fibers

axons

the

immediately

somatosensory

40%

and

cortex, located

60%

about

through

CLINICAL

4

the

lower

pyramids tract.

The

lateral gray

medulla, and lateral

part

of

matter

80–90%

continue

of

in

the

corticospinal the

of

tract

white

the

corticospinal

matter.

ventral

fibers

contralateral descends

As

horn

to

spinal the

it descends, synapse

cross cord

full

decussation

lateral of

leave

lower

the

the

length

axons on

at

as

the

the

tract

of

weakness

contralateral

the

cord and

in

•

the

enter

contrast

the

muscle

in

the

below

muscle

to of

upper

lower

skeletal

the

body.

this

level,

weakness

an

is seen.

motoneurons,

motoneurons

will

to

that any

result

weakness

at

part

in an the

the are

muscles

A lesion

motoneuron

and

occur

ipsilateral

the

innervate.

bodies

of

on

motoneurons.

to

cell

side

If lesions

bodies

cortex

in muscles

corticospinal

In

UMN

is seen

level

their of

cell

ipsilateral axons a lower

ipsilateral of

the

lesion.

cerebral

brainstem m e d u l la p e r U p

Corticospinal

tract

Pyramidal

in

medulla

decussation

Extensor

biased

Lower

UMN

motor

muscles

of

Lo w e r

tracts

neurons upper

m

e

d

u

to

ll

Medullary

pyramids

Pyramidal

decussation

a

limb C

ervical

A lesion

here

spastic ipsilateral

in

flaccid

below

here

in that

and

at

the

lesion

ro

a is

Corticospinal

level

of

(flexor

lesion

Lower muscles

anp cl

is the

results

weakness

ipsilateral

a

that

and

A lesion

the

results

weakness

si

tract biased

UMN

tract)

LMN

motor of

neurons lower

to limb L u m ba r s p i na l c o d r

Figure

III

4

6. Course

of Axons with

of Upper Representative

Motor

Neurons Cross

in the

Medulla

and

Spinal

Cord

Sections

257

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Reflex A

innervation

reflex

is

of

initiated

motoneuron

Pharmacology

by

and

muscles,

the

response

is

skeletal a

muscle

stimulus

produces

sensory

of

a motor

stimulus

a sensory

neuron,

response.

In

arises

from

which

reflexes

receptors

in

turn

innervates

involving

in

the

a

skeletal

muscle,

and

the

motor

Biochemistry

spinal

a contraction

cord,

muscle

lower

or

relaxation

motoneurons

reflexes.

Upper

of

form

one

the

motoneurons

or

more

specific

provide

skeletal

motor

muscles.

In

component

descending

of

control

the

skeletal

over

the

reflexes. Physiology

Medical Genetics Both

alpha

and

gamma

motoneurons

are

lower

motoneurons

that

participate

that

innervate

in

reflexes.

• Pathology

Alpha

motoneurons

extrafusal

BehavioralScience/Social Sciences

muscle

fibers,

postural, •

Both so

muscle

spindle,

which

ends

of

the

fibers.

used

Commonly deep

The

afferent

limb

in

tested

The

supply

sensory

are

the

muscle

basic

a group

unit

fine

fibers,

muscle

fibers in

connected

length

for

of

and

in rate

of

movements

which form

skeletal

are

the

parallel

with in a

modified

muscle

muscle

change

contain

reflex

a muscle

neuron).

(patellar)

stretch

the

extrafusal

length

of

greater

reflexes.

fibers,

extrafusal

density

of

These

reflexes

Segment

L2–L4

is

monosynaptic

spindle, are

and

sensory

useful

in

the

and

clinical

efferent

exam.

Muscle

n.)

Tested

Quadriceps

S1

Elbow

C5–C6

(musculocutaneous

Elbow

C7–C8

(radial

n.)

Triceps

Forearm

C5–C6

(radial

n.)

Brachioradialis

The

stretch

in

(myotatic)

muscle

response

to

all

muscles

Muscle

tone

the

stretch

The

best

reflex. muscle

(myotatic)

stretch

of

is

the

is

n.)

Gastrocnemius

n.)

Biceps

reflex

stretch

and

spindles

ipsilateral.

neuron,

Involved

(femoral

(tibial

Ia

Ankle

Muscle

reflex

that the

muscle. primary

tension

is the The

stereotyped

stretch

mechanism

present

in

all

resting

contraction

reflex

is

for

regulating

muscle.

a

of

basic

reflex

is

muscle

that

muscle

Tension

a

in

occurs

tone. controlled

by

reflexes.

example Tapping spindles.

of the

a

muscle

patellar Stretch

of

voluntary,

reflexes

Cord

Knee

innervates

unit,

receptor

myotatic)

consists

motor

motor

intrafusal

stretch

(stretch,

limb

horn

movements.

Reflex

25

a

with

muscle

tendon

(lower

as

the

coarse

ventral motoneuron

intrafusal

spindle

involved

those

a

The

monitor

Muscles

than

the

alpha

activity.

fibers. acts

in

single

constitutes

reflex

muscle

receptors

cells

A

motoneurons

skeletal

these

large

fibers. which

and

Gamma

Microbiology

are

muscle

stretch ligament

of

the

spindles

or

deep

stretches activates

tendon the

reflex

is

quadriceps sensory

the

knee

muscle endings

jerk and

(Ia

its

afferents),

CHAPTER

and

afferent

impulses

receptors that

supply of

antagonist

leg

terminate GTOs

are

in

of

Ib

and

regulate

Stimulation pole

of

of each

causing

alpha

case,

THE

SPINAL

CORD

stretch

motoneurons

muscle

and

a

sudden

inhibit

hamstrings).

activity

also

muscle.

gamma

the

motoneurons spindle

increase

in

to

muscle

of

causes contract,

a muscle

in

increase in

turn,

motoneurons the

and

muscle

innervate

muscle

intrafusal

which

tendon.

increases

which,

innervate

motoneurons

sensitivity

and

to

muscles.

gamma

directly Upper

GTOs,

agonist

by

in

Golgi that

muscle

respond

force

uses

endings of

and

the

inhibit

reflex

nerve

junction

in

influenced

stretch.

influence

the fibers

innervate

and

be

This of

Increases

that

can

at

motoneurons to

tension.

extrafusal

neurons

sensitivity

muscle

an

that

Gamma

and

the

groups

fibers

the

antagonists

reflex

their

this

muscle

tendon

afferent

motoneurons.

motoneurons

(in

from

the

simultaneously

encapsulated

with in

facilitate

and

impulses

of

impulses

monitors are

series

generated

tone

upper

reflex

collagenous

rate

Some

contraction

Afferent

These

between

firing

causes

knee.

stretch

polysynaptically

cord.

stimulate

interneurons

oriented tension

the

|

reflex

(GTOs).

or

Muscle

the

through

muscle

organs

to

monosynaptically This

at

stretch

inverse

tendon

transmitted

fibers

quadriceps.

the

muscle

force

Ia

muscles

Inverse

the

by

the

extension

The

are

carried

4

spindles muscle

activates

alpha

gamma to

fibers

by

spindles

stretch. located

at

the

motoneurons,

tone.

NOTE Collaterals dorsal Dorsal

root

Dorsal

root

to UMN

columns

lesions

•

stretch

•

Clasp

knife

reflex

due

to

– oversensitive

– LMNs

Golgi

tendon

in

ventral

organs

root LMN

spindle

(activated muscle

muscle

interneuron +

Muscle

Hyperactive

in:

reflexes

Inhibitory

ganglion

result

by

↑

Leg

in

extensor muscles

stretch)

(quadriceps)

Leg

Motor

end

flexor

muscles

plates

(hamstrings)

Patellar

tendon

Golgi

tendon

organ Muscle

by

stretch

in

muscle

Inverse

force)

reflex (causes

(activated ↑

stretched

muscle

to

Figure

(causes

contract)

Figure III

muscle

4

III

7.

4

7. Muscle Muscle

Stretch Stretch

and Golgi Tendon Reflex and Golgi Tendon

muscle

stretch

Components Reflex

reflex activated to

relax)

Components

25

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Flexor The

withdrawal flexion

causes

withdrawal

reflex

withdrawal

extension Pharmacology

reflex

of

reflex

in

the

is

a protective

stimulated

which

the

reflex

limb.

This

contralateral

in

which

reflex

limb

is

a stimulus

may

be

(usually

painful)

accompanied

extended

to

help

by

support

a crossed

the

body.

Biochemistry

CLINICAL

Physiology

To

Medical Genetics

correctly

identify

between one

lesions will

diminish

BehavioralScience/Social Sciences

A

of

any

a

form

motoneuron

a

of

motor in

a

the

either

the

key

to

muscles.

hypoactive

muscle

because Therefore,

with

distinguish to

affected

in

reflex.

combined

to

lesion

muscles,

the

(hypotonicity)

of

paresis

of

result

tone

component

able a

skeletal

will

muscle

be

Because

reflexes

motoneuron in

must

contract

condition

lower

one

motoneuron.

voluntarily

the

result

weakness,

lower

reduction

the

lesions stretch

motor

to

be

of

and

motoneurons

of versus

ability will

part

reflexes

muscle

cause

upper

them

lesion

stretch

an one’s

distinguishing

Pathology

the

of

CORRELATE

lower lower

suppressed

or

absent

reflexes.

Microbiology •

NOTE

Early

sign:

that With

lower

motorneuron

lesions,

of

signs

fasciculations

a

twitch

(twitches

visible

on

the

or

contractions

of

muscle

fibers

skin)

the •

constellation

muscle

produce

combining

paresis

Later

sign:

fibrillations

(invisible

1

atrophy

of

to

5

ms

potentials),

detected

with

(almost

always)

with electromyography

suppressed/absent and

atrophy

reflexes, is known

as

fasciculations, a

flaccid

•

Pronounced

•

Flaccid

wasting paralysis

Neurologically,

ipsilateral

upper

inhibitory

effect

paresis

of

muscles

skeletal or

postural

flexion

(i.e.,

postural

extension

Lesions

the

muscls

can

still

motoneuron

which

normally

flexor

reflexes

stroking Normally,

toe

and

paresis and

to

motoneuron

paresis

A

that

A

lesion

pyramids

of

between will

the cause

the

is

or

lesions

big

of

spinal

cord

altered

is

performed

as

the

cause

lesion, great

abdominal

disuse

and of

atrophy

of

paresis. result

site

an

the

constellation

a spastic

of

the

ipsilateral

by

stimulus. tract

of

the

The

motoneurons

will

in

reflexes,

the

painful

reflexes,

below

cutaneous

extension

reflexes,

and

muscles

a corticospinal by

flexor

upper

result

these

reflex

a slightly

With

known

the below

lesions

of

Babinski

with

hyperactive

of

known

lesions.

is

lesions

reversal best

the

toe.

other

contralateral

the

foot

of

reflexes.

characterized

reflexes

lesions,

in

the

for

the

are

rigidity

location

because

by

test

the

net

rigidity

decerebrate

rigidity;

The

motoneuron

increases

or

of

Two

upper

cutaneous

ipsilateral

level

of

toes.

in

with

The sole

on

stretch

that

decorticate or

a

combine

reflexes

as leg)

disuse,

have

they

motoneuron

of

response.

which

other lost

anywhere the

the

flexion

the

Upper result

accompanied

sign. of

present,

altered

is

lesion

below •

is

also

muscles,

also

seen the

decorticate

muscle

motor

Babinski surface

of are

lower

are

be

tract

result, tendon

depending

produce

a

a

deep

of

leg)

stimulating

is plantar

fanning

combining

•

the

reflex

cremasteric,

and

as

corticospinal

or may

rigidity.

a flexor

lateral there

Babinski

arm

lesion

As

extension

only

lesions

is

the

the

decerebrate

yield

stretch

and

the

the

hypertonia

midbrain

by

of

reflexes.

muscle

muscles

contracted

Upper

the

the

level

stretch

arm

of

weakened

be

the

the

including

The

produce of

at

muscle with

of

above

midbrain

atrophy

on

hypertonic.

(i.e.,

lesion.

and

motoneurons

overall

hyperactive

26

or

paralysis.

In in

signs skeletal

contrast

a spastic

lesion.

spastic

paresis

lesion. cerebral

a contralateral

cortex

and spastic

the

medulla

paresis

above below

the

the level

decussation of

the

of lesion.

the

CHAPTER

Right

Upper

THE

SPINAL

CORD

Cerebral

motor

cortex

(UMN)

Precentral

A &

|

Left

neuron

A

4

B:

gyrus

Spastic paresis contralateral

B Caudal

and below

Brain

medulla

lesion

stem

(decussation)

C:

Spastic

weakness ipsilateral

Lateral corticospinal

Spinal

and

cord

lesion

below

C

tract

D

&

E:

Flaccid

paralysis ipsilateral Function: Voluntary

refined

and

at

level

of

lesion

movements of

the

distal

D

extremities Lower neuron

Table

III

Upper

4

Figure

Figure III 4

2.

Versus

Upper

Motor

Spastic

Neuron

8.

III

4 8. Upper Versus Upper Versus

Lower

Motoneuron

E motor

Skeletal

(LMN)

Lower Lower

muscle

Motor Neuron Lesions Motor Neuron Lesions

Lesions

Lesion*

Lower

paresis

Flaccid

Hyperreflexia sign

Increased

Disuse

present

muscle knife

area

No tone

Lesion†

paralysis

Decreased of

muscles

speed

of

of

body

*Deficits

contralateral

†Deficits

ipsilateral

Babinski

Fasciculations

reflex

atrophy

Decreased Large

Neuron

Areflexia

Babinski

Clasp

Motor

the

Atrophy

voluntary

or and

movements

Loss

involved ipsilateral

at

muscle

the

Small and

level

of

below

the

of of

or

atonia

muscle(s)

voluntary area

tone

of

movements the

body

affected

lesion

lesion

26

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Sensory Two

Pathways sensory

systems,

anterolateral Pharmacology

Biochemistry

from

peripheral

systems, in

the

dorsal the Physiology

Medical Genetics

column–medial

or is

on

a

to

neuron

that

nerve.

the

third

cord,

in

a tract

neuron

in

that

is

somatosensory

BehavioralScience/Social Sciences

3

neurons

conscious

to

the neuron

and

the

in

synapses axon

CNS. the

of

of The

the

thalamus.

cortex.

into

the

with

a

of The

the information

receptor

second

axon

and

sensory

cerebral

sensory

information

first

the

a

system convey

levels

innervates

carries

The

spinal

carried

primary

and

lemniscal

use

receptors

ganglion

a spinal

stem and

to

system,

sensory

root of

synapses

Pathology

first

dorsal

brain

projects

dorsal

sensory

the

root

midline

the

(spinothalamic)

In

has spinal

cord

second

of

the

neuron

the

third

the in

crosses

second

axon

body in

neuron

neuron

the

both

a cell

then neuron

cortex.

Midline Parietal Right

Left

lobe

Brodmann areas

Postcentral

Somato

gyrus

sensory

Microbiology

3,

1,

2

Cerebral cortex

cortex

Thalamus 1:

first

order

neuron

2:

second

order

always

crosses

in

neuron

sensory

in

CNS

ganglion

3

Third

order

neuron

(axon

midline) Brain

3:

third

order

neuron

in

thalamus

Courses a

tract

or

in

stem spinal

cord

or

lemniscus 2

Neuron

#2

ipsilateral Second

(always

Dorsal crosses

midline cell

cell

near

Receptor order

neuron

Figure III

4 III 9. 4 General 9. General

root

Sensory

Pathways Pathways

is #1

ganglion

(DRG)

(pseudounipolar

1

body) First

26

body

neuron

order neuron

Figure

cell to

neuron)

CHAPTER

Ascending The

4

|

THE

SPINAL

CORD

Pathways

2

most

sensory

important

ascending

information

to

the

pathways cortex.

Pathway

use

Key

a

general

3

neuron

system

features

are

Function

Dorsal

Anterolateral

touch,

conscious

system

system

convey

below.

Overview

Discriminative column–medial lemniscal

to

listed

3

neuron

propriocep

tion,

vibration,

Pain

and

system:

1 ̊

neuron:

cell

body

2 ̊

neuron:

decussates

3 ̊

neuron:

thalamus

in

DRG

pressure

temperature

(spinothalamic) (VPL) Abbreviations:

Dorsal

DRG,

dorsal

sense,

vibratory,

the

via

or

fasciculus and

carries

lateral

to

the

cord

lower

cuneatus

that

part

of

the

medial

midline

as

of

(VPL)

nucleus

the

medial of

Cells internal ascend

project

to

the

primary

located

in

the

most

these

arcuate

portion

cells

VPL

(somatosensory) parietal

the

and

of

the

nucleus,

The

spinal

the

through

of

and

rise

to

the

fibers

brain

stem

lemniscus.

posterolateral

thalamocortical area

of

fasciculus

medial

ventral

that length

gracilis give

is

and

medulla.

and

the

levels,

cord the

of

nucleus

in

the

extremities

part

the cord.

to

cord

ascend

ascend stem

spinal

trunk.

upper

nuclei

and brain

on

the

the

in

the

closest

gracilis

in

primary ganglia,

spinal

lower

fasciculus

fibers

the

of

the

of

lower

of

medullary

the

From

somesthetic anterior

in

terminate

thalamus.

the

coalesce

the

cells

found

through

lemniscus the

in

root

then

situated

columns

neurons

dorsal

and

cervical

from

in

The

the

and

ganglion

neurons

fibers

is

and

dorsal

root

limbs.

funiculus

levels,

input

the

second

dorsal

thoracic

carries

second

in

extremities

upper

form

respectively.

the

cord

lower

at

medulla,

lemniscus

Fibers

the

dorsal

their

the

in

and

fibers,

for

proprioceptive)

trunk

bodies root

information

conscious

the

cell

spinal

and

of

the

with

all

only

fasciculi

reach

cuneatus, cross

the

to

synapse

nucleus

from

processes

nucleus.

sensory or

dorsal

at

gracilis 2

their

cuneatus

found

central

spinal

the

input

These

the

have

found

carries

from

myelinated

fasciculus

trunk.

carry

sensations

fasciculus

cuneatus,

posterolateral

(kinesthetic

system

gracilis,

fasciculus

upper

pressure this

ventral

system

position

heavily

gracilis

midline

in

in

cord

fasciculus The

lemniscal joint

and

neurons

enter

VPL,

cortex

system

column–medial touch,

afferent

ganglia;

lemniscal

discriminative

In

root

column–medial

The

the

dorsal

→

the

fibers postcentral

gyrus,

lobe.

26

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Right

Pharmacology

Left

Postcentral

Cerebral

gyrus

cortex

A

Biochemistry

B Thalamus 3 Physiology

lateral

nucleus Medial

C

Pathology

Ventropostero

Medical Genetics

N.

Cuneatus

N.

Gracilis

(VPL)

lemniscus

Medulla

2

BehavioralScience/Social Sciences Function:

Fasciculus

Conscious

proprioception,

fine

vibration,

touch,

pressure,

2

limb (lateral Dorsal

point

Spinal

columns

discrimination

T5↑ cuneatus–upper

column)

cord

Fasciculus

Microbiology

limb Lesion:

(medial

Loss

of

Site

above

of

senses

D Dorsal

lesion:

Affected

side

of

T6↓ gracilis–lower

column)

root

ganglion

body

cell

(DRG)

1 A,

B,

and

C:

Contralateral

and

Receptor

below

Pacinian D:

corpuscle

–vibration

Ipsilateral

and

below

Meissner

corpuscle

–touch muscle

spindle

–proprioception

Figure

III Figure4

10. III

Dorsal 4 10.

Column Dorsal Column

Pathway–Medial Pathway–Medial

CLINICAL

Lesions

of

vibratory of

the

(e.g.,

the

dorsal

and ability

to

size,

dorsal

columns

pressure identify

the

consistency,

column–medial

sense

using

between

a 128

Hz of

loss

using

fork.

an

are

Romberg

columns

joint

sensation,

called

sense

evaluated

the

There

object, the

sign

and

position

discrimination.

only

lesions

dorsal

of

point of

shape),

tuning

the

a 2

characteristics

lemniscal

lesions

in and

form,

System

CORRELATE

result

sensations,

Lemniscal System Lemniscal

is

astereognosis

of by

also

touch.

Typically,

testing used

midline

is loss

vibratory to

(vermal

distinguish area)

of

the

cerebellum.

Romberg

sign

If there eyes the

is a closed,

dorsal

interruption compensated has of

26

is

tested

marked this

asking

the

deterioration is

columns of

by

of

a positive (or

for problems

cerebellar

damage.

by

dorsal

visual and

posture

Romberg roots

proprioceptive

balance

patients

(if

sign, of

input

to

the

their patient

suggesting

spinal carried

place

by

input

to

the

cerebellum.

tends

to

sway

with

the

With dorsal

eyes

with

the

lesion

the

eyes

columns

Therefore, the

together.

sways) that

nerves).

feet

open,

the

in

open, can

if this

the is

be

patient

is indicative

CHAPTER

Primary

Neuron

somatosensory

#3

Crossing

Thalamus

Lemniscal

(VPL)

lemniscus

axons

in

lower

fibers

thalamus

#2

in

dorsal

ascending

pyramids

Medial m

cuneatus

From

CORD

nuclei L o w e r

Fasciculus

SPINAL

a m e d u ll p e r U p

medulla

column

THE

(VPL)

Medullary Neuron

|

cortex

to Medial

4

T5

e

d

up

lemniscus

Cuneate

Dorsal

nucleus

column

ul l a

Gracile

nucleus

nuclei

including upper

A

lesion

here

that

are

the

lesion

limb

results

in

ipsilateral

C

e r

v

ic

a l

deficits

and

s

below

p

i na

l

Crossing

axons

(internal

arcuate

of

neurons

#2

fibers)

c or

Fasciculus

Fasciculus

cuneatus

Fasciculus

gracilis

Fasciculus

gracilis

gracilis

Neuron

#1 Lower

From

T6

motor

down

neuron

including lower

limb L u m b a r s p in co r d

Lower

a l

motor neuron Reflex

Figure

Anterolateral The

anterolateral extremities

Pain

and

temperature

spinal

are

Dorsal III

via

thinly

and in

the

pain,

Lemniscal

Column/Medial

System

Lemniscal

in

System

in the

the

Spinal

Spinal

Cord

Cord

temperature,

and

crude

touch

sensations

cell

bodies and

couple

synapsing

of in

horn

in

gray

dorsal

root

unmyelinated

segments

the

the

dorsal

in

dorsal

the

horn.

matter.

ganglia

white

coalesce The the

to

form

the

spinothalamic brain

stem

nucleus cortex

commissure

send in

the

just

to

postcentral

and

through in

temperature gyrus.

the tract

courses

terminate

pain

below

spinothalamic tract

CORRELATE

Because

Axons

root

dorsolateral

The

second

from

these

and fibers.

tract neuron cells

enter Their

of

Lissauer

cell cross

bodies

in

the

VPL

central in the nucleus

information

the

canal

of

ventral entire

part length

of to

the

the the

spinal of

of

thalamus. primary

the the

cord

the

pain

enters

the

of

spinothalamic

the

cord

and

crosses

or

spinal

brain

contralateral

temperature almost

cord,

as

any

loss

will of

in

result

pain

as

unilateral

tract

stem

soon

lesion

the in

and

it

spinal a

temperature.

the is an

extremely

useful

clinical

sign

and

lateral

funiculus.

spinal Cells

Medulla

Medulla

CLINICAL

This ventral

and

and

information have

a

dorsal

Dorsal

system

myelinated

descend

entering

Column/Medial 4 11.

trunk.

fibers

or

located

carries and

cord

ascend

before

11. Figure

tract)

system

the

fibers

4

(spinothalamic

from

the

III

synapse

cord in

somatosensory

the

because

and

with

VPL

limbs, the

it means analgesia the

stem.

segments everything

if a patient

one

location

contralateral

brain

that on

side

of

the

side The

below below

of

of

that

trunk

lesion the

analgesia the

presents

the

lesion

must

spinal

or be

cord

begins

1

to

and

includes

on or

2

level.

265

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Right

Pharmacology

Left

Postcentral

Cerebral

gyrus

cortex

Biochemistry A

B Physiology

Medical Genetics

Thalamus 3

Ventropostero lateral

nucleus

(VPL) Spinothalamic Pathology

BehavioralScience/Social Sciences

Brain

tract

stem

Medulla

C

Microbiology D Spinal

Lesion: Anesthesia and

(loss

of

cord

pain

temperature 2

sensations)

Ascend

Dorsal

1–2

horn Site

of

lesion:

Affected

side

in of

or

descend

segments Lissauer’s

tract

body DRG

A,

B,

C,

and

Contralateral lesion; the

D: below

tract

intact

1

the rostral

Receptor

to

lesion

F igure Figure III

26

4 12. 4 12. IIISpinothalamic

Spinothalamic Tract (Anterolateral

Tract System) (Anterolateral

System)

CHAPTER

Primary

Neuron

somatosensory

#3

4

|

THE

SPINAL

CORD

cortex

Thalamus

(VPL)

To e r U p p u ll a m e d

thalamus

(VPL)

Spinothalamic

tract

Spinothalamic

tract

Spinothalamic

tract

Lo w e r m

Lissauer’s

From

arm

C

e r

v

ic

lesion

here

in

deficits

results

that

are

contralateral

and

segments the

d

ul

l a

a l s

A

e

tract

pi n

al c o

1–2

r

below

lesion Pain/temp

Ventral

white

Neuron

fiber

commissure

#2

in

dorsal

horn Pain/temp

From

Lu m b a r s p in a l co r

leg

Neuron

fiber

Axons d

commissure

#1

Spinothalamic

Figure

Spinocerebellar The

tracts

spindles

help

13.III Anterolateral 4 13. Anterolateral

System System

in in the the Spinal Spinal Cord Cord and

Medulla and

in

ventral

below

white central

canal

tract

Medulla

pathways

spinocerebellar

muscle

IIIFigure4

cross

and

monitor

and

mainly

GTOs

carry

to

modulate

the

unconscious

cerebellum,

movements.

proprioceptive where

this

are

2 major

There

input

information

is

from used

to

spinocerebellar

pathways:

•

Dorsal lower

•

which

tract—carries

Cuneocerebellar from

The

spinocerebellar

cell

the

bodies is

cuneocerebellar

input

from

the

lower

extremities

and

trunk.

situated

tract—carries upper of

the in

tract

proprioceptive

extremities dorsal the

upper

spinocerebellar

spinal are

and

found

cord in

from the

input

tract T1 medulla

to

the

cerebellum

in

Clarke’s

trunk.

to

are L2. in

The the

found cell external

bodies

of cuneate

nucleus, the nucleus.

267

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

CLINICAL

CORRELATE

Lesions tracts

that are

affect

only

uncommon,

of hereditary Pharmacology of

diseases

The

there

is a

Cerebellar

group

cortex

in which Biochemistry degeneration is

common

of

Cuneocerebellar

a prominent these

tract

is

ataxia.

Physiology •

Left

spinocerebellar

pathways most

Friedreich

the but

spinocerebellar

feature.

Right

Usually

inherited

as

an

Medical Genetics autosomal Inferior

recessive

•

May

involve

dorsal

Pathology

and

trait

cerebellar spinocerebellar

columns,

tracts,

Brain

peduncle

stem

corticospinal tracts, BehavioralScience/Social Sciences External

cerebellum Dorsal

•

Ataxia symptom

of

gait

most

common

initial

cuneate

spinocerebellar

nucleus

2

tract

DRG

Microbiology

1 From upper Dorsal

limb

(muscle

spindles)

horn Spinal 2

Clarke’s

cord

nucleus

DRG 1

From lower (muscle

Figure

26

III

4

14. Figure Spinocerebellar III 4 14.

Spinocerebellar

Tracts

Tracts

limb spindles)

CHAPTER

Ipsilateral

loss

of

vibratory

sense

in

lower

4

|

THE

SPINAL

CORD

limb

A Ipsilateral

B

loss

sense

in

of

upper

vibratory

limb

Ipsilateral C

spastic

E

weakness Horner’s F

syndrome

G

(at

T1)

D

Ipsilateral

flaccid

paralysis

Contralateral pain

Figure Figure anatomy

III

III 4 15. 4 15. Major depicted

Major spinal in myelin

A Fasciculus D Anterolateral sympathetic

spinal cord neural cord neural components myelin stained

stained section

Gracilis,

B Fasciculus

system, neurons),

E Dorsal

loss

and

components and clinical

section of of upper thoracic

Horn,

G Ventral

Cuneatus, F Lateral horn

(lower

of

temperature

upper cord.

and anatomy

C Corticospinal horn motor

clinical depicted

thoracic

in

cord.

tract,

(preganglionic neurons)

26

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

Pharmacology

Biochemistry

Features a

to

cord

look

for

to

identify

Cervical

section: Dorsal

• Is Physiology

there

a

large

ventral

columns

horn? Medical Genetics

(DC)

Corticospinal Fasciculus

YesNo

tract

cuneatus

(CST)

Lower Fasciculus

motor

gracilis neurons

C5–T1,

or

L2–S2

Pathology

T2–L1, C1–C4 BehavioralScience/Social Sciences

Spinothalamic tract

•

Are

both

dorsal

columns

present?

YesNo Thoracic Microbiology Above

T5

Below

DC

T5 Lateral

•

Is

there

a

lateral

horn

horn

(contains

preganglionic

present?

sympathetic from

YesNo

T1–L2

neurons

CST

T1–L2) SpTh

C1–C8

or

LMN

L3–S5

Lumbar DC

CST SpTh LMN

Sacral DC

CST SpTh LMN

Figure

27

(LMN)

Figure III

4 III16.4

16. SpinalSpinal

Cord: Cord:

Levels Levels

(SpTh)

CHAPTER

Spinal

UMN

Cord

cell

Medial

THE

SPINAL

CORD

body

lemniscus

Dorsal

spinocerebellar

lower Pyramidal

decussation

Loss

(unconscious from

To

2

gracilis

skeletal

in

limb

and

point

Alpha

motor

(LMN)

Fasciculus

gracilis

(Vibration,

touch,

in

vibration, joint

and

(brown) and

pain

and

begins

below

lesion:

temperature 1–2

segments

lesion

conscious

proprioception

from

lower

limb)

Spinothalamic and

tract

nucleus

at

Hemisection

Muscle

(T1–L2)

(pain

temperature)

LMN

Clarke’s

below

nerves

lesion:

(purple);

weakness

sensation

neurons spinal

flaccid

lesion

below

sensation

impaired

(UMN)

of

discrimination,

Contralateral

Corticospinal

and

level

proprioception,

spastic

muscles

upper

sensation at

impaired

position Midline

all

Ipsilateral

limb)

Nucleus

of

weakness

proprioception

Reflex

|

Lesions

tract

tract

4

T1

spindle

afferent

(la)

synapse

Alpha Neuron

in

dorsal

motor

neuron

horn

Pain,

Fibers

temperature

Vibration, A

delta

touch,

conscious

proprioception

fiber Alpha

motor

(LMN)

to

muscles

Figure

III

4

17.

Spinal

Cord

Overview Figure

III and 4 17. Brown Spinal

Séquard Cord Overview Left

neurons skeletal

in

lower

Syndrome and Brown Tenth

Thoracic

limb

with Séquard

Lesion Syndrome

at with Left

Tenth Lesion

at

Thoracic

Segment

Segment

271

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Brown

Séquard

syndrome

Hemisection

of

principal columns, Pharmacology

the

upper

cord

results

motoneuron

and

the

in

a lesion

pathway

spinothalamic

of

of

tract.

each

the

of

the

3 main

corticospinal

The

neural

tract,

hallmark

of

systems:

one

a lesion

to

or

these

both 3

the dorsal

long

tracts

is

Biochemistry that

the

•

Physiology

Medical Genetics

•

patient

Lesion

of

below

the

Lesion

of

joint the • Pathology

presents

the

2

ipsilateral

corticospinal

level the

of

signs

tract

the

and

results

1 contralateral

in

an

sign.

ipsilateral

spastic

paresis

injury.

fasciculus

position

gracilis

sense,

tactile

or

cuneatus

results

discrimination,

and

in

an

ipsilateral

vibratory

loss

sensations

of

below

lesion.

Lesion

of

the

spinothalamic

temperature

BehavioralScience/Social Sciences

with

tract

sensation

results

starting

1

or

in

a contralateral

2 segments

loss

below

the

level

of

pain

of

the

and

lesion.

At

the

touch Microbiology

muscles

level

of

the

modalities

lesion, as

supplied

by

there

well the

as

will

pain

be

and

injured

an

ipsilateral

loss

temperature,

spinal

cord

of

and

all

an

segments

sensation,

ipsilateral

(Figure

including flaccid

III

4

paralysis

15).

Polio

CLINICAL Tabes

CORRELATE

patients

(pins

and

present

needles

polyuria,

and

with

paresthesias

sensations),

Romberg

pain,

a.

Flaccid

paralysis

b.

Muscle

atrophy

c.

Fasciculations

d.

Areflexia

e.

Common

at

bladder

spinal

cord

levels.

There

results

above is

a

the

loss

muscle

of

of

spinal

cord

inhibition fibers

muscle

amount

of

of

that

during

detrusor

minimum

lesions

sacral

nerve

detrusor

Thus,

from

the

parasympathetic the

a.

“Paresthesias,

b.

Associated

CORRELATE

Spastic

the

pain, with

ataxia,

positive

closed,

Argyll

Common

filling

Amyotrophic

stage. to

causing

a

at

Progressive

b.

Primary

lumbar

sacral

spinal

cord

spinal

nerve

roots.

motor

innervation

the

detrusor

with bladder.

272

CORRELATE

a

segments Loss with

muscle

continuous

lesions or

dribble

to the

of

pelvic of

contraction

in

a full

of

the

sacral

loss

results

cord

spinal

• Spastic

urge

Anterior

from

sensory sways

pupils,

eyes

Common

Spinal DC

b.

All

c.

Common

d.

Spastic

and

paralysis

(ventral

lower

tract)

limbs

reflexes in

cervical

atrophy (corticospinal

in

tone

Artery

a.

muscular sclerosis

paralysis

in

(ALS)

upper

limbs

enlargement

(ASA)

Occlusion

spared else

bilateral at

signs mid

thoracic

levels

bladder

splanchnic

urine

with

suppressed

levels

Sclerosis

lateral

• Flaccid

results

syphilis, sign:

Robertson

Lateral

a.

c.

bladder

stage

Romberg

the

incontinence.

Atonic

polyuria”

late

reflexes c.

innervate

responds

stretch,

the

Dorsalis

• Increased

CLINICAL

levels

sign.

Tabes

CLINICAL

lumbar

of

ASA

bladder from

the Figure

Figure III

4

III

4 18. Lesions 18. Lesions

of the Spinal of the Spinal

Cord

Cord

I

horn)

in

CHAPTER

4

|

THE

SPINAL

CORD

Poliomyelitis Poliomyelitis in

the

results

ventral

muscles

with

recover

from

horn

by

the

most

the

a relatively

selective

poliovirus.

The

accompanying

function,

destruction disease

hyporeflexia

whereas

and

others

of

causes

progress

lower

paralysis

hypotonicity. to

motoneurons

a flaccid

Some

muscle

of patients

atrophy

and

may

permanent

disability.

Amyotrophic

lateral

Amyotrophic system

lateral disease

typically cord.

Patients

at

both

cervical with

may

Gehrig and

of

the

bilateral of

be

Lou

upper

levels

weakness

nuclei

(ALS,

affects

present

spastic stem

sclerosis

that

begins

bilateral brain

sclerosis

the

cord

involved

is

of

Lower

pure

The

progresses

weakness

limbs.

a relatively

motoneurons.

and

flaccid lower

disease)

lower

the

motor

disease

either

up

upper

limbs

motoneurons

or

in

down

the

and the

later.

Subacute

Combined

CLINICAL

Degeneration

a.

Vitamin

b.

Demyelination

B12,

pernicious of

• Dorsal

Subacute

anemia

the:

columns

CORRELATE combined

present (central

and

peripheral

degeneration

paresthesias,

weakness,

Babinski

antibodies

to

patients

bilateral sign

spastic

Babinski

signs,

and

myelin) • Spinocerebellar

tracts

• Corticospinal c.

Upper

tracts

thoracic

or

intrinsic

factor.

(CST)

lower

cervical

cord

Syringomyelia a.

Cavitation

b.

Bilateral

loss

the

of

c.

of

level

As

the

the of the

disease

weakness;

cord

(usually

pain

and

of

progresses,

the

destruction

there flaccid

upper

of

at

lesion

eventually

atrophy

cervical)

temperature

limb

ventral

is

paralysis

and

muscles

horn

CLINICAL

muscle

due

CORRELATE

Syringomyelia

may

present

with

Arnold

Chiari

to hydrocephalus

cells

and

I

malformation.

Hemisection:

Brown

DC

Séquard a.

DC:

Syndrome

Ipsilateral

senses b. CST

and Spth

c.

d.

of

below

temp

and of

the

vibratory lesion

Contralateral

loss

segments

loss

Ipsilateral

position level

1–2

ipsilateral

at

below

the

level

paresis

below

of

of

NOTE

lesion the

Syringomyelia

lesion

the

level

level

of

of

“cape

like”

results loss

of

in pain

a “belt and

like”

or

temperature.

lesion

LMN: the

e.

and

tract:

and

CST: the

LMN

loss

at

Spinothalamic pain

(cervical)

Flaccid

paralysis

at

the

lesion

Descending Horner

hypothalamics: syndrome

• Facial

hemianhidrosis

• Ptosis

(slight)

(if

Ipsilateral cord

lesion

is

above

T1)

• Miosis

Figure

III Figure

4

III

19. Lesions 4 19. Lesions

of the Spinal Cord of the Spinal Cord II

II

27

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Occlusion This

of

artery

anterior

lies

anterior

in

spinal

including Pharmacology

the

spinal

the

anterior

artery

the

artery median

interrupts

sulcus

blood

corticospinal

tracts

of

supply

and

the

to

spinal

the

cord.

Occlusion

ventrolateral

spinothalamic

tracts.

of

parts

of

the

level

Below

the

the

cord, of

the

Biochemistry lesion,

the

patient

exhibits

a

bilateral

spastic

paresis

and

a bilateral

loss

of

pain

and

temperature.

Physiology

Medical Genetics

Syringomyelia Syringomyelia canal,

is a

usually

medulla. Pathology

BehavioralScience/Social Sciences

in

Early

sensation

in

lower

motoneurons

flaccid

paralysis

fibers

and

the

anterior

of

(drooping

eyelids),

Tabes

dorsalis

as

There

paroxysmal Owing

dorsalis

are

almost

of

pains,

nence.

the

unsure

diagnostic

ataxia,

step

pupillary

Subacute

combined

degeneration

Subacute

combined

degeneration

patchy

losses

resulting and affected.

responses

sometimes

in pressure

of

myelin

a bilateral sensations

the

spastic below

Tabetic

most

paresis

and lesion

sense,

with

cord

by of

a

the

or with

inconti tabes

characteristic also

dorsal

astereognosis,

reflexes

may

and

present

with

pupils).

commonly

and a bilateral sites.

is caused

individuals

anemia.

columns

T4 ptosis

face.

stretch

Robertson

through

It

position

walk

is Horner

degeneration

patients

pernicious

dorsal

the

and

cavitation

T1

neurosyphilis.

diminished

is

expands,

hypothalamic

the

the

secondary and

is seen to

in

the

bilateral

constriction),

pathways,

(Argyll

related in

of

ground

stride”.

of

in

or

spinothalamic

in

descending

(pupillary

and

as

of cavitation

resulting

of

central

regions

temperature

destruction

sweating)

vibration

the

abnormal

deficiency,

of

and

the

the

cord

manifestation

miosis

proprioceptive

where

the

compressed, late

roots

well

pain

neurons

of

dorsal

of

involvement

(lack

as

of

“high

of

of

other

When

manifestation the

loss of

of

impaired

and

to

A

result

anhidrosis

be

result

sympathetic

possible

may

loss

are

consists

and

a

muscles. a

syndrome

is one

as

cavitation involve

bilateral

horns

limb

may

commissure.

ventral

upper

progressive

but

is a

white

the

degeneration

columns.

there

preganglionic

Horner

cord

forearms

occurs

innervating

dorsalis

disease,

in

by

spinal

hands in

segments.

Tabes

characterized

cervical

the

which

bilateral

27

the

crossing

syndrome, Microbiology

in

fibers

disease

the

Myelin

in The

cases

disease

lateral

of is

corticospinal

alteration in

of both

CNS

vitamin

B12

characterized

by

tracts, touch, and

vibration, PNS

is

The

LEARNING

Brain

Stem

5

OBJECTIVES

❏

Answer

questions

about

cranial

nerves

❏

Answer

questions

about

sensory

and

❏

Solve

❏

Demonstrate

❏

Interpret

scenarios

on

midbrain

❏

Interpret

scenarios

on

components

problems

concerning

motor

neural

systems

medulla

understanding

of

pons

of

the

ear,

auditory,

and

vestibular

systems

The

❏

Demonstrate

❏

Solve

❏

Interpret

scenarios

on

brain

❏

Interpret

scenarios

on

reticular

brain

The to

pons

the

is

The

the

The

problems

stem

medulla.

is

pons

brain 12

in

is

the

nerves

blood

3

most

middle

home

of

to

the

gaze

brain

stem

lesions

formation

continuous

is

conjugate

supply

stem

parts:

rostral

and

horizontal

and

overlain

by

with

the

the

origins

midbrain,

just

the

cerebellum.

spinal

or

the

begins

the

below

the The

pons,

and

the

diencephalon. medulla

is

caudal

cord.

sites

of

termination

of

fibers

in

9 of

(CNs).

NERVES

cranial

nerves, Four

chlear

nerves

nerves,

cervical

into is

is continuous

stem

cranial

midbrain.

enter

divisible

the

and

of

concerning

midbrain

CRANIAL Two

understanding

the or

exit spinal

the

cranial (CN

V,

oculomotor

VI,

VII,

glossopharyngeal, from

the

and

nerves,

the and

VIII),

vagus, medulla.

trochlear

(CN

trigeminal,

Fibers

enter and of

III

abducens, or

exit

hypoglossal the

accessory

and

IV),

facial, from

the

arise

and pons.

from

Three

nerves

(CN

IX,

nerve

arise

from

the

vestibuloco

X,

cranial and

XII),

the

cord.

27

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Cingulate

gyrus

Fornix

Thalamus

Corpus

Pineal Biochemistry

Pharmacology

callosum

gland Septum

Superior

pellucidum

colliculus

Hypothalamus Inferior colliculus Medical Genetics

Physiology

Cerebral

Optic

chiasm

Pituitary

aqueduct

Midbrain Pathology

BehavioralScience/Social Sciences Tonsil Pons Fourth

ventricle Medulla

Microbiology Figure

Olfactory

bulb

Olfactory

tract

III Figure

5

1. III

5

Brain: Mid 1. Brain: Mid

Sagittal Sagittal

Section Section

Optic

chiasm

Pituitary Optic

nerve

(II) Mammillary

Oculomotor

nerve

body

(III) Cerebral

Uncus

Trigeminal

peduncle

Abducens

nerve

nerve

(VI)

(V) Facial

nerve

(VII)

Vestibulocochlear Trochlear

nerve

nerve

Glossopharyngeal

nerve

Pyramid Vagus

nerve

(X)

Olive Accessory Cervical

spinal

nerve

(XI)

nerves Hypoglossal

Figure Figure

27

(VIII)

(IV)

III

5

III 2.

5 2. Brain:

Brain:

Inferior

Inferior

View View

nerve

(XII)

(IX)

CHAPTER

Pretectal

nuclei

(Light

Optic

5

|

THE

BRAIN

STEM

chiasm

reflex) I

Pineal

II

body

Third

(Olfactory

tract)

(Optic

nerve)

ventricle Mammillary

Optic

Superior

body

tract

Thalamus

colliculus

III Cerebral peduncle

Inferior Midbrain

colliculus

IV

III,

IV V

IV VI

Pons V,

Cerebellar

VI,

VII,

VIII

VII

peduncles Upper

VIII

medulla IX,

X,

XII

IX

Fourth Lower

ventricle

medulla

Crossing

point

forming

Dorsal

medial

and

column nuclei

X of

fibers

lemniscus

corticospinal

Medial

Olive

tracts

XII

lemniscus

XI

Corticospinal

tract

(Pyramid) Dorsal Spinothalamic and

tract

descending

hypothalamic

Afferent

fibers

aggregates

to

arise

nerves

motor

organized

to

nerve

the

midline, nucleus brain

and

All

they

sensory nerve

Brain Brain

the

nuclei.

in that

or

3. IIIIII 55 3.

enter

sensory nuclei.

component

cranial

the

nerves in

are

functional

of

cranial

neurons from

closest

level

of

of

cranial

the

Ventral

axons

FigureFigure

nerves

columns

Dorsal

CNS

motor a series

of

Cranial Cranial Nerve: and

terminate

in

efferent nuclei

situated virtually

Anatomy Surface

relation

that

discontinuous

at

Surface Nerve:

of

nuclei

are

lateral every

the transverse

fibers

according

situated to

cranial

contribute

columns

Anatomy

to

components

sensory

Motor are

found

or

and

contain.

be

and

Motor

nuclei will

Stem Stem and

to

medially, motor

nuclei.

A

sectional

stem.

27

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Periaqueductal gray

matter

Cerebral

III

nucleus

and

of

Edinger

Westphal

nucleus

aqueduct Superior

Pharmacology

Medial NOTE

The

colliculus

Biochemistry geniculate

body descending

hypothalamic

fibers

spinothalamic

tract.

MLF

(nucleus)

Medial

lemniscus

Spinothalamic course Physiology

with

the

Medical Genetics

tract

and

descending

Red

hypothalamic

fibers

Corticospinal

tract

nucleus

Substantia

nigra

Cerebral Pathology

BehavioralScience/Social Sciences

peduncle

III Corticobulbar

tract

Figure III

Figure

5 III4A.5

4A. Upper Upper

Midbrain; Midbrain;

Level Level of

Nerve III of Nerve

III

Microbiology

Cerebral

Inferior

aqueduct

colliculus

Trochlear

nucleus

MLF

Superior Spinothalamic and

tract

cerebellar

peduncle

descending

hypothalamic

fibers Medial

Corticospinal

and

corticobulbar

tracts

Figure5 III

Figure

Cerebellar (cut

lemniscus

Basis

III 4B.

5 Lower 4B. Lower Midbrain; Midbrain;

Level CN Level of Nucleus of Nucleus

hemisphere

pontis

IV

CN

IV

Vermis

section) Superior

Medial

longitudinal

fasciculus

(MLF) Fourth

Spinothalamic and

Main

descending

sensory

nucleus

fibers

Motor

lemniscus

Corticospinal

and

corticobulbar

tracts

Figure

III Figure

5

4C. Middle III 5 4C. Middle

Pons; Pons;

Level of Nerve Level of Nerve V

of

nucleus

V

27

ventricle

tract

hypothalamic

Medial

cerebellar

peduncle

V

V

of

V

CHAPTER

Medial Fourth

ventricle

Spinal

tract

longitudinal

THE

BRAIN

STEM

nucleus

and

of

V

Cerebellum

Spinothalamic and

|

fasciculus

Dentate

nucleus

5

Su Superior

tract

descending

cerebellar ce

ng

hypothalamic

fibers

Ve Vermis

Fa Facial

Superior olivary

nucleus

s

Medial

lemniscus

cus

Corticospinal

and

corticobulbar

tracts

peduncle

colliculus

Nu Nucleus

of

nerve

VI

Nu Nucleus

of

nerve

VII

VII

VI

Figure

Figure III 5

4D. III

5 Lower 4D. Lower Pons; Pons;

Level

of ofNerves Nerves VI and VIVII and

VII

Medial Fourth

longitudinal

fasciculus

ventricle Hypoglossal

Vestibular/cochlear

nuclei

Dorsal

motor

nucleus

Solitary Inferior

cerebellar

nucleus

of

nucleus

nerve

and

Spinothalamic and

nucleus

olivary

Medial

lemniscus

tract

descending

Hypothalamic Spinal

Inferior

tract

peduncle

VIII Ambiguus

X

nucleus

nucleus

X

(and

fibers tract of

and V

IX)

XII Pyramid

(corticospinal

tract)

Figure

III

5

4E.

Open

Medulla Figure

III

5

4E.

Open

Medulla

27

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

Internal fibers

forming

medial Pharmacology

Nucleus

gracilis

Nucleus

cuneatus

arcuate

lemniscus

Biochemistry

Spinal

tract

of

Spinal

nucleus

of

Spinothalamic Physiology

Medical Genetics

and

V

tract

descending

hypothalamic

fibers

Decussation of Pathology

pyramids

BehavioralScience/Social Sciences

Figure III III5

Figure

Table Microbiology

III

5

1.

Cranial

Nerves:

Functional

54F.4F.

Closed Closed

Features

CN

Name

Type

Function

Results

I

Olfactory

Sensory

Smells

Anosmia

II

Optic

Sensory

Sees

Visual

III

Oculomotor

Medulla Medulla

Motor

Innervates lar

SR,

muscles:

IR,

MR,

IO

adduction

important

extraocu

(MR)

of

Lesions

field

Loss

of

Only

nerve

light

(anopsia)

reflex to

Diplopia,

most

deficits

with

be

affected

external

Loss

of

III by

MS

strabismus

parallel

gaze

action Ptosis

Raises

eyelid

(levator

palpebrae Dilated

superioris) Constricts

pupil

(sphincter

Accommodates

CN

IV

Name

(ciliary

Type

Trochlear

Motor

pupillae)

Superior

down

and

(makes

and

eyeball

pain,

(V2)

skin

sensation

of

maxillary

face,

palate, maxillary

nasal teeth

Mandibular General two

sensation thirds

face,

to

lateral

tympani,

tongue,

of

tensor

skin

mastication medial

and mylohyoid, palati

Jaw

stairs

from

general

of

blink

reflex

of over

general

pain

of over

sensation

in

general

sensation

toward neuralgia—intractable

V2

or

in teeth in

mandibular weakness

deviation

VII

maxillary

mandible,

tongue,

in

side

sensation

maxilla,

Trigeminal tensor

lesioned

with

and

anterior

with

forehead/scalp

V2—loss skin

down

of of

teeth,

masseter,

digastric,

with

Lesions

down

away

V3—loss

teeth

pterygoids) of

anterior mandibular

muscles

(temporalis,

belly

of

of

mandibular

Motor

280

tilts

Loss

General cavity,

(V3)

going

V1—loss

forehead/scalp/

cornea

(V1) Maxillary

(touch, of

of

looking

Trouble

sensation

reflex

eye

Head

General

light

response

Weakness adducted

out)

temperature)

Ophthalmic

near

of

Results

Intorts

Mixed

of

loss

muscle)

oblique—depresses eyeball

look

Trigeminal

Loss

Function

abducts

V

pupil,

V3

territor

in weak

chewing side

II

V

CHAPTER

Table

III

5

1.

Cranial

Nerves:

Functional

Features

Name

Type

Function

VI

Abducens

Motor

Lateral

Results

rectus—abducts

eyeball

of

Mixed

THE

BRAIN

STEM

To

muscles

of

posterior

facial

belly

stylohyoid,

expression,

of

internal

behind

Taste

in

blink

Pain

ear

behind

2/3

of

tongue/

Eye

forehead,

hyperacusis;

of

nerve

loss

of

in

Bell facial

canal

ear or

dry

cannot

wrinkle

reflex,

Alteration

anterior

“pseudoptosis”

droops,

cannot

palsy—lesion

glands)

Skin

of

gaze,

mouth

eye,

loss

strabismus

parallel

of

close

(submandibular,

sublingual

of

Corner

digastric,

stapedius

Salivation

Lesions

Diplopia, Loss

Facial

|

(continued)

CN

VII

5

and

taste

(ageusia)

red

palate Tears

VIII

Vestibulocochlear

Sensory

(lacrimal

Hearing

Sensorineural

Angular

acceleration

Linear

IX

Glossopharyn

Mixed

gland)

acceleration

Oropharynx

geal

(head

turning)

hearing

Loss

of

balance,

Loss

of

gag

loss

nystagmus

(gravity)

sensation,

carotid

reflex

with

X

sinus/body Salivation All of

(parotid

sensation

gland)

of

posterior

one

third

tongue

Motor

to

one muscle—stylopharyngeus

X

Vagus

Mixed

To

muscles

of

for

swallowing

(V)

and

palate

and

except

pharynx

tensor

stylopharyngeus

Nasal

palati

speech,

Dysphagia,

all

muscles

Sensory

of

palate

droop

of

larynx

pointing

away

from

To

GI

of tract

glands

CN

XI

Name

larynx GI

in

Motor

muscle

foregut

rotation

and

cord

Loss

of

gag

reflex

Loss

of

cough

with

IX

and

to

reflex

and

midgut

Results

opposite

side

Weakness

(sternocleidomastoid) Elevates

vocal

tract

Function

Head

side

laryngopharynx

smooth

Type

Accessory

and

affected

(phonates) Hoarseness/fixed

Sensory

regurgitation

(IX) Uvula

To

nasal

of

turning

Lesions

chin

to

opposite

side rotates

scapula

Shoulder

droop

(trapezius)

XII

Hypoglossal

Motor

Tongue

movement

hyoglossus,

(styloglossus,

Tongue

genioglossus,

intrinsic

and

pointing

(affected)

side

toward on

same

protrusion

tongue is muscles—palatoglossus by X)

Abbreviations:

CN,

cranial

nerve;

IO,

inferior

oblique;

IR,

inferior

rectus;

MR,

medial

rectus;

MS,

multiple

sclerosis;

SR,

superior

rectus

28

PART

Anatomy

III

|

NEUROSCIENCE

Immunology SENSORY

Each

AND

of

the

courses Pharmacology

following

through

the

medial

dorsal the

ascending

brain

Medical Genetics

lemniscus

column

or

stem

SYSTEMS

descending

and

is

neural

found

cross

the

in

midline

of

nuclei.

at

every

in

the

in

tracts,

fibers,

transverse

spinothalamic cord

or

fasciculi

sectional

level.

pain

and

temperature

bodies

and

cortex

of

and

conscious

the

in

from

brain

the

represents

discriminative

axons

emerging

part

in

and

for

The

after

any

found

medulla

proprioception.

in

of

the

anterolateral

crossed

temperature

tract,

thalamus

pressure,

(part

represents

spinothalamic

ML,

cell caudal

the

the

stem,

ML

dorsal

result

in

a loss

proprioception

of

from

the

body.

tract and

conveying

the

the

from

immediately

vibration, of

the

conscious

medulla

Lesions

side

to

and

axons

cuneatus)

pathway

the

touch,

contralateral

spinal

the

the

and

pressure,

discriminative

The

contains

(gracilis

neuron

vibration,

column

BehavioralScience/Social Sciences

(ML)

nuclei

second

touch,

Pathology

5

NEURAL

Biochemistry The

Physiology

MOTOR

in

to

any

sensations

part

from

of the

system)

axons the

of

thalamus

the

has

the and

brain

stem,

contralateral

its

second

cells

neuron

cortex.

result side

of

of

origin

in

the

Lesions

in

a

the

loss

of of

in

the

pathway the

pain

and

body.

Microbiology The

corticospinal

ron

pools

the

spinal

the

body

The

tract

for

lower

cord.

sympathetic

constriction),

ptosis to

Descending

may

also

in

site

in

brain

the

stem

on

in

Lesions

their

way

skeletal

hypothalamus

to

muscles

and

on

of

syndrome

interneu

of

stem.

terminate

and

and

paresis

brain

in to

eyelid), the

the

the

arise

cord.

motoneurons,

a spastic

stem

Horner

of

lower

through

produce

spinal

this

pathway

consists anhidrosis

course

preganglionic

of

produce miosis

(lack

of

an

(pupillary

sweating)

in

the

lesion.

fibers Therefore,

a contralateral

longitudinal gaze,

the

innervate to

of

course

with

brain

stem

lesions

pain

and

loss

of

the

spinothalamic

fibers

producing

in

the

Horner

temperature

lateral

syndrome

sensations

from

the

body.

horizontal

the

fasciculus vestibular

skeletal dorsal

which

produce

is nuclei,

muscles

midline

course

fasciculus ocular

brain

the

side

stem.

result

medial

fibers,

the

(drooping the

brain

and

close

lesion

hypothalamic the

which

the

syndrome.

ipsilateral

The

in

Horner

of

tract

fibers

through neurons

ipsilateral

activity

course this

hypothalamic

crossing

limbs

of to

descending

part

the

motoneurons

Lesions

contralateral

without

face

controls

of

through

and

that the

brain medulla

bundle

the

move

the

internuclear

a fiber

interconnecting

nerve the

stem to

nuclei

of

eyeball.

and

also

the

spinal

ophthalmoplegia

This contains cord.

and

centers CN fiber

III,

IV,

for

and

bundle

VI,

courses

vestibulospinal Lesions

disrupt

of

the

the

vestibulo

reflex.

MEDULLA

In

the

caudal

medulla,

column–medial gracilis

and

medulla ascend

28

2

of

lemniscal nucleus

(the in

the

the

neural

systems—the

pathways—send

cuneatus

crossing

axons

medial

lemniscus.

give are

rise the

corticospinal

axons to

internal

axons

across that

arcuate

the

decussate fibers),

and

dorsal

midline. in which

The the

nucleus

caudal then

form

and

CHAPTER

The

corticospinal

(pyramidal)

ventromedially medulla

just

travel

below

down

The

the

olives

the

send

crossing

climbing

peduncle.

the

pyramids

The

in

fibers

in

dorsal

the

fibers

into

are

a key

the

inferior

pyramids,

THE

BRAIN

STEM

course

in

column

|

the

caudal

nuclei,

and

then

tract.

rostral

inferior

olives

the

decussate

corticospinal

convoluted

(olivocerebellar)

cerebellar

these

from

(lateral)

the

the

contained

of

axons

the

to

contain

are

Most

of as

lateral

olives

which

medulla.

cord

located

The

inferior

the

spinal

are

medulla. nuclei

tracts,

through

5

two

olivary the

thirds

nuclei.

of The

cerebellum

the olivary

through

distinguishing

the

feature

of

the

medulla.

The in

spinothalamic the

the

tract

lateral

part

spinal

of

nucleus

Cranial

of

spinal

to

nerve

lies

to

point

the

cells

in

the

face

CN

V

The

to

entry

of

enter

the

brain

synapse

and

nucleus

the

fifth

cells

(CN

spinal and

in pain

rostral

the

in

a

tract

the

together and

near

position of

upper

pons.

and

pons

spinal

located spinal

from

nerve

the

the

is

The

extends

cranial

in in

V)

cord.

conveying

receives

into

visceral

CN

VII,

Nucleus

the

trigeminal

cervical

cord

Central

temperature

but

(C2)

processes

from

sensations

descend

in

the

from

spinal

tract

of

nucleus.

the

the

CNS

by

and

gastrointestinal

sensory

IX,

and

axons CN

IX,

all

have

all

general

and

and

X.

sensations

neurons

X

of

VII,

outside

the

their

special

These

include

carried

by

cell

visceral

these

bodies

afferent

taste,

in

cranial

nerves.

ganglia

associated

CNS.

ambiguus nucleus

inferior

ambiguus olive.

tenth

cranial

tenth

nerve,

palate

causing

regurgitation

A

of

uvula

motor

These

visceral

in

floor stem, and

to

liquids,

CN

motoneurons of

the

deviate

and

it

foregut

of

course nerve

soft

produce from

is

palate,

the

muscles swallowing.

located

lateral

the

to

ninth

insignificant. larynx,

In

nerve causing

of and

the and

pharynx,

paralysis

lesioned

in

dorsal in

ipsilateral

laryngeal

CN

X

are

This

preganglionic and

ninth the

difficulty

situated

nucleus

the and

the

soft

nasal

hoarseness,

and

X

ventricle.

supplies

the

will away

in

motoneurons this

of

lesion

of

fourth

the

in to

weakness

of

large

muscles

resulting

nucleus

of cells

component supply

unilateral

weakness

Dorsal

from

The fibers

the

column

arising

nerves. these

esophagus.

pharyngeal

is a

Axons

upper

thorax

this

stem

on

nucleus

carried

Taste

brain

nerve

of

ganglion

cardiorespiratory,

the

course peduncle

V.

trigeminal horn

the

trigeminal

solitary

The

CN

fibers cerebellar

nucleus

fibers

with

of

the

dorsal

lateral of

and

Solitary

of

the

just

the

tract

hypothalamic

below

V

nucleus

analogous

descending

Nuclei

nucleus

The

the

medulla

and

Nerve

Spinal

and

the

midgut

parts

is a

major

fibers

innervating

of

gastrointestinal

the

to

the

hypoglossal

parasympathetic

nucleus

nucleus terminal

ganglia

of

the in

the

tract.

28

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Hypoglossal

nucleus

The

hypoglossal

and

fourth

innervate Pharmacology

Physiology

all

Medical Genetics

The

accessory

The

of

the

near

nucleus

tongue

the

sends

muscles

midline

axons

except

just

into

the

beneath

the

the

central

hypoglossal

canal

nerve

to

palatoglossus.

accessory

nucleus nucleus

accessory

nerve to

cranial

BehavioralScience/Social Sciences

enter

from

the

affect

fibers

the

sternocleidomastoid

rootlets

the

and

nerve

medullary

spinal

the

(CN

join

As

accessory

nerve.

trapezius

muscles.

(CN of

exits

cord.

the

pass

the

foramen.

fibers

XII)

spinal

nucleus,

glossopharyngeal

olive

hypoglossal

cervical

and

jugular

and

of the

the

the

accessory cavity,

the

of

in

the

cranial

through

not

between

is found

arise

cavity

The

Microbiology

is situated This

Biochemistry

magnum

Pathology

nucleus ventricle.

IX)

of

result,

the

of

the

foramen

vagus

spinal

accessory

and

vagus

(CN

cerebellar

medially

axons

to

the

nerve

X)

the

the

lesions

do

supplies

nerves

peduncle.

between

spinal

exit

intramedullary

The

inferior

more

fibers a

The

through

exit

The

olive

and

the

pyramid.

PONS

The

pons

The

cerebellum

is

cerebellar the

located

pons

and which

nuclei

to

The

the fibers

The the

28

lemniscus

horizontal

from

medial fourth

are

by

has

changed

middle

diffuse

of that

the

the

brain

midbrain

the

the

pons

carries

the

the

fibers

is

by

3

dorsal

pairs

dominated

fibers

of by

from

This

of

surface

pontine

ventral

pons.

pons that

(rostrally).

stem

peduncle. of

in

and

between

cerebellar feature

the

and

an

lemniscus.

The

longitudinal

near

fibers from the

the

lateral

lemniscus,

cochlear

situated the

in

tract in

ventricle.

found

surface

coursing

orientation

both

ventral

more

is still

spinothalamic

lateral

is

distinguishing

tracts

lemniscus

medial

ventricle

to

than

in

enter

the

the

medulla

and

cerebellum

in

are

the

peduncle.

corticospinal

together

connected

enlargement

the

transversely

cerebellar

course

The

the

(caudally)

is

ventral in

tracts

medial

It

The

large

key

corticospinal

medial more

a

is the

middle

medulla

fourth

cerebellum

in

the pons.

cerebellum.

form

the

embedded

the

The

the

enlargement

The

the

peduncles.

fibers,

The

between overlies

the

midline

forming

the

but

middle

a dorsoventral

is

now

separated

cerebellar

orientation

from

peduncle. in

the

The

medulla

to

pons.

descending

hypothalamic

fibers

continue

to

pons.

ascending

auditory

lateral nuclei

fasciculus

pathway,

lemniscus to

the

(MLF)

carries inferior

is

is the

colliculus

located

lateral

bulk of

near

and of

the

the

just

ascending

dorsal auditory

midbrain.

midline

just

beneath

to

a

CHAPTER

Cranial

Nerve

Abducens abducens

just

lateral

Facial

nucleus

facial

from

the

(the

curve the

the

stem

nuclei

the

midline

in

the

floor

of

the

abducens

the

fourth

ventricle

located

at

the

ventrolateral

around genu

of

to

the

posterior

the

facial

pontomedullary

side

of

nerve),

nucleus.

the

then

Fibers

abducens pass

nucleus

ventrolaterally

to

junction.

nucleus nucleus

lies

impulses are

cerebellar

peduncle.

Vestibular

nuclei

vestibular

immediately

from

found

nuclei

abducens

at

are

nucleus,

both

the

by

way

near

extend

the

the

posterior

nucleus

medulla.

are

found

CN

VIII

CN

nuclei.

just

surface

the

of

cochlear

junction

the

into

to of

pontomedullary

located

and

ventral

ears

lateral

of

the

VII

and

The to

pons

the

inferior

lateral

to

nuclei dorsal

of

and

the

Motor

ventral

fibers

Trigeminal

of

cochlear

the

nuclei

cochlear

part

of

at

the

pontomedullary

terminate

junction.

here.

nuclei

Nucleus—Pons

The

motor

nucleus

nucleus of

nerve

the

Main

These and

Sensory main

sensory

The

main

sensory

scalp,

oral

Spinal

Trigeminal

Central

motor

located

in

adjacent

the

to

supply

lateral

pons

the

just

point

the

of

medial exit

muscles

pterygoid

located

receives cavity,

and

Nucleus—Spinal

of

(Figure

to

or

the

entry

5

main

of

mastication IV

from sensations spinal

just

lateral

to

the

sensory trigeminal

(masseter,

3).

the cells from

is

a

mid in the

the

tactile

and

pressure

motor

nucleus.

sensations

from

the

face,

dura.

cord

nucleus from

processes

the

is

nucleus nasal

trigeminal

in

is

fibers and

nucleus

extending

temperature cells

V and

medial

cavity,

spinal

nucleus,

CN

Nucleus—Pons

The

The

of

trigeminal

fibers.

temporalis,

on

is

internal

olivary

cochlear

All

near

curve

the

olivary

Cochlear

found

nucleus

brain

auditory

The

is

nucleus

forms

superior

the

STEM

MLF.

motor

receives

The

BRAIN

nucleus

facial

Superior The

THE

Nuclei

to

motor

exit

|

nucleus

The

The

5

to caudal pons

the

pons continuation through

trigeminal face

descend

of the

medulla

ganglion in

the

the

main to

sensory

the

cervical

conveying spinal

tract

pain of

V

cord. and

and

synapse

nucleus.

28

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Mesencephalic

NOTE VPM and

relays taste

touch, (CN

pain,

VII,

temperature

IX) sensations

(CN to

The

V)

mesencephalic

nerve

cortex.

Nucleus—Midbrain

and

muscles Pharmacology

nucleus

extends of

into

of the

mastication,

CN

V

is

midbrain.

located

It

extraocular

at

receives

the

point

of

entry

proprioceptive

muscles,

teeth,

of

input

and

the

the from

periodontium.

fifth joints, Some

Biochemistry these limb

Physiology

fibers of

synapse

the

jaw

monosynaptically

jerk

on

the

motoneurons,

forming

the

sensory

reflex.

Medical Genetics

Ophthalmic Somatosensory Pathology

cortex

(CN

V1)

BehavioralScience/Social Sciences

VPM (neuron in

#3)

Maxillary

thalamus)

(CN

V2) 12

Microbiology

34

Mandibular (CN

V3)

Ventral trigeminal tract

Mesencephalic

Muscle Motor

nucleus

spindle

Main

of

V

afferent

sensory

nucleus

of

V

nucleus of

Tactile

V

To

afferent muscles

Pain CN

of

V

Nerves V3

mastication

afferent

VII,

(from

skin

external V2

IX, in

and

or

auditory

Spinal

tract

X

near meatus)

of

V

V1

Spinal

Figure

III Figure

5 5.

branches Dotted

28

Shaded III 5

trigeminal

5.

nucleus

areas indicate Shaded

the lines of indicate

regions areas

3 concentric divisions

of face indicate

of numbered

“onion and

mouthskin” that regions have

emanating a rostral to caudal

caudal

representation

in

the

spinal

and

CN “onion V. posteriorly representation nucleus

scalp innervated regions of Dotted skin”

lines regions fromthe in of

by branches face and indicate emanating

nose spinal V

in

and nucleus the

brain

of the scalp concentric posteriorly mouth of V in stem.

3

divisions innervated

from

of CN V. by

numbered nose

the thatbrain have stem.

a

rostral

to

of

CHAPTER

Cranial

Nerves

Four

cranial

emerge the

V,

VI,

nerves

from

VII,

emerge

the

the

from

the

to

the

middle

of

pons.

The

nerves

The

abducens

corticospinal the

Cranial

junction.

nerve.

lateral

from

VIII

pontomedullary

vestibulocochlear

midline

and

facial

nerve

tract.

The

(CN

VI,

VII,

nerve

is

VI)

emerges

trigeminal

and

medial

THE

BRAIN

STEM

to

near

the

V)

emerges

(CN

|

VIII

located

nerve

5

pons.

MIDBRAIN The

midbrain

The

cerebral

(mesencephalon)

ventricles,

passes

colliculi

are

duct.

The

from

the

just

contain

corticospinal

in

The

the

medial

The

MLF

and

the

the

of

the

the

cerebral

The

superior

pretectal

light

aque

bilaterally

region

oculomotor

midbrain.

is

located

complex.

reflex. The

The

fourth

superior

received

The

pupillary the

and and

lemniscus.

gaze.

fibers.

largest

nucleus

brain

because

nigra

and

of

utilize

to

be

The

This

massive

cerebral

peduncles

interpeduncular

midbrain.

cells

fossa

and

and

the

appears

is

the

black

melanin GABA

to

dark

pigments.

as

descending

periaqueductal

near

It

contain

Dopamine

tract

the

located

the

nigral

spinothalamic

ventrolateral

to

in

above

lateral in

front

from

colliculi

information

the

diencephalon.

third

peduncles.

is

continues

in

and

the

midbrain

eyes

corticobulbar

cut

lemniscus

the

of

both

ventrally

substantia

together

fibers of

cerebral

nigra

in

course

axon

involved

freshly

of

pons

inferior

auditory

colliculi

and the

the

Neurons

by

extend

substantia

brown

aspect

the

connects

The

processes

superior

between

The

dorsal

interneurons

peduncles

that

midbrain.

movements

the

contains

the

nuclei

direct

cerebral

space

on

between

channel

the

colliculus

cochlear

beneath

narrow

through

found

help

area

a

inferior

colliculi

is located

aqueduct,

neurotransmitters.

hypothalamic

fibers

gray.

midline,

just

beneath

the

cerebral

aqueduct.

The

mesencephalic

central

Cranial

Nerve

The

nucleus the

Two

cranial

onic

the

trigeminal

at

nerves

the

Axons

of brain

level

nerve

are

located

on

either

side

of

the

nerve

arises

in

the

to

trochlear near

found

just

superior

the

periaqueductal The

gray oculomotor

beneath

the

near

the

nucleus

and

periaqueductal

gray

colliculi.

midbrain:

the

the

that

the

oculomotor

oculomotor fossa.

arise

oculomotor

nerve the

from

interpeduncular

axons

adjacent

stem

the

from

the colliculi.

(CN

III)

and

the

nerves.

midbrain

the

beneath inferior

are of

emerge

IV)

just and

Westphal

parasympathetic lies

located

superior

Edinger

oculomotor

which

the

of

(CN

the

is

the

midline

trochlear

from

nucleus

between

near

The

of

Nuclei

trochlear

midline the

nuclei

gray.

posterior

from

the

nucleus CN

III

and also

nucleus

of

exits

ventrally

contains Edinger

pregangli Westphal,

nucleus.

decussate midline

in

the just

superior inferior

medullary to

the

velum inferior

and

exit

colliculi.

28

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Corticobulbar

(Corticonuclear)

Corticobulbar

fibers

motoneurons Pharmacology

Biochemistry

cortex

in and

skeletal

Physiology

Pathology

Innervation

serve

as

cranial

influence

lower

muscles.

the

nerve

This

source

nuclei.

of

of upper

in

Nerve

motoneuron

Corticobulbar

motoneurons

Cranial

all

brain

Nuclei

innervation

fibers

arise

stem

nuclei

in

of

the

that

lower

motor innervate

includes:

•

Muscles

of

mastication

•

Muscles

of

facial

•

Palate,

pharynx,

•

Tongue

(CN

•

Sternocleidomastoid

(CN

V)

expression

(CN

VII)

and

(CN

X)

–

(partially

bilateral)

Medical Genetics larynx

XII) and

trapezius

muscles

(CN

XI)

BehavioralScience/Social Sciences

UMN Right

Left

to

innervation

LMN

in

nerves

is

cranial bilateral

Microbiology Upper

Cerebral

motor

neuron

Precentral

A UMN to

gyrus

innervation

LMN

in

nerves

cortex

(UMN)

spinal

is B

contralateral Caudal

Brain

medulla

stem

Lower

motor

neuron

in

a

CN

(decussation)

Spinal

cord

Lateral corticospinal

C

tract

Function: Voluntary

refined

Skeletal

movements of

the

muscle distal

extremities

D

E

Lower

motor

neuron

Figure III 5

Figure

III 5 6. Upper Motor 6. Upper Motor Spinal Spinal

The nantly input cortex. VII)

28

corticobulbar

innervation

bilateral, from The receive

in

that

corticobulbar major a

of

each

exception

cranial

lower axons

contralateral

Nerves Nerves and

Neuron Neuron Cranial and

nerve

that

innervation.

only

Innervation Innervation Nerves Cranial

lower

motoneuron arising

is

(LMN)

in

from some

both of

of

Nerves

motoneurons a the

the

of

cranial right LMNs

is nerve and

of

nucleus the

the

left facial

predomi receives cerebral nerve

(CN

CHAPTER

CLINICAL

Facial

upper

motor

motoneuron

nucleus

lower

is

of

bilateral. the

can

the

upper

The

A

nerve of

forehead,

the No

nerve

some

in

(e.g., facial

eyes)

and

other

BRAIN

STEM

the

from

corticobulbar

muscles,

the fibers

causing

on

of

to

only

a

side

of

the

face

are

nucleus

left, of

the

to

the to

this

means

and

a

eyes)

is

muscles that

lesion

complete

an

the

one

of

the

corner

to of

of

(and

seen

ipsilateral

inability

drooping no

the

the

wrinkle

the

mouth.

corner

other

because

may

of

facial

virtually

receive

corticobulbar without

corticobulbar

the

shut

to

the

motor every

other

innervated.

weakness

a deviation

lead (e.g.,

lead

bilaterally

injured

nerve

will

a drooping

If these

transient

away

Palsy)

hypoglossal

innervation.

and

Clinically,

nerve

motoneurons

nucleus.

deficits

is

facial

facial

cranial

motoneurons

seventh

expression

will

cranial

nucleus

undergo

Bell

of

the

motor

contralateral

individuals,

corticobulbar

deviate

the

facial

lesion

on

cranial

muscles

lesion

corticobulbar

deficits).

the

muscles

shut

mouth

In

to

of

the

most

forehead

facial

only.

lesion

in Like

of

the of

is contralateral

fibers

facial

wrinkle

innervation

a

motoneurons

significant. innervation

(which

between

paralysis

A

face

however,

corticobulbar

lower

clinically

corticobulbar

corticobulbar

mouth,

of

and

the

differentiate

•

THE

CORRELATE

innervation different

motoneurons,

muscles

•

|

Paralysis

The

of

5

there

fibers atrophy fibers.

If,

is transient

tongue

mainly are

lesioned,

or

fasciculations

for

example,

weakness

toward

the

contralateral

side

tongue and

the

of

right

the

the

may

lesion

right

upon

is

tongue

protrusion.

CLINICAL Cortex

Cortex

CORRELATE

Lesion

A:

left

lower

Lesion

B: complete

face

weakness

UMN

UMN A

Facial UMN

of

left

face

weakness

nucleus

pons

(LMN)

Upper

face

ABBREVIATIONS

Lower Wrinkles

Shuts

Flares

UMN

division

Normal:

face

LMN

= upper

= lower

motoneuron

motoneuron

division

forehead

eye

nostrils

Smiles

L

R

Figure

III

Figure 5 7.

III 5 7. Corticobulbar Corticobulbar

Innervation Innervation

of

the of

Facial the

Motor Facial

Nucleus Motor

Nucleus

289

PART

III

|

NEUROSCIENCE

Anatomy

Immunology EAR,

AUDITORY,

Each

ear

middle Pharmacology

AND

consists ear;

of

and

3

the

VESTIBULAR

components:

fluid

2

filled

SYSTEMS

air

spaces

filled

of

spaces,

the

the

inner

external

ear

and

the

ear.

Biochemistry The

external

extends

ear

to

auditory of

oval

Pathology

the

malleus,

Medical Genetics

BehavioralScience/Social Sciences

and

incus,

The

middle

the

tympanic

cause

and

ear

ear

into

lies

the

in

membrane,

and skeletal

the

to

the

in

Vibrations

of

the

ossicles

are

ear

to the

which

the

(eardrum) ossicles

is

meatus,

through

the

external

vibrate.

middle

Move

ear

transferred

(i.e.,

the

through

the

ear.

bone, oval

the

loss.

inserted

The the

ear

is

transmit

them

is inserted

membrane

and

3 ossicles ossicles

malleus

into

of

auditory

and

tympani the

chain

These

membrane

tensor

when

where

window.

energy

the

inner

membrane

tympanic

stapes

muscles,

auditory travel

of

the

minimal

external waves

vibrations

temporal to

the

the

Sound

inner

the

by

with

and

tympanic

stapes).

received

damage

the

membrane

inner

pinna

causes

and

vibrations

small

the

membrane.

eardrum

window

the

includes tympanic

canal

ment Physiology

the

the

exposed

of

to

loud

to

in the

stapedius,

connects amplify

the

oval

fluid

of

tympanic window.

contract sounds.

the

the

to

The

Two prevent

middle

ear

Microbiology cavity air

communicates pressure

with

to

ear

be

The

inner

sacs

(utricle

and

that

contain

patches

movements vestibular cells.

equalized

consists

of

of

composition ionically

like

the

hair

with

cells

duct

it

fluid

but

in

an

of

endolymph

is

important

has

extracellular

the

lies

to

the

sacs bathes

The

function

outside

allows

interconnected cochlear

airborne and

duct)

vibrations channels hairs

of

the

composition

hair

or of

the hair

of

intracellular of

the

the

the

ionic

space. for

fluid,

and

respond

inorganic

extracellular

of

ducts

and

which

membrane.

membranous)

which the

tube,

tympanic

that

endolymph,

because

a typical

the

eustachian

and

cochlear

is unique it lies

the

(semicircular

or

filled

of

(osseous

channels

Both

are

via

sides

a labyrinth

receptor

head.

labyrinth

both

and of

the

nasopharynx

on

saccule)

Endolymph

intracellular

the

an

ionic cells.

Perilymph,

endolymph

filled

labyrinth.

Spiral

Scala

ganglion

vestibuli

Scala

(perilymph)

media

(endolymph) Stria

Ampulla

vascularis

(endolymph

Semicircular

production)

duct

Tectorial

Ossicles

membrane

Semicircular canal

Basilar

membrane

Organ

of

Scala

Corti

tympani

(perilymph) VIII

nerve

(cochlear Cross BA

one

Tympanic membrane

window

tube

5 8. Structures III 5 8. Structures

the

cochlea

Apex

(High

pitch)

Ear Inner

Ear

window

III

of

Base

Round

Figure Figure

29

turn

through

BA

Eustachian Oval

section

of the

of

Inner the

(Low

pitch)

division)

CHAPTER

5

|

THE

BRAIN

STEM

Semicircular ducts

(endolymph) Semicircular canals

(perilymph)

Ampulla Utricle

(endolymph)

Malleus Saccule (endolymph) Incus Scala

vestibuli

(perilymph) Stapes Scala

media

(endolymph) Tympanic membrane

Scala

tympani

(perilymph Oval

Round

window

Endolymph

High

K+

Perilymph

Low

Na+

The

Eustachian

III

5

Figure

III

of

Endolymph

9. Distribution

5

9.

Distribution

of

and Perilymph Perilymph

in

in

Endolymph

Inner Inner

cochlear

CLINICAL

duct

respond

is

to

The

cochlear

contains

hair

cells

frequency

brane

and

the

duct

on

sound

waves of

2 and an

the

a quarter

at

highly

hair

the

It

at

the

the

the

of

of

the

rosis)

cochlea

and

membrane. the

basilar

whereas

the

Middle

cells,

oval

bony

basilar

cochlea,

apex

hair

to

within flexible,

of

contains

ossicles

displacement base

cells

ear. the

turns

maximum

cells

stimulate

inner by

elongated,

cause

hair

of

transmitted

coils

situated

maximally

receptor

vibrations

stimulation

sounds

auditory

airborne

window.

High

and

Ear Ear

System

which

cy

Vestibule

tube

Figure

Auditory

window

CORRELATE ear

diseases

result

in

because

of

provided

by

Lesions

of the

spiral

ganglion

auditory

hair

form

the

part

of

bilaterally

the

to

organ

first

superior

the

frequen

or

nuclei

and

the

Axons olivary to The

superior

central

axons

nerve.

All

the

cells

in in

the

the

binaural

lateral

lemniscus

olivary

nuclei

and

pons. input

and

the

bipolar in

the

temporal

however,

Each input

lateral from

lemniscus the

contralateral

carries

information ear

predominates.

derived

amplification

ossicles.

facial bone an

nerve (Bell

in

palsy)

increased

the

brain

may

stem

result

sensitivity

to

in loud

cells

synapse

in

nuclei

superior use

the

auditory inferior

sounds.

the

CLINICAL

olivary binaural input

colliculus from

both

CORRELATE

Presbycusis

results

at

of

the

base

the

from

a

loss

loss:

air

of

hair

cells

cochlea.

from in

the CLINICAL

midbrain.

in

loss

cochlear

cochlear The

carries to

these

axons

ventral

otoscle

hearing

innervate

from

of

junction of

nuclei receive

axons

media,

mem

low

cochlea.

peripheral

pontomedullary

nuclei sources.

The

cranial

nuclei.

auditory sound

the

whose

Corti.

eighth

enter

the

bodies

of

the

cochlear

localize

cochlear

cell

of

nerve

dorsal

the

the

part

innervate are

input

of

eighth

and

nuclei

cells

cochlear the

ventral

contains

(otitis conductive

a reduction

hyperacusis, The

a

CORRELATE

ears; Sensorineural bone

conduction

>

conduction

>

conduction

Conductive air

hearing

hearing

loss:

bone

conduction

291

PART

III

|

NEUROSCIENCE

Anatomy

Immunology The

inferior

(MGB) primary temporal Pharmacology CLINICAL

Biochemistry

CORRELATE

Lesions

Causing

Lesions

of the

Hearing

cochlear

colliculus of

the

sends

thalamus.

auditory

cortex

gyrus

association

area

Wernicke’s

area,

auditory

From

the

located

on

(Heschl’s

gyrus;

makes

connections

the

cortical

information MGB, the

the posterior

Brodmann

for

other

the

or

stem in a

at

cochlear the

part

of

hearing

cortex hearing sound

is most

(A). in

result

the

a

source

likely

of

the

comprehension

transverse

The cortex,

of

adjacent

auditory

including

language.

Cerebral

Superior temporal

lesions

bilateral

to

cortex

gyrus

auditory

suppression ability

If a patient loss

in the

parts

the

42).

BehavioralScience/Social Sciences stem, thalamus, or

decreased

hearing

of

and

the

Left

result

sensorineural

brain

(B).

41

body to

eighth

junction

All other

the in a

and

Microbiology significant

nuclei

unilateral

loss

Pathology structures

geniculate projects

inside Medical the Genetics brain

pontomedullary

profound

medial

Loss

Right Physiologynerve

the

radiation portion

areas

with

area

to auditory

in

middle

eighth

nerve,

or

cochlear

higher

levels

of

the

auditory

to

of

presents one

ear,

ear, nuclei,

and

a with

the

inner

Medial

localize

geniculate Thalamus

body

a

lesion ear, not

at

Inferior colliculus

system. Lesion

B

Midbrain Lateral lemniscus

Superior Pons

olivary nucleus

Spiral Trapezoid

ganglion

body Cochlear hair Lesion

A

Cochlear nucleus

Figure III 5 10. Auditory ⯑⯑⯑⯑⯑⯑⯑⯑⯑Auditory

⯑igure

Hearing Conductive: interrupted.

Sensorineural:

29

System System

Loss passage Causes:

damage

of

sound

obstruction,

to

waves

through

external

otosclerosis,

cochlea,

CN

otitis

VIII,

or

central

or

middle

ear

is

media

auditory

connections

cell

CHAPTER

Auditory

test:

vibration

is

louder

in

Rinne

test:

place

tuning

louder

in

normal

THE

BRAIN

STEM

is

conductive

tuning

not

heard,

loss

→

sensorineural

fork

on

vertex

ear;

if

on

then

loss

Vestibular

fork affected

of

skull.

If unilateral

unilateral

conductive

sensorineural

loss

loss →

→

vibration

is

ear.

place

vibration

mastoid

place

process

fork

in

(bone

front

no

air

conduction

after

→

air

conduction

present

of

ear

bone

conduction) (air

conduction after

until

conduction).

If

is gone;

bone

if

conduction

unilateral

unilateral

is gone.

System

Sensory

receptors

The

vestibular

and

the

The

utricle

system

saccule

in each

the

from

crest

and

hair

the

Vestibular

gravity.

the

There

detect

the

head.

The

in

and

a and

are

3 semicircular

Each

semicircular in

3

kind

in

they

plane

the

utricle

of

hair

cells

ducts

in

the

inner

contains

acceleration

an

resulting

ducts—anterior,

lie

in

the

3

poste

planes

depolarize

hair

of

hair

cells

in

the

in

positional

duct

angular

will

hyperpolarize

patch

detects

semicircular

that

any

one

containing

changes

such

head

labyrinth

each acceleration

canal.

that of

of

one

opposite

space.

cells

in

a

semicir

corresponding

duct

labyrinth.

nuclei

There

are

4 vestibular

vestibular

nuclei

receptors

nuclei receive

located

fibers

cells

receptors, ducts.

sacs, linear

oriented

movements in

2 large

to

sensory

semicircular

semicircular

movements

duct

of

the

to

relative

horizontal—are

Circular cular

are

a bony of

kinds

in

responds

head

circular

rior,

saccule

in

2

other

macula

lying

ampullary

the

the

Each

changes

contains

and

and

a macula.

in

|

Tests

Weber

ear,

5

in

terminate

in

located

in

afferents

the

from

semicircular

the

the

rostral

the

vestibular

ducts,

vestibular

nuclei

medulla

and

nerve,

utricle,

and

the

flocculonodular

and

caudal

pons.

which

The

innervates

saccule.

Primary

vestibular

lobe

of

the

cerebellum.

Vestibular

fibers

Secondary supply

vestibular the

production

of

represent remain of

our

the

efferent on

opposite

to

right,

The

These

nuclei to

that

limb

the

the

head will

turning

right

eighth

then left

the to

of

send

abducens the

left

eye.

The

IV,

and

movements. of

the

the

vestibulo

turning.

to

the

the

increases

axons

by

ocular

reflex

The and

net

effect

example,

the of

of

hairs

the

cells

rate

to

to

the

MLF oculomotor

abducens

stimulating

ocular

the

right

these

to nuclei

head

horizontally

right

right

oculomotor to

the left

is

that

to

semicircular

vestibular

the

to Most

direction

turns

in

the

the

eye

neck.

vestibulo

nerve nerve

in

head

following

the or

horizontal

eyes

and

the

movements

head

on

the

the

the

firing

right left

of

MLF in

enables

the

is based

when

using

which of

the

involved eye

reflex,

movement

stimulates

way

join

are

compensatory

ocular

its

nuclei, fibers

during

left

right

nerve

eye,

These

movement

For to

vestibular

VI. These

horizontal

move

the

vestibulo target

nucleus.

right

in

III,

a stationary

eyes

adducts

abducts look

eye

of

Head

ducts.

CN

corresponding

both

structures.

rectus

a

originating

of

conjugate

focused

and

and

nuclei

understanding

turning

the

fibers,

motor

nuclei. nucleus

right lateral both

medial rectus eyes

will

left.

29

PART

III

|

NEUROSCIENCE

Anatomy

Immunology NOTE

Vestibular

Vestibular posture,

functions:

equilibrium,

Three the

VOR

Pharmacology

System semicircular

head.

supply

are

4

lobe

of

Fibers

of

CNs

nuclei

the

angular

acceleration

respond nuclei

VIII.

nuclei

Vestibular

nodular

to

saccule

vestibular

CN

motor

respond

and

from the

movements.

to in

from III,

IV,

also

linear

the

medulla

the

and

vestibular

and

VI,

receive

and

and

deceleration

acceleration

and

pons,

nuclei

thereby send

which join

information

pull

MLF

and

conjugate to

of

receive

the

regulating

of

the

the

eye flocculo

cerebellum.

Medical Genetics Vestibulo

CLINICAL

A lesion Pathology(in

utricle

There

information

Physiology

ducts

The

gravity.

Biochemistry

(VIII)

this

Ocular

Reflex

CORRELATE

of

the

vestibular

example,

vestibular

on

nystagmus

tion

of

the

fast

correction

eyes

nuclei

the

with

toward back

to

or

nerve

H e a d

r o ta t e s to

r ig h t

left) produces a BehavioralScience/Social Sciences slow

devia

the

a

lesion

and

the

right.

N

a

a g m y s t

y e s

u s

tra c k

(fa s t c o m p o n e n t ) lso w

(

c o m

Microbiology

p o n e n t )

VOR

➍

Lateral

rectus

Both

Medial

muscle

eyes

look

left

rectus

muscle

III

VI ➊

Medial longitudinal

Endolymph stimulates

fasciculus

Cerebellar Vestibular

peduncles

ganglion VIII Vestibular nuclei ➋ Lesion (see

site

Increases nerve

Clinical

firing

rate

Correlate) ➌

Stimulates

vestibular

nuclei

Lateral tract

Figure Figure

294

III

III 5

5 11. 11.

Vestibulo Vestibulo

vestibulospinal (to

Ocular Reflex Ocular

antigravity

(VOR) Reflex

muscles)

(VOR)

flow hair

cells

CHAPTER

Caloric

Test

|

THE

of

the

BRAIN

STEM

NOTE

This

stimulates

stem

function

Normal

5

the in

horizontal

semicircular

unconscious

ducts;

can

be

used

as

a

test

of

brain

Cold

patients.

water

mimics

a

lesion

vestibular

system.

results:

•

Cold

water

•

Warm

•

COWS:

irrigation

water

of

irrigation

cold

ear of

opposite,

→

nystagmus

ear

→

warm

to

nystagmus

opposite to

side

same

side

same

First—Slow

Component

(Slow

Tracking)

R

L

Second—Fast

Component

(Nystagmus)

R

L

(Left

side

lesion)

Figure

III Figure

5

12.

III

5

Vestibular

12.

CLINICAL

Vestibular

dysfunction

Vertigo

(the

space)

may

(nuclear,

perception result

brain

severe

in

be

and

certain

stem

caused

than by

disease spaces

characterized accompanied episodes,

2–3

the

by

abrupt,

by

tinnitus

stand

are

mild

of

either

peripheral

the (end

in

brain

stem

or

the

nerve) vertigo

disease. a

lesion.

subject

The

suggests

including

central

organ,

structures.

strongly

drugs,

or

external or

Chronic

central

central

is usually vertigo

lesion.

anticonvulsants,

(i.e.,

Vertigo

aspirin,

may

alcohol,

antibiotics.

in cochlear

middle and

recurrent or

nausea/vomiting, to

and weeks)

(common in

the

vestibular

a variety and

a peripheral

involving of

System

CORRELATE

from

rotation,

lesion

pathways)

sedatives

the

inability

a

result

disease

longer

Ménière fluid

of

from

peripheral

persisting also

may

System

Vestibular

deafness a sensation

age)

may

vestibular attacks

of

(usually of

result parts

vertigo in

from of

the

lasting only

fullness/pressure

one

distention

of

labyrinth. minutes ear).

In

in

the

It

is

to

hours,

acute ear,

and

an

seen.

29

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Eye

Movement

For

the

Control

eyes

abducens

Pharmacology

Biochemistry

Horizontal

Medical Genetics

together

are

gaze and

(conjugate

gaze),

interconnected

is

PPRF

by

controlled

by

2

(paramedian

the

gaze

the

nuclei

longitudinal

centers:

pontine

oculomotor

medial

frontal

reticular

and

fasciculus

eye

field

formation,

(MLF).

(contralateral

ipsilateral

gaze).

Nystagmus Nystagmus by

Pathology

move

nuclei

gaze),

Physiology

to

Systems

a

refers

rapid

to

reflex

direction

of

although

rotatory

rhythmic

oscillations

movement

the

rapid

in reflex

or

the

of

opposite

movement

vertical

the

eyes

slowly

direction. or

nystagmus

the

fast

may

to

one

side

Nystagmus phase.

also

It

is

followed

defined

is usually

by

the

horizontal,

occur.

BehavioralScience/Social Sciences Unilateral

vestibular

nystagmus. response

to

cortex

Microbiology

in

nerve

a pathologic

the

pathology,

response

or

right

nerve

In

to

nuclei

are

vestibular

causing

eyes

and the

both

the

of

slowly

quickly

is

to

the

the

the

loss

back

act

left.

head

to

right,

result

initial correction

of as

they

is

the

not

move,

the

direction

a

vestibular

phase

is

attempt if

balance

if

in

slow

example:

This

did

the

the

this

and

may

the

phase

unopposed

look

lesions

Consider

Because

eyes

fast

because

are

nystagmus.

moving

nucleus nystagmus,

pathology.

lesioned,

to

vestibular

vestibular

nuclei

both

vestibular

or

the

left the

been

slow

of

cortex of

the

2

sides,

the

stimulated,

phase

the

by

vestibular

between have

the

made

a

pathologic

responds

the

fast

by

phase

of

the

nystagmus.

NOTE

The

To remember

the

of vestibular toward from

nystagmus

the the

direction

warm cool

mnemonic

water

COWS:

of in

water side,

the

a caloric

side

and

remember

fast

phase test

away

integrity

integrity

of in

by

performing

into

an

the

external the

by

the

•

Cool

•

Opposite

cool

•

Warm

into

inhibited the

intact)

on

eyes

the the

slowly

nystagmus

ear

cool

water the

moves

phase

external

toward the

duct

the

same

of

side,

and

cool

eyes

a the

water

quickly

ear.

ear

away

lesion;

the

opposite

from

move

are

in

quickly was of

activity

is

moves

fast

phase

the

cool

where

slowly

water

complex or

water

Introduction

duct

vestibular

induced

ear

moved

side.

horizontal

ear

is cool

external

warm

same

corrective the

to

eyes the

the

stem

or

the

eyes

the

where to

The

the

turn,

brain

warm into

causes

not

nystagmus

mimics

of

nystagmus

introduced and

did

indicator

introduces

water

head

toward

a fast

an

a vestibular

examiner

Warm

the

be

reflex,

an

semicircular

(if

can

this

which

Because

producing

water

in

test

meatus.

horizontal

cortex

reflex

To

test

direction.

introduced,

ocular

patients.

auditory

opposite

back

vestibulo

a caloric

stimulates the

the

comatose

of

the

water

was

introduced. •

Same

HORIZONTAL

The move spot

eyeballs

on

to

planes

29

the

is or

a

of the

eyes

each

eye.

presence

different

abduction

movements.

in

both

retina

possible,

GAZE

together

position

diplopia,

shifted

eye

move

and

causes

gaze,

CONJUGATE

position the and

muscles adduction

conjugate as

a The

of

gaze.

unit

so

slightest

a double

on

the

and

retina cranial

of

both

The

that

an

ocular

weakness image, of nerves eyes

muscles

image

falls in

the

indicating the

side.

involved

in are

function

the

of

most

one

image

Although horizontal

the

to

a corresponding

movements that

affected

together,

on

has gaze conjugate

important

eye been in

all

CHAPTER

Abduction is

of

by

(CN

the

III).

to

the

(CN

brain

stem, are

cerebral

when

the

the

centers

for

known

as

neurons

in

synapse

with

within

the

results

by

Lesions

in

inability in

the

neither abducting

course

fibers

eye

the

be

right.

or

the

interconnected

their

by gaze,

either

interconnections

to

MLF the

adducts exhibits

the

the

net

effect

the

pontine both

the

in eye

pontine

pons

is

the

of

eyes

to

center the

of

the

left

the

right

the

and

by axons

to

axons

that

cross

contralateral frontal

eye

and

Horizontal

nucleus

reticular

contained

sends

on

right.

abducens

also reach

a

center,

send

actually

to

stimulation gaze

is

as

activated

neurons

center

center

acts

pontine When

which

control area

gaze

paramedian

nucleus,

MLF

This

a second

center

gaze

One

8).

gaze.

gaze

pontine

right

an

on

results left.

The

bilaterally on

the

PPRF,

abducens

the

centers.

a

gaze the

left

field,

saccadic to

the

right

oculomotor

MLF.

result one

is lesioned

eye

field,

of

the

MLF

to

the must

to

conjugate

area

horizontal

The

of

adduct

gaze MLF

abduct

ventricle

are

through

right

nucleus

fourth

permit

nerve

muscle look

STEM

per

the

oculomotor

nuclei

gaze

In

the

contralateral

of

in

or ipsilateral

in The

right

to

will

the

(Brodmann

gaze.

center.

movement

the

field

for

in

activation

the

to

attempted If

bodies gaze

eye

active

BRAIN

which is

gaze,

rectus

the

that

moves,

oculomotor

eyes

and

interconnected

eye

center

eye

activation

from

nucleus

lesion

gaze

nucleus.

horizontal

2

frontal

center

frontal

and

is

head

the

be

beneath

MLF

by

medial

These

the

eyeball

horizontal

both

VI)

just

muscle,

the

THE

system.

by

the

is a

pontine

oculomotor

the

left

that

midbrain.

horizontal

cell

immediately

therefore,

when

controlled

pontine

the

is

in must

the

(CN

in

rectus of

|

Gaze

is

This

fibers

vestibular

lobe,

the

effect

midline

the

right

muscle and

nucleus the and

is

contralateral

formation.

net

lateral

innervated

the

rectus

pons

or

the

gaze

center

It

moves

frontal

The

to

the

to

nerve

the

Adduction

is

look

lateral

eye.

Horizontal

Horizontal the

right

to

by

VI).

which

eyes

abducens

MLF.

and

of

muscle,

close in

target

Control

in

the

situated

in

(CN

oculomotor left

aqueduct,

fibers

gaze

the

largely

nerve

both

the

left

adduct

III)

the

the

performed

rectus for

and

and

is

abducens

medial

nerve eye,

active

In

the

Therefore,

abducens right

eyeball

by

formed

is

each

innervated

5

attempted

internuclear

ophthalmoplegia

attempted in

an

left

eye (as gaze

gaze inability

to

abducts might (Figures

to

the

in

opposite

adduct

the

normally be

the III

5

in 13

eye

exhibits

multiple and

III

there

For

right

but

case

which

side.

is an

example, on a

a

an nystagmus.

sclerosis), 5

14),

and

the

a nystagmus.

29

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Lesion

sites

are

indicated Right

by

Pharmacology

Paramedian

Biochemistry

Cerebral

pontine

reticular

Physiology

Left

1–4.

formation

cortex

eye

(PPRF)

fields

frontal

(Area

8)

Medical Genetics

Abducens nucleus Pathology

Medial

BehavioralScience/Social Sciences

longitudinal

fasciculus

(MLF)

L

in Oculomotor nucleus

Microbiology

Right

lateral rectus

Left

muscle

medial

rectus

Abducts

Right

Adducts

eye

Left

Figure Figure

Table

III

Lesion

5

2.

III

Clinical

5

III 13.

5

13.

Voluntary

Voluntary

CN

2.

Right

PPRF

3.

Left

Horizontal

VI

Right

eye

Neither

MLF

an

frontal

eye MLF,

medial

field

can

Gaze

look

right right

ophthalmoplegia look is

oculomotor

Neither longitudinal

look

cannot (this

mus;

29

eye

eye

intact

formation

Gaze

Conjugate

cannot

Internuclear Left

Abbreviations:

Conjugate

Symptoms

Right

Left

Horizontal

eye

Correlate

Examples

1.

4.

muscle

seen

fasciculus;

to

lesion); in

eye

how

can

multiple

look PPRF,

(INO) right;

convergence

distinguish right

is an

eye

has

INO

from

nystag

sclerosis

right; paramedian

but

slow pontine

drift

to reticular

left

CHAPTER

Ask

patient

to

look

to

the

right—response

shown

below

CLINICAL

Normal

The with

nucleus

PPRF,

horizontal inability RL

may

the

gaze. to

THE

BRAIN

STEM

is coexistent

center Lesions

look

include

paralysis

|

CORRELATE

abducens the

5

to

the

for

lesion

a complete because

the

ipsilateral

result

in an side,

ipsilateral VIIth

nerve

and facial fibers

ADDUCT

ABDUCT

loop

1

over

the

CN

VI nucleus.

2

Figure Figure

Table

III

5

3.

III III

5

5 14. 14.

Normal/Abnormal

Lesion

Location

Right

Abducens

nerve,

Right

Abducens

nucleus,

Normal Normal

and and

Responses

to

Abnormal

Right

#2

Gaze

Horizontal

Conjugate

Gaze:

Part

1

(Results)

eye

Neither

cannot

eye

can

paralysis)—may complete

Gaze

Horizontal

Symptoms

#1

Horizontal

Abnormal

look

look be

right

facial

right

(abduct)

right slow

(lateral drift

gaze left

and

paralysis

29

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Ask

patient

to

look

to

the

right—response

shown

below

Normal

Pharmacology

Biochemistry

RL

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

3

4

Microbiology

Figure

Table

III

5

Lesion

4.

Figure

III 5 15. Normal 5 15. Normal

III

Normal/Abnormal

and and

Abnormal Abnormal

Horizontal Horizontal

to

Horizontal

Gaze:

Responses

Location

Left

MLF,

Symptoms

#3

Left

Internuclear

Part

Gaze

2

(Results)

eye

gence

ophthalmoplegia

Gaze

cannot

look

intact;

right

right; eye

conver

exhibits

nystagmus

Left

cerebral

cortex,

#4

Neither

eye

drift

to

lower

left; face

upper Abbreviation:

MLF,

BLOOD

SUPPLY

Vertebral

Artery

This

artery

is

transverse by

passing

the

a branch

Branches

•

of

Anterior

the

BRAIN

right:

weakness

limb

but

seen

with

and

slow right

right

weakness

STEM

subclavian upper

that

6 cervical

foramen medulla

vertebral

spinal spinal

Posterior and

the

be

magnum. and,

at

ascends

The the

through

vertebrae.

It

vertebral

caudal

the

enters arteries

border

of

foramina

the

of

posterior continue

the

up

pons,

join

two

thirds

the fossa

to

the form

artery.

cervical •

the of

the

the

look

fasciculus

THE

of of

through surface

basilar

longitudinal

TO

processes

ventral

30

medial

can may

inferior the

dorsolateral

artery

artery, cord

include:

which and

the

cerebellar part

supplies

artery of

the

ventromedial

the

ventrolateral part

(PICA), medulla

which

of

the

of

medulla

supplies

the

cerebellum

the

CHAPTER

Circle

of

5

|

THE

BRAIN

STEM

Willis

Anterior communicating

Anterior

cerebral

Internal

carotid

Middle Posterior

cerebral

communicating Superior

Posterior

cerebellar

(medial

(lateral

cerebral midbrain)

pons) Paramedian

(medial

pons)

Basilar Anterior Vertebral

inferior

(lateral

Anterior

spinal

(medial

medulla)

Posterior

inferior

(lateral

Figure

III

5

Figure

Basilar

16. 5

Arterial

16.

Supply

Arterial

of

Supply

of the

the

cerebellar

medulla)

Brain

Brain

Artery

The

basilar

medullary nates

near

arteries.

artery

is formed

junction.

It

the

rostral

of

the

•

joining

of

the

the

the

2

ventral

pons

anterior

Anterior

artery

by

vertebral

midline

dividing

inferior

arteries of

into

cerebellar

the

the

at

pons

the

and

2 posterior

arteries

ponto termi cerebral

(AICA)

and

the

cerebellar

cerebellar region

Pontine

branches,

arteries.

cerebral

artery

follows

artery,

regions artery,

of

the

course

of

the

eighth

cranial

nerve

ear

inferior

superior

rostral

which

inner

inferior and

Superior

cerebral

include:

artery, the

the

of which

which the

supplies

part

of

the

pons

and

the

cerebellum supplies

part

of

the

rostral

pons

and

the

cerebellum

which

circumferential

the

the

basilar

supplies

anterior •

of

include

Labyrinthine and

•

the along

arteries.

Branches

•

by

ascends border

Branches

paramedian

At

III

cerebellar

pons)

supply

much

of

the

pons

via

paramedian

and

vessels

end

of

the

midbrain,

Paramedian supply

the

the and

basilar

circumferential

artery

divides branches

into of

a pair the

of

posterior

posterior

midbrain.

30

PART

Anatomy

III

|

NEUROSCIENCE

Immunology BRAIN

STEM

There

are

parts Pharmacology

Biochemistry

of

nerve

the

stem

pons

(CN

if

the

lesion

to

one

or

stem

is

any

in

a

fibers

lesion

VII,

or

the

of

of

the

brain

the

or

or

cranial

deficit. in

A

Horner

for

nerve

the

unilateral

The

X,

or

(CN

be

seen

with

(corticospinal,

fibers).

Lesions

in

hypothalamic

to

is always

cranial pons

XII).

will

tracts

descending

injure

upper

deficits long

lesion

syndrome

IV), IX,

hypothalamic

except

to

nerves. or

(CN

ascending

descending tracts

uncommon

III

medulla

the or

is

cranial

(CN

upper

stem,

it

more

midbrain

descending

long

results

First,

one

to VIII),

the

contralateral

that

lesions.

involving

the

in

more

stem

spinothalamic,

to

result

brain

without

VI,

lemniscus,

brain

the

localizing

localize

a lesion

lamic

the

descending

seen

the

fibers hypotha

ipsilateral

to

the

side

of

lesion.

BehavioralScience/Social Sciences

Medial

Medullary

Medial

Medial

the

both

of the

the

with

a

the

medial

and

the

frequently

spinal

artery

lesion

of

with

the

and

in

the

Upon

5

as

medulla

both

of and

produce

protrusion,

the

the

the

medullary

cranial

nerve

tract.

of

limbs

of

Medial

corticospinal

deficit the

occlusion

17).

nerve the

a contralateral in

of

III

hemiparesis

sensations

nerve

result

hypoglossal

spastic

produce

atrophy.

the (Figure

lemniscus

vibratory

hypoglossal

tongue

most

contralateral

lesions

pressure,

Lesions

is

anterior

produce

lemniscus

touch,

of

to

lesions

half

or

presents

lesions

tract

syndrome

artery

syndrome and

Syndrome

medullary

vertebral Microbiology

brain

Second,

will

Pathology

to

will

lower

medial Medical Genetics

keys

signs

V),

Physiology

2

LESIONS

sign

Corticospinal

limbs.

proprioception

and

body.

an

tongue

ipsilateral deviates

paralysis toward

of the

side

lesion.

Medulla

Nucleus Vestibular

of

solitary

tract

nuclei Dorsal

Inferior

cerebellar

Hypoglossal

motor

nucleus

of

nucleus

peduncle

Spinal tract

B

trigeminal and

nucleus

CNs Nucleus

Inferior

X

ambiguus

Descending spino

IX,

hypo thalamic olivary

and tracts nucleus CN

XII A

Medial

Pyramid

lemniscus

Figure Figure

30

III

5 17. III

5

Medulla 17.

Medulla

Lesions Lesions

CN

X

CHAPTER

Medial

Medullary

Anterior

Syndrome

Spinal

•

Pyramid:

•

Medial

5

|

THE

BRAIN

STEM

A

Artery

contralateral

spastic

lemniscus:

paresis

contralateral

loss

of

tactile,

vibration,

conscious

of

with

proprioception •

XII

nucleus/fibers:

deviation

Lateral

Medullary

PICA,

Wallenberg

•

Inferior

•

Vestibular

•

Nucleus

the

Spinothalamic

•

Descending

in

of

from

larynx,

lesion)

pharynx,

reflex

loss

ipsilateral

(face) loss

Horner

(body)

syndrome

Syndrome

lesion

from are

the

involved

tract

contralateral

the

occlusion

the

vagus

are

of

vestibular

nerves,

or and

the

PICA.

the

the

spinothalamic

Lesions

of

nausea,

and

spinal

tract

The

cochlear

cranial

parts

nucleus

and

the

nerves

of

or

CN

tract

descending

VIII, of

V.

hypotha

Lesions

of

the

the

vagus or

will

Lesions

of

Lesions

the

of pain

the and

of

the

and

spinal

from syndrome,

the

The from

sensations

are

lost

side

and

and

be

the

deficit

in

Horner

syn

produce

nystagmus, the

fast

vertigo,

component

will

of on

the

face

droop

in

the the

corneal and

may

dysphagia

the

(difficulty

affected

diminished

or

trigeminal

nerve

ipsilateral

blink

scalp

on

a

reflex

temperature

and

produce

side,

and

the

lesion.

result

nucleus

pain the

limbs

will of

sensations

from

may

palate

the

and

the

ipsilateral

nystagmus,

medulla

nerve

face

an

may

vestibular

exiting

tract

the

sensation

lesion.

nerves

temperature

produce

pathways

is a

glossopharyngeal

medullary

sensations

there

away

sensations

contralateral

If

hoarseness.

deviate

temperature

anhidrosis).

nuclei

side

and

fibers

and

vestibular

swallowing)

uvula

ptosis,

vomiting.

from

a pain

body.

hypothalamic

miosis,

the

produce

and

descending

(i.e.,

away

lesions

limbs

of

drome

Taste

gag

pain/temperature

results

the and

tracts

paralysis of

Contralateral

syndrome

involved

Lesions

the

loss

(Wallenberg)

medullary

ipsilateral

(away

fibers.

the

just

X):

hypothalamics:

Spinothalamic

in

tongue

ataxia nystagmus

pain/temperature tract:

glossopharyngeal

be

IX,

dysphagia,

ipsilateral

limb

nausea/vomiting,

(CN

dysarthria,

V:

ipsilateral

vertigo,

ambiguus

•

long

tongue

B

nuclei:

Spinal

lamic

paralysis

side.

peduncle:

Medullary

The

lesion

Syndrome

→

nuclei

flaccid

to

Syndrome

•

Lateral or

protrusion

cerebellar

palate

Lateral

ipsilateral

on

side will

losses ipsilateral

to

the

gag

produce of

be

are

absent

half

intact.

a

the In

alternating; lesion

reflex.

loss

face.

of Touch

lateral these

but

are

lost

from

trunk.

altered

if

the

solitary

nucleus

is involved.

30

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Medial

Pontine

Medial

pontine

basilar Pharmacology

Biochemistry

nerve

and

lesion

is

the

into

tract

of

on

Lesions

of

Lesions

the

may

limb

of

lesion

be

of

of

the

be

affected

affected

if

the

abducens if

the

the

lesion

eyes

Lateral

are

forcefully

Pontine of

inferior

cerebellar

the

long

nerve

in

tract

Spinothalamic

tract

contralateral

of (i.e.,

Lesions

of

vertigo,

nausea, the

produce

Lesions pain

descending

side an

of and

limbs.

and

internal

rectus).

This

results

in

complete

weakness

of

lesion.

alteration

the

abducens may

the

side

usually

of

dry

and

taste

from

red),

nucleus be

and

the loss

(which

a lateral

anterior

of

the

includes

gaze

contralateral

result

pons) be

the

the

or

to

the

paralysis

the

in

which

lesion.

pons,

and

the

the

pons).

syndrome, The

caudal tract

anterior (rostral

cranial

pons, of

temperature

V

the nerves

the

in

trigeminal

both

lesions.

sensation

deficit

in

the

lesion.

and

pathways

Again, Lesions

sensorineural

and sensations

produce

an

ipsilateral

Horner

syn

anhidrosis).

nuclei

tract

the

medullary fibers.

and

and

fibers

and

vomiting.

spinal

lateral

nucleus

a pain

of artery

body.

and

temperature

in

in

spinal

produce

and

occlusion cerebellar

hypothalamic

vestibulocochlear

ptosis,

ipsilateral

as

descending

lesions

from

superior

same

and

vestibular

of

the

an

there

hypothalamic

miosis,

the

an

lateral

produce

the

(eye

facial

limbs

drome

from

will and

the

rostral

Lesions

to

(caudal

involved

be

the

include PPRF),

pons

artery

spinothalamic will

both

body.

produce

the

pons

include

of

side.

of

lacrimation

directed

dorsolateral

tracts

involved

facial

Syndrome

Lesions

The

the

reflex.

to the

involving

and

proprioception

and

pons

affected

side

of

limbs

of

caudal

the

also of

blink

in

hemiparesis

caudal

the

the

may loss

center

spastic

deficit the

paralysis

to

on

dorsally

gaze

the

(from

exiting

corneal

nerve

pons.

in

exiting

gaze

nerve

the

caudal

syndrome,

abducens

a contralateral

expression

tongue,

medullary

the

contralateral

eye

nerve

extends

horizontal both

the

medial

sensations

lateral

facial

of

in

the

produce

nerve

facial

the

thirds

motor

30

fibers may

nerve

but

produce

ipsilateral

facial of

of

two

the

as

to

vibratory

attempted

muscles

the

branches

exiting

lemniscus

facial

same

lesion

abducens

of

diplopia

If a

paramedian

the

medial

the

lemniscus,

lesions

the

the

lesions

and

strabismus

be

the

lemniscus pressure,

Lesions

the

of

affects

The

and

medial

localize

tract

Medial

of

will and

lesions

touch,

Microbiology

pons,

occlusion

lesion

tract. the

signs

Corticospinal

BehavioralScience/Social Sciences

from this

corticospinal

corticospinal

nerve

Pathology

results

a minimum,

deeper

long

the

At

laterally.

The Medical Genetics

syndrome

artery.

extends

Physiology

Syndrome

of

(caudal

the

fast

the

cochlear

hearing

nucleus

of on

the

phase

pons) of

the

produce

nystagmus,

nystagmus

nucleus

or

will

auditory

be

away

nerve

loss.

the

trigeminal

ipsilateral

nerve side

of

result half

the

only face.

in

a loss

CHAPTER

Lesions

of

paralysis, tion

and

of

face

facial of

nerve

taste

on jaw

and

the

the

and

from

salivation,

Lesions

the

the loss

loss

trigeminal

side

of

toward

structures

anterior

of

nerve

the

the

associated

the

the

two

corneal

pons)

weakness

lesioned

of

the

ipsilateral tongue,

|

THE

BRAIN

STEM

facial

loss

of

lacrima

reflex.

(rostral

lesion,

produce

thirds

5

of

result

in

muscles

of

complete

anesthesia

mastication,

of

and

the

deviation

of

side.

Pons

Vestibular

nuclei

Inferior

Abducent

nucleus MLF

cerebellar

peduncle

Spinal

trigeminal

nucleus

and

tract B

CN

VIII

(vestibular

nerve) CN

VII

Nucleus

CN

VII Medial

Lateral spinothalamic

tract

lemniscus

Corticospinal CN

tract

VI A

Figure Figure

Medial

Pontine

Syndrome

Paramedian

Corticospinal

•

Medial

•

Fibers

Lateral

of

Basilar

tract:

Pontine

VI:

Artery

contralateral

lemniscus: of

Pons Pons

(A)

Branches

•

III III 5 5 18.18.

spastic

contralateral medial

Syndrome

loss

of

hemiparesis tactile/position/vibration

sensation

strabismus

(B)

AICA

•

Middle

•

Vestibular

•

Facial taste

cerebellar

peduncle:

nuclei: nucleus (anterior

vertigo, and

two

reflex;

hyperacusis

•

Spinal

trigeminal

•

Spinothalamic

•

Cochlear

•

Descending

ipsilateral nausea

fibers: of

nucleus/tract:

nucleus/VIII hypothalamics:

and

ipsilateral

thirds

tract:

ataxia

facial

tongue),

nystagmus

paralysis;

lacrimation,

ipsilateral

contralateral fibers:

vomiting,

ipsilateral salivation,

pain/temperature

pain/temperature ipsilateral ipsilateral

loss and

hearing Horner

loss loss

of

corneal

(face)

(body)

loss syndrome

30

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Pontocerebellar

Angle

Pontocerebellar

angle

(schwannoma) Pharmacology

Biochemistry

Schwann the

cells

tumor

VII

vestibular

it

exerts

may

seen signs

This

is

usually

caused

is

a slow

growing

nerve

(or

pressure

expand

on

the

that

the

the

part

of

must

the

be

originates

auditory

the

the

to

neuroma

which the

compress

lesion

lesion

acoustic

commonly

to

localize

an

tumor,

lateral

anteriorly

together

indicates

less

by

caudal

fifth

brain

pons

nerve.

stem,

outside

of

but

the

from nerve).

As

where

The

cranial

the

absence

brain

CN

of

stem.

Medical Genetics

Medial

Midbrain

Medial BehavioralScience/Social Sciences

and nerve

spastic

hemiparesis

results

in

with also

the

in

a

brain

be of

The

wrinkle

any

affected.

will

be

the

from CN

occlusion

III

medial

are

lesion

tract

able

to

the

of seen

shut

the

as

eye

III,

the

the

corti

peduncle.

and

an

external

accommodation

and

produce

contralateral

cortico

bulbar

a drooping

(blink

of with

cerebral

lesions

involvement

weakness

branches along

pupil), CN

Corticospinal The

of

(dilated affecting

face

of

affected,

aspect

mydriasis

limbs.

lower

patient

in

of

ptosis, stem

both

a contralateral

mouth.

fibers

fibers result

will

results

Exiting

corticospinal

As

convergence

syndrome

artery.

lesions

strabismus.

Syndrome

(Weber)

cerebral

Third

the

(Weber)

midbrain

posterior cobulbar

Microbiology

VIII.

the

and

tract

syndrome

CN

grows,

deficits

long

Pathology

in

emerges

nerve

Physiology

of

Syndrome

of

reflex

is

fibers

the

corner

intact)

and

of

forehead.

Midbrain

Posterior for

commissure

vertical

A

Medial

geniculate

Substantia

body

Superior

colliculus

Nucleus

of

Medial

Red

tract

lemniscus

nucleus

tract

FigureFigure

Dorsal

Midbrain

Tumor

in

•

•

30

Pineal

(Parinaud)

Syndrome

CN

III

IIIIII 55

19. 19.

Midbrain Midbrain

(A)

Region

Superior

colliculus/pretectal

pupillary

abnormalities

Cerebral

aqueduct:

CN

area:

noncommunicating

paralysis

of

hydrocephalus

upward

gaze,

III

tract

B Corticobulbar

center

gaze

Spinothalamic

nigra

Corticospinal

and

conjugate

various

CHAPTER

Medial

Midbrain

Branches

(Weber)

of

•

Syndrome

5

|

THE

BRAIN

STEM

(B)

PCA

Fibers

of

pupil,

ptosis)

•

Corticospinal

•

Corticobulbar

Cortex

or

III:

ipsilateral

tract: tract:

Capsular

oculomotor

contralateral

palsy

(lateral

spastic

contralateral

strabismus,

dilated

hemiparesis

hemiparesis

of

Lesions

Brain

lower

face

stem

Lesions

Spinal

Cord

Hemisection

Dorsal columns

(DC)

Corticospinal tract

(CST)

Spinothalamic

Complete

All

anesthesia

signs

long

and

lower

contralateral

face

weakness

deficits

contralateral

tract

CN

produce

signs

tract

(SpTh)

Two

signs

ipsilateral

ipsilateral

to

below

lesion

One and

sign

contralateral

lesion

and

below

lesion

except

for

ipsilateral Horner’s syndrome

• Loss

• Spastic

of

pain

weakness • Altered

and

temperature

vibratory sense

All

sensory

face

or

system body

contralateral

lesions

from

Long

produce

tract

produces

All

give

rise

to

Long

deficits.

one

deficits.

of

corticobulbar contralateral

tract side;

findings: loss

temperature Lesion

Lesion

findings:

contralateral

No

fibers lower

is

cranial face

brain

nerve

same

weakness.

at

side

as

stem:

at

affected

and

cranial

nerve

level

of

Figure III

20.

5 20. Strategy

Strategy for

ALL

on

and separate

from

on Lesion side

III 5

(P&T)

NOT pain

signs

others.

findings.

Figure

of

CN

for the

Study

the

Study

of

is opposite

at

spinal P&T

cord

level

on

loss.

Lesions of

Lesions

30

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Parinaud

Syndrome

Parinaud

syndrome

superior Pharmacology

combined

Biochemistry

may

Physiology

usually

colliculi.

The

with show

an

bilateral

pressure.

municating

hydrocephalus.

a

result

sign

of is

a

abnormalities

or

of

tumor of

(e.g.,

accommodation

Compression

pineal

paralysis

cerebral

or

slightly

reaction)

the

compressing

upward

dilated and can

gaze,

pupils,

signs

aqueduct

the

vertical

of

which

elevated

result

in

noncom

Medical Genetics

Pathology

FORMATION

The

reticular

formation

and

integrate

the

the

regulation

lar

responses,

is

located

in

the

brain

actions

of

different

parts

muscle

and

reflex

activity

stem

of

the

and

functions

CNS.

It

to

plays

an

coordinate

important

role

BehavioralScience/Social Sciences

CLINICAL Microbiology

leus

light

intracranial

as

common

pupillary

impaired

RETICULAR

Neurons

occurs

most

CORRELATE

in degenerate

both

the

of

behavioral

Reticular raphe

in Alzheimer

and

locus disease.

coeru

The

arousal,

and

and

control

of

respiration,

cardiovascu

sleep.

Nuclei

raphe

nuclei

extending

are

from

(e.g.,

the

[5

HT])

in

mood,

the

dorsal from

a

narrow

medulla

raphe

column to

the

nucleus)

l tryptophan and

cells

the

in

the

Cells

synthesize and

aggression,

of midbrain.

midline in

serotonin

project induction

to

vast

areas

of

non–rapid

of

some

of

the

raphe

(5

hydroxytryptamine

of

the

CNS.

eye

brain

the

They

stem, nuclei

play

movement

(non

send

projections

a

role

REM)

sleep.

Cells

in

most

brain

areas

levels

of

norepinephrine

The

the

gray of

the

synthesize in are

the

in cells,

dorsal

the the

horn

gray

midbrain.

the

of in

is a

from spinal

cord.

and

cortical

REM

Opioid

projections of

norepinephrine

control

evident

(central)

aqueduct

ueductal

30

coeruleus involved

periaqueductal

cerebral

level

locus

activation

(arousal).

(paradoxic)

collection

of

receptors which

sleep.

nuclei are

descend

to Decreased

surrounding present to

modulate

on

the many pain

periaq at

the

in

The

LEARNING

OBJECTIVES

❏

Use

❏

Solve

knowledge

cerebellum,

of

of

The

cerebellum

The

cerebellar

of

the

and

The

pons.

the

lateral

flocculonodular

The

the

of

the

medulla,

between

functions it

in

performs

the

lobe

vermis multiple

muscles the

intermediate of

and

found

cerebellum

of

skeletal that

part

pons is

a midline

consists

indicates

the

is

derived

the

cerebellum

the

planning

these

tasks

from and and

by

the the

fine

comparing

an

performance.

consists

of

to

contractions;

actual

cortex

limbs, the

circuitry

ventricle

muscle an

maps maps

fourth

the

skeletal with

these

dorsal

The

intended

several

cytoarchitecture

concerning

located

aspect

tuning

cerebellar

FEATURES

metencephalon. dorsal

of

problems

GENERAL The

6#

Cerebellum

part hemisphere

is

in

vermis

involved

Vermis

and

the

the is

in

lateral folds

body.

controls of

2

parallel

The the

and

hemisphere

of

and

motor

balance

contains

arrangement proximal

controls in

hemispheres.

folia)

topographic

axial

involved

control

cerebellar (or

of

musculature

distal

musculature,

planning.

and

Intermediate

eye

movements.

hemisphere

Lateral

hemisphere

Superior vermis

Cerebellar peduncle

Anterior

lobe

Flocculonodular Posterior

lobe lobe

Inferior vermis

Figure

III Figure

6 III1. 6 1. Cerebellum Cerebellum

30

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Table

III

6

1.

Cerebellum

Region

Function

Vermis Pharmacology

Biochemistry

ate

and

intermedi

Principle

Ongoing

zones

motor

Input

Spinal

cord

execution

Hemisphere

(lateral)

Planning/coordination

Cerebral

cortex

inferior

and

olivary

nucleus Physiology

Medical Genetics Flocculonodular

lobe

Balance

and

eye

Vestibular

movements

Pathology

nuclei

(VIII)

BehavioralScience/Social Sciences Major

input

to

(restiform

the

cerebellum

body)

cerebellum

and

travels

travels

middle

in

the

in

the

cerebellar superior

inferior

cerebellar

peduncle cerebellar

peduncle

(MCP).

Major

peduncle

(ICP)

outflow

from

the

(SCP).

Microbiology Cerebellar All

Cytoarchitecture

afferent

SCP.

and

Most

outflow

efferent

afferent leaves

Table

III

6

in

2.

projections

input the

Major

the

the

cerebellum

cerebellum

to

the

fibers

the

ICP

the

and

Enter

Cerebellum

Vestibulocerebellar

ICP

Excitatory

Spinocerebellar

ICP

and

terminals

SCP

MCP

(decussate)

ICP

cells

(glutamate)

(decussate)

Excitatory terminals

ICP,

superior

cerebellar

Internally,

the

(medullary

inferior

cerebellar

peduncle;

MCP,

middle

cerebellar

on

Purkinje

cells

peduncle;

SCP,

peduncle

cerebellum

consists

of

an

outer

cortex

and

an

internal

white

matter

substance).

cortex

has

3

cell

Molecular fibers

(the

Purkinje

ing

(outer of

of

(middle

to stem.

one

of

Purkinje

of

the

the

to

deep

The

molecular is

the cells,

single

basket

cells).

layer)

inputs

A

includes

granule into

the

cortex.

projects

layer) the

extends

firing

cerebellar

brain

layer

layer All

the

layers:

axons cell

Purkinje cortex.

31

on

granule

Olivocerebellar

Abbreviations:

•

and

Function

fibers

•

or efferent

Target

pontocerebellar

The

MCP, most

Via

(Cortico)

Climbing

ICP,

MCP;

Cerebellum

Tract

Mossy

traverse

in

SCP.

Afferents

Name

of

enters

the

and

cerebellar

exits

stellate

cells,

plus

dendritic

tree

parallel of

the

layer. most

cerebellum

axon

and extensive

important are

only from nuclei

layer directed

axons

of

each or

Purkinje Purkinje

to

of

vestibular

the

cerebellar

toward

influenc cells

cell

leave

the

and nuclei

of

the

CHAPTER

•

Granule

cell

glomeruli. a granule The

cell

cell

other

6

and

3.

of

the in

stellate

only the

Cell

contains

surrounded

Golgi

cells,

excitatory

cerebellar

cells–are

Cerebellum:

Name

layer) is

axons is

neurons

basket,

III

(innermost glomerulus

and

granule

All

Table

layer Each

Golgi by

which

a

glial

synapse

neuron

within

cortex–including

cells,

granule

capsule with the Purkinje,

cells, and

granule cerebellar

Target

(Axon

cerebellar

Termination)

Function

GABA

Inhibitory*

cell

Glutamate

Excitatory

Stellate

cell

Purkinje

cell

GABA

Inhibitory

Purkinje

cell

GABA

Inhibitory

Granule

cell

GABA

Inhibitory

The

internal

are

white

the

only

matter

outflow

contains

nuclei

Transmitter

Purkinje

cells

cells.

Types

cell

*Purkinje

and

Golgi,

Granule

cell

CEREBELLUM

inhibitory.

Deep

Golgi

THE

cortex.

cell

cell

|

contains

Purkinje

Basket

6

from

the

the

deep

cerebellar

cerebellar

cortex.

nuclei.

31

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

Anterior

Paravermal

lobe

Posterior

Vermal Primary

lobe

Flocculonodular

lobe Biochemistry

Pharmacology

fissure

Anterior

Hemisphere (lateral) Posterior Physiology

Medical Genetics Dentate

Posterolateral

nucleus

fissure

Flocculus Nodulus

Pathology

BehavioralScience/Social Sciences Emboliform nucleus

Fastigial

Purkinje

cell

axons

nucleus

Globose

GC:

Golgi

cell

BC:

Basket

cell

nucleus Interposed

Microbiology

GrC:

nuclei

Granule

cel

A

Parallel

fiber Molecular

Cerebellar

+

+

+

+

layer

cortex BC

Purkinje GC Climbing fiber

(from

olivary

cell

PC GrC

–

nuclei)

+

Granule

–

+

layer

cell

layer

– Deep

+

CB nuclei

Mossy

+

fiber

cord,

(from

pontine

vestibular

spinal

nuclei,

or

nuclei)

+

B

Figure (A)

Parts

(B)

Topographic

(C)

Cytology

of

the

cerebellar arrangement

(A) Parts of the

III

cortex of

6

2.

Figure and the

III

skeletal and

arrangement

the

(C)

Two

kinds mossy

of the

lateral,

of

nuclei

the

together

by parts

by

by Purkinje

of the

Purkinje

cells

cerebellum cells

cerebellum

cortex

the

deep

cerebellar

nuclei

nuclei,

input

Both

together of

linked

interposed

excitatory

fibers.

parts

controlled

cerebellar

nucleus,

linked

by

cerebellar muscles

to

fastigial

and

deep

Cytology

medial

the

Organization nuclei

controlled

of skeletal

From

Organization

Cerebellar cerebellar

muscles

of the cerebellar cortex cerebellar cortex

(B) Topographic

Cerebellar 6 2. deep

enter

types

and

the

in

the

firing

internal

white

matter

are

nucleus.

cerebellum

influence

the

dentate

in of

deep

the

form

of

climbing

cerebellar

fibers

nuclei

by

axon

collaterals.

Climbing on

fibers

the

monosynaptic

Mossy fibers

312

originate

contralateral

side

exclusively of

excitatory

fibers provide

represent an

indirect,

the

input

the

axons more

from

medulla. to

Purkinje

from diffuse

the Climbing

inferior fibers

olivary

complex

provide

a

of

direct

nuclei

powerful

cells.

all

other

excitatory

sources input

of

cerebellar

to

Purkinje

input. cells.

Mossy

CHAPTER

All

mossy

sends

its

angle

fibers

that

cell

into

run

axons

an the

to the

input The

from

Golgi

excitatory

layer,

the

in

on

it

surface

dendrites fibers

turn

granule

where

cortical

apical mossy

cell

effect

molecular

parallel

stimulate

excitatory cells.

exert

axon

(i.e.,

of and

inhibits

the

off

the

granule at

cell,

fibers). cells.

parallel

granule

Each collaterals

parallel

Purkinje

from

the

cells.

gives

fibers which

90

THE

CEREBELLUM

degree

granule

cells

of

|

cell a

These Golgi

6

the

receive

granule

activated

it

in

the

first

place.

The

basket

fibers

of

and

stellate

granule

cells,

cells,

which

inhibit

also

Purkinje

receive

excitatory

input

from

parallel

cells.

Circuitry The

basic

directly

Purkinje lar

cerebellar from

cell

nuclei

•

circuits

climbing

axons

in

an

with

and

project

orderly

Purkinje

begin

fibers

to

Purkinje

from

and

cells

parallel

inhibit

fibers

the

deep

that of

receive

excitatory

granule

input

cells.

cerebellar

nuclei

or

the

vestibu

fashion.

cells

in

the

flocculonodular

vermis

lobe

project

to

the

lateral

vestibular

nucleus. •

Purkinje

cells

in

the

•

Purkinje

cells

in

the

interposed •

(globose

Purkinje

cells

intermediate and

in

project

the

to

fastigial

hemisphere

emboliform)

lateral

the

nuclei. primarily

project

to

the

nuclei.

cerebellar

hemisphere

project

to

the

dentate

nucleus.

Dysfunction •

Hemisphere

lesions

→

dysdiadochokinesia, •

Major

Vermal

lesions

→

truncal

symptoms: dysarthria,

intention

tremor,

nystagmus,

dysmetria,

hypotonia

ataxia

Pathway

Purkinje first

ipsilateral

scanning

cells degree

→ motor

deep cortex

cerebellar →

nucleus; pontine

dentate nuclei

→

nucleus contralateral

→

contralateral cerebellar

VL

→

cortex

31

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Precentral gyrus Upper

motor

Net

neurons

effect:

Right

side

of

controls Pharmacology

Biochemistry

on

right

the

Physiology

Cb

muscles side

of

body

Medical Genetics VL/VA (thalamus) Red Fastigial

Pathology

nucleus

(midbrain)

nucleus

BehavioralScience/Social Sciences

Superior

Cb

peduncle Interpositus nucleus

Microbiology Dentate Purkinje

nucleus

cell

axons

Lateral hemisphere

Paravermal Vermis

hemisphere

Left

Right Rubrospinal

Corticospinal

Figure

Table

III

6

4.

Cerebellar

Major

Areas

Efferents

From

the

Deep

III Figure

6

tract

tract

3. Cerebellar III 6 3. Cerebellar

Efferents Efferents

Cerebellum

Efferents

to:

Function

Cerebellar Nucleus

Vestibulocerebellum

Fastigial

Vestibular

Elicit

(flocculonodular

nucleus

nucleus

response

positional to

changes

Spinocerebellum

Interpositus

Red

Influence

LMNs

(intermediate

nucleus

of

movement

of

eyes the

and

trunk

in

head

lobe)

hemisphere)

rubrospinal

Reticular

hemispheres)

Dentate

Thalamus

nucleus

VL)

then

(VA, cortex

Influence which sequence

31

via

tracts

the to

reticulospinal adjust

posture

and and

effect

movement

formation

Pontocerebellum (lateral

nucleus

on effect

LMNs voluntary

and

precision

via

the

corticospinal

movements,

tract, especially

CHAPTER

Efferents

from

influence

all

the

deep

upper

interposed

nuclei

ventrolateral

The

VL

the

firing

leave

(VL)

Axons

through

of

the

other

and

in

Cerebellar

SCP,

the

to

the

from

the

midline,

primary

corticobulbar

cerebellar

reticular

through

axons

cross

projects

and

mainly

SCP

terminate

in

the

motor

cortex

and

influences

neurons.

nuclei

influence

formation

and

dysfunction

is

upper

vestibular

motoneurons

in

the

red

nuclei.

Lesions

hallmark

without

of

cerebellar

paralysis

expressed

or

paresis.

ipsilaterally

contralateral the

CEREBELLUM

and

CLINICAL The

THE

and

dentate

and

|

thalamus.

thalamus

deep the

the

leave

particular,

the

of

corticospinal

from

nucleus

nuclei In

nucleus

nucleus of

cerebellar

motoneurons.

6

because

motor

spinal

falling

cord.

Symptoms the

cortex,

Thus,

and

side

of

major

the

the

Lesions

that

include

the

hemisphere

Lesions

that

include

the

hemisphere

with

the

of

the

the

lesions

cerebellum fibers

cerebellum

CORRELATE

movement

cerebellar

corticospinal of

intended

with

outflow

lesions

toward

tremor

associated

then

unilateral

a

cross will

Anterior

are

projects

to

the

their

way

to

on

result

in

a patient

lesion.

of

vermis

degeneration

present

with

lesions

result

ependymomas

lesions

are

from

alcohol

gait

ataxia.

from and

usually

the

abuse

Posterior

result and

vermis

medulloblastomas present

with

are

or truncal

ataxia

involving

An

distal

intention

tremor

example,

if of

tremor

is barely

the

Dysmetria The

is

a patient

tremor

pointing)

Gaze

too

mus

often

cerebellar

lose

penny

is

performed.

For

up

a slight

a

penny,

approached.

The

a

movement

to

nose

reduced

and

at

the

proper

place.

test.

ability

supination

to

of

the

perform forearm,

at

a

asynergy

of

divide

the

words

muscles

into

responsible

syllables,

for

thereby

speech.

disrupting

the

the

oscillate

eyes

a

few

try

particularly

with

the

fast

to

times

fix

on

before

with

acute

component

a

point:

they

They

settle

cerebellar

usually

may

on

the

pass

damage.

directed

it

target. The

toward

or

A nystag

the

involved

occurs The

the

lesions

vermal result

Patients

with

dorsal

columns

their their

with

muscles

an feel

acute

cerebellar

flabby

on

insult

palpation,

that and

includes deep

the

tendon

deep reflexes

diminished.

to

Vermal

or

stop

the

pronation

by

present,

usually

Lesions

the

be

nuclei.

usually

of

pick

hemisphere.

cerebellar

gait).

the

finger

is

when

then

coarse,

Hypotonia

are

caused

occurs and

may

is

to the

as

are to

speech.

soon

nystagmus

mostly

rest.

inability

patients

dysfunction

stop

with

is

dysarthria, of

dysfunctions,

pace.

dysarthria

scanning

of

asked as

at

performing

such

is

increases

is absent

is the

difficulty

quick

melody

and or

movements,

moderately

number

movements

lesion

(adiadochokinesia)

alternating

a

voluntary

cerebellar

noticeable

has

Scanning

when a

is evident

Dysdiadochokinesia

In

seen

with

fingers

(past

patient

produce

musculature.

balance eyes

region in

difficulty

vermal by with

maintaining

damage the their

may

Romberg eyes

posture, be

sign. open;

gait,

differentiated In in

cerebellar

dorsal

or

from

balance those

lesions, column

lesions,

(an with

patients patients

ataxic a

lesion

will

sway sway

closed.

315

7#

Basal

LEARNING

❏

OBJECTIVE

Solve

problems

GENERAL The

Ganglia

concerning

general

features

of

the

basal

ganglia

FEATURES

basal

ments.

ganglia The

•

initiate

major

and

provide

components

Striatum,

which

of

consists

gross the

of

control

basal

the

over

ganglia

caudate

skeletal

muscle

move

include:

nucleus

and

the

putamen

(telen

cephalon) •

External

•

Substantia

•

Subthalamic

Together

the

back

to

pathways one

(in

the

motor

cortex

direct

use

a

population

of

and

and

the

pallidus

ventrolateral

a

known

inhibitory

to

indirect from

after

process

globus

interconnected

inputs cortex

the

(telencephalon)

diencephalon)

are

extensive

of

midbrain)

cerebral

as

by the

(in

structures

known driven

segments

nucleus

these

circuits

internal nigra

with

thalamus,

are

and

basal

ganglia

areas

of

large

relay as

in

the

VL

the

mediate

a second

the

antagonistic

Both

cortex, of

of

but

pathways.

cerebral

to

inhibits

nucleus

2 parallel

nucleus

“disinhibition”

neurons

(VL) form

pathways

and

both

project

thalamus. their

Both

effects,

population

of

whereby inhibitory

neurons.

Direct In

Basal

the

direct

neurons

in

inhibitory their

Pathway

pathway, the

excitatory

caudate

neurons

in

segment

GABA

input pathway

of

axons

thalamus

(VL). excites results

the

the

of Because

the

motor in

input

nucleus

neurotransmitter,

internal

The

Ganglia

an

the

and

striatum,

which

project

to

globus

pallidus.

internal their cortex.

increased

from

the

putamen.

and

use

inhibit

segment input The level

the

net

γ

aminobutyric

the

cortical

of

pallidus is

the

projects

to

(GABA) in

project

disinhibited,

to the

in and

as

neurons

disinhibition

excitation

striatal

activated acid

GABA

globus

thalamus

effect of

cortex disinhibition,

additional

of

to

cerebral Through

the

the

the

the

thalamic direct

promotion

of

movement.

31

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Indirect In

Basal

the

indirect

striatal Pharmacology

Biochemistry

the

additional

GABA

inhibits

Pathology

of

GABA the

use

The level

GABA

neurons

the

net

as

the

their

the

in

the

of

cortical

external

of

the

the

level

disinhibition

in

and

of

the

cortical the

the

pallidus

subthalamic of

of

projects

project

globus

pallidus.

the

excites

pallidus,

which

inhibiting

pathway of

in

and

to

nucleus

indirect

a suppression

to

globus

excitation,

to

neurons

project

globus

segment the

also

inhibitory

segment

the

internal

excitation,

cortex

These

neurotransmitter,

segment

decreases

cerebral

putamen.

disinhibition,

This effect

and

in

external

neurons

of

from

nucleus

Through

thalamus.

movement. decreased

also

nucleus.

input

caudate

GABA

axons

inhibitory

excitatory

the

which

subthalamic Medical Genetics

in

striatum,

The

Pathway

pathway,

neurons

inhibit

Physiology

Ganglia

unwanted

results

in

movement.

BehavioralScience/Social Sciences

Plane

of

section

Microbiology Corpus

Lateral

Caudate Internal

capsule:

Anterior

limb

Globus

limb

nucleus

pallidus

Thalamus

Third

Figure

31

ventricle

Putamen

Genu

Posterior

callosum

III

7 1.

Figure Horizontal

III or Axial

7Section 1.

through

Basal

Ganglia

ventricle

a

CHAPTER

7

|

BASAL

GANGLIA

NOTE Cortex Both neurons

Glutamate

Indirect

Input Globus

GABA/Enkephalin

pallidus

external

basal

ganglia in

series,

pathways and

utilize

2

GABA

a “disinhibition.”

center

Striatum

segment

NOTE

(acetylcholine) Dopamine

Dopamine

GABA/ Substance

Direct

GABA

P

acetylcholine

Substantia

nigra

pars

Subthalamic

Globus Glutamate

nucleus

pallidus

internal

Output

pars

arrows:

In

and

addition

neurons

cholinergic

to

Dopaminergic The

GABA the

cortical

excitation.

inhibits

the

Cholinergic

effect

motor

neurons (Ach)

drives

III Figure 7 2. Basal

neurons,

effects

in of

of

IIIGanglia 7 2.

the

2 other the

Ventral

anterior/

ventral

lateral nuclei

area

Pathways

excites

found

nigra

within indirect

D2

the pathway,

of

indirect

or the

through

sources or

excites

pathway

the

direct

substantia

dopamine

Dopamine

indirect

pathway.

effects

neurons

striatum.

choline

the

enhance

indirect

Supplementary

inhibitory

Figure

Dopamine

pathway; the

GABA

center

excitatory

arrows:

direct drives

nigra

thalamic

Shaded

the

reticulata

Thalamus

Clear

(ACh)

compacta

Substantia

segment

drives

chemically

significant

pathways.

in

drives

the the

direct

midbrain direct

pathway

project

to

pathway, through

the

increasing D1

receptors

and

receptors.

striatum

have

decreasing

the

opposite

cortical

effect.

Acetyl

excitation.

31

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

Pharmacology

Biochemistry

NOTE

PhysiologyAll basal ipsilateral

Pathology

ganglia

connections

are Genetics with Medical

cortex.

BehavioralScience/Social Sciences

Microbiology

Figure III 7 3. MRI of Horizontal Section Figure III 7 3. MRI of Horizontal Section through Diencephalon, Basal Ganglia, and Basal Ganglia, and Cortex

(a)

(a) Thalamus Thalamus (b)

Capsule Axons (d) Posterior Internal

(g)

Capsule Putamen

Callosum (i)

32

Wernicke’s

(b) Head of Caudate

Head

Containing Limb of

(g)

(h)

(e) Broca’s

Putamen Oral

of Caudate Nucleus (c)

Corticobulbar Internal Capsule Primary Motor

(e)

Speech

(h) Comprehension

Genu

Visual Area

Broca’s

Nucleus of Internal

Axons Primary Visual

(c) Genu of Internal Capsule Containing Corticobulbar (d) Posterior Cortex (f) Splenium

Cortex (i) Wernicke’s Motor Area

through Diencephalon, Cortex.

(f)

Speech

Limb of

Splenium of Oral Comprehension Area

of Corpus Corpus Area

Callosum

CHAPTER

7

|

BASAL

GANGLIA

A L

G

B F E

C

H D K

J

I

Figure

III 7 Figure

(A)

4. III

7Coronal 4. Coronal

(A) caudate caudate

pallidus (D) ventricle Meynert

internal globus (I)

Section Section

nucleus nucleus segment pallidus

optic (H) (K)

chiasm anterior preoptic

(B) (E)

through through

Basal Basal Ganglia

putamen (C) globus pallidus (B) putamen (C) globus

septal nuclei (F) fornix internal segment (J)

Ganglia and Other

basal nucleus commissure (L) internal hypothalamus

external segment pallidus

(G) lateral ventricle (H) (E) septal nuclei

of Meynert (K) (I) optic capsule,

and Other Subcortical

preoptic chiasm

anterior limb (L) internal

(D) globus external anterior (F)

hypothalamus (J) basal capsule,

Subcortical Structures

Structures

segment

commissure fornix (G) nucleus anterior

lateral of

limb

32

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

Table

III

7 1.

Diseases

of

the

Basal

Disease

Clinical

Parkinson

Bradykinesia,

Pharmacology disease

Ganglia

Manifestations

Notes

cogwheel

Biochemistry rolling (resting)

pill gate,

stooped

rigidity, tremor,

posture,

depression,

Loss

shuffling masked

of

pigmented

substantia face,

Lewy

dementia

bodies:

sions,

Medical Genetics

Disease

Huntington Pathology

disease

and

Clinical

Manifestations

Chorea

(multiple,

rapid,

movements),

changes,

dementia

Onset:

20−40

from

α

causes toxic

eosinophilic

inclu

synuclein

of

parkinsonism:

insults

(e.g.,

infections,

vascular,

MPTP)

Notes

movements), athetosis BehavioralScience/Social Sciences writhing

neurons

intracytoplasmic

contain

Known Physiology

dopaminergic

nigra

random

Degeneration

(slow,

causing

personality

years

of

of

ventricular

dilatation)

Autosomal

dominant

Unstable 4,

Microbiology

GABAergic

atrophy

nucleotide

which

Disease

of

for

shows

anticipation

in

caudate

repeat

codes

Treatment:

neurons

head

on

huntingtin

neostriatum,

nucleus

gene

(and

in

chromosome

protein and

antipsychotic

genomic

agents,

imprinting

benzodiazepines,

anticonvulsants

Wilson

disease

Tremor,

asterixis,

parkinsonian

(hepatolenticu

symptoms,

chorea,

lar

symptoms;

fatty

degenera

tion)

or

cirrhosis

“wing

of

Autosomal

neuropsychiatric change,

liver,

Accumulation

hepatitis,

tremor

recessive

may

of

(Descemet be

in

Motor snorting, often

liver,

transport

brain,

producing

and

eye

Kayser

Fleischer

flinging

movements

of

limbs

tics

and

vocal

sniffing, obscene

commonly

tics

(e.g.,

uncontrolled

basal

ganglia

penicillamine

(especially (a

putamen)

chelator),

zinc

acetate

absorption)

Hemorrhagic

destruction

subthalamic

nucleus

Hypertensive

syndrome

in

copper

ring)

(blocks

Tourette

in

beating”

Treatment:

Wild,

copper

membrane,

Lesions

Hemiballism

defect

Treatment:

of

contralateral

patients

Antipsychotic

agents

and

vocalizations), associated

with

OCD

and

ADHD Abbreviations: compulsive

32

ADHD, disorder

attention

deficit

hyperactivity

disorder;

MPTP,

1

methyl

4 phenyl

1,2,3,

6

tetrahydropyridine;

OCD,

obsessive

CHAPTER

CLINICAL

Lesions/diseases

of

disorders of

these

seem

altering

Lesions

of

the

is

nigra

Parkinson

patients

reduction

in

is

the

upper

tone.

pill exhibit

or

crosses

the

effects

of

Lesions

to

cortex. in

An

blood–brain

parts

of

Chorea

being

produces may

–

in

superimposed

4)

and

–

the

is

indirect

pathway.

in

muscles muscle

an

to

ballistic

that

are

their

which

inhibit

motor expressed

tremors

to

a

precursor

disturbances,

chorea

and

chase

overactive

involuntary

in

face,

seem

in

a at

Skeletal

drugs,

result

with tremor

a dopamine

hyperkinetic

and

seen

with

lesions

in

these

to

the

refers in in

to the

is

by

dominant

severe

include

inheritance

degeneration athetoid

a transient

slow,

of

jerks

(chromo

GABA

movements,

complication

neurons

progressive

in

some

children

with

involuntary

and

but

may

may

be

movements involve

that

any

observed

in

are

muscle

group.

many

diseases

most It

is

that

ganglia.

(often

predominantly

seen

with

athetosis) the

(contraction spasmodic

writer’s

like, hands

disease

basal

blepharospasm

worm and

Huntington

involving

close),

quick

disorders.

fingers

Dystonia

and

autosomal

behavioral

chorea

noticeable

the

exhibits

purposeless,

movements.

fever.

Athetosis

involve

voluntary

Symptoms

Sydenham

present

movements

characterized

striatum.

rheumatic

•

anticholinergic

underactive,

expressionless

dopa,

or

The

on

chorea

dementia,

to

L

the

increased

individuals are

dancelike

is

of

The

of an

which

known

combined

fingers.

posture,

produces

cortex

movements.

the

hypokinetic

best

neurons

because

pathway

involuntary

be

Huntington some

to

in

movements.

indirect

nucleus.

that

•

the

indirect cortex

from

subthalamic

•

the

spontaneous range

seen

barrier,

Most

the

and

The

the

the

Parkinson

on

overactive

of

during

for

acetylcholine

numerous

diseases

•

gait

rest.

or

cortex

movements,

stooped

at

direct

dopaminergic

rigidity

include

the

underactive

Because

cogwheel

Strategies

the

of

tremor

a

GANGLIA

movement

tremor

movements.

amplitude

rolling

with or

either

initiating

and

BASAL

two.

an

disease.

accelerating

gravity.

in

problems

symptoms

of

result

degeneration

velocity

limbs

the

spontaneous

Parkinson

classic

festinating

that

the

have

the

Other

center

in

affect

between

halt

present tremor

preferentially

or

by

generally involuntary

pathway slow

caused

substantia

an

|

CORRELATE

ganglia

balance

direct that

disorder

to

the

disturbances

the

basal and

disorders

pathway,

rest

the

(“dyskinesias”)

7

of

torticollis

cramp

is

truncal the

of

slow,

prolonged

oculi

of

arm

the

and

movement

Examples

orbicularis

(pulling

(contraction

a

musculature.

head hand

include

causing

the

toward

eyelids

the

muscles

on

shoulder), attempting

write).

Hemiballismus usually projectile contralateral

results seen

in

hypertensive

movement to

from

of the

involved

a lesion

of

patients. a

limb

and subthalamic

the

subthalamic

Hemiballismus is

typically

nucleus refers

observed

in

to the

a

violent

upper

limb

nucleus.

32

PART

Anatomy

III

|

NEUROSCIENCE

Immunology •

Tourette

syndrome

movements

of

involves the

facial

limbs.

It

is

and

vocal

frequently

tics

that

associated

progress with

to

jerking

explosive,

vulgar

speech.

Pharmacology

Biochemistry

•

Wilson the

disease

changes, ring

Physiology

Medical Genetics

aid

results

accumulation tremor, around in

of

the

the diagnosis.

from

an

copper

in

dystonia, outer

and cornea

abnormality the

liver

athetoid (Kayser

Untreated

patients

of and

copper

basal

movements Fleischer

succumb

cirrhosis.

Pathology

BehavioralScience/Social Sciences

Microbiology

Figure

32

III

7

5. Basal

Ganglia

Connections

may

causing

Personality

develop. ring)

usually

metabolism,

ganglia.

A be because

thin

brown

present

and of

hepatic

8#

Visual

LEARNING

OBJECTIVES

❏

Use

❏

Solve

❏

Answer

knowledge

of

problems

EYEBALL

Light

must

eyeball

pass

before

and

concerning

questions

AND

humor

Pathways

reflexes

lesions

of

the

visual

pathways

NERVE

through

the

reaching

nerve

visual

about

OPTIC

optic

the

CLINICAL

cornea,

aqueous

retina.

It

humor,

must

then

pupil,

pass

lens,

through

the

and

vitreous

layers

of

Vitamin the

A, necessary

reach

and

the

cones

photoreceptive transduce

Photopigments tional

in

rods

Thus,

rods

and

rotransmitter

Rods

and

cells

(Figure

form

the

the

optic

the

CNS.

in

cones III optic

Open

and

cones

release

the

a

to

The

into

a

in

and

these

close, the

outer

segments

membrane

photons, of

reduction

this

causes

a

This

of of

in

deficiency

synaptic Axons

from

which

enters

2).

axons

angle

contacts

glaucoma

leading IOP

light

conforma

the

transduction,

humans.

Dietary

vitamin

A causes

resulting

in

visual

night

blindness.

membranes released.

and

a

is

to

that

project

ganglion

cells

converge

at

cranial

cavity

through

the

the

a

[IOP])

is

on

the

acquire

pressure

more

neu

bipolar

myelin

sheath

chronic

progressive

from

condition

due

to

between

the

(often

decreased

(painless)

a balance

cells

to the optic

visual

with

loss

to At of

increased of

and,

formation

disc foramen.

oligodendrocytes

reabsorption

fluid

ganglion

optic

if

and

left its

CLINICAL

aqueous untreated,

drainage

The from

most

glaucoma

CORRELATE

common is

decreased

cause

of

open

drainage

angle into

the

globe.

Narrow tion

of

impairment

canal •

retinal by

rods

neurotransmitter

the

synthesized

molecular

hyperpolarization amount

of

potentials.

pigments.

neurotransmitter

8

blindness.

photons

absorb

less

cones.

be

dark.

these

humor,

and

structure

have

intraocular

the

cones

channels

cones,

nerve,

disc,

and

rods

from

molecular

sodium

and

of

energy

rods

the

causes

the

•

light in

change

alteration of

layer

for

retina cannot

to

CORRELATE

angle with

gency anhydrase

glaucoma

increased

treatment

prior inhibitors,

is IOP

an

due to and/or

surgery

acute

to

blockade often

(painful) of involves

or the

chronic

canal

(genetic) of

Schlemm.

cholinomimetics,

of

Schlemm.

condi Emer carbonic

mannitol.

32

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Ciliary

muscle

(CN

parasympathetics)

Dilator

Sclera Pharmacology

III

pupillae

(sympathetics)

Biochemistry Choroid

Constrictor (CN

Retina Physiology

pupillae

III

parasympathetics)

Medical Genetics Fovea

(in

(cones

macula)

Cornea

(V1)

only) Lens Anterior

Optic Pathology

chamber

disc

BehavioralScience/Social Sciences

Iris

Vitreous

Posterior

humor

chamber

(production

of

aqueous

humor)

Microbiology

Canal

of

(drains

Figure Figure

VISUAL

REFLEXES

Pupillary

Light

When in

light

carried

send

The

Edinger

nerve

axons

and

cranial Edinger the

ipsilateral

reflex).

32

into in

to

the

the

to

III III 8 8 1.1. The The Eyeball Eyeball

to

the

ciliary

optic

it

nerve

(direct

stimulates to

is

the

light

photoreceptors

pretectal

nuclei

on

area. both

parasympathetic

Because light reflex)

Cells

in

of

fibers cells

in

into

one

eye

and

contralateral

and the

results

pretectal

sides.

nucleus

parasympathetic

ganglion. shining

retinal

the

Westphal

preganglionic

nuclei, pupil

eye,

nucleus

rise

Westphal

an

Edinger

Westphal gives

nerve

humor)

Reflex

is directed

impulses

area

Schlemm aqueous

the results

that

pretectal in pupil

the pass area

constriction (consensual

oculomotor in

the

third

supply

both of

both

light

CHAPTER

Table

III

8

1.

Pupillary

Light

Reflex

|

VISUAL

PATHWAYS

Pathway

Afferent

Pretectal

8

area

Limb:

Light

stimulates

retinal

cells

up

CNII

ally

CN

II

→

impulses

ganglion

which

to

the

travel

projects

bilater

pretectal

nuclei

(midbrain) Edinger

The

pretectal

nucleus

projects

Westphal nucleus

bilaterally

→

Edinger

Westphal

nuclei

(CN

III)

Ciliary Ganglion

Efferent

Limb:

CN

Edinger

Westphal

nucleus

(preganglionic

Pupil

→

III

parasympathetic)

ciliary

ganglion

ganglionic

(post

parasympathetic)

pupillary

→

sphincter

muscle

→

miosis

Because

cells

bilaterally,

in

the

shining

(direct

light

reflex)

Because

this

cortically

blind

pretectal

light

in

and

the

reflex

not

still

object.

to

The

•

the

for

Edinger

supply

to

round).

image

of

This

the

object

to

Pupillary of

the

depth

of

light

reflexes

remains

field.

pineal

near

the

A

With are

look

on

the

tumors, pretectal

but

on

who

is

part results

of

and

tabes

nuclei

just

curvature

the

both

This

the

retina

rostral

common The to

the

in the

ciliary relaxes

the (become

permitting

rectus

the

the

the

muscles

allows in

the

each

contraction

pupils,

dorsalis).

to

lens,

medial

nose).

gives

is

nerve

convexity

of

optic

image

of

the

eye. the

apparatus

both

direct

with

neurosyphilis

constrictor a greater

and

accommodation–convergence pupil

the

arise

muscle its

of

of fibers

from

this

increase

from

aperture

a

accom

retina.

of

Robertson the

the

oculomotor

index

the

at

from

the

of to

occurs

components:

the

lens

the

same

that

looked

fibers

of

toward

smaller

type

via

contraction

to

lost,

3

eye

just

increases

refractive

focus

the

fibers

Contraction

the to

Argyll

This

reflex).

person

parasympathetic

the

(miosis)

iris.

of

pass

allows

from

focus

intact.

MS,

and

increases

eyes

efferent

that

muscle.

constriction

muscle

reflex

of having

parasympathetic

object

results pull

the

Preganglionic

and

a nearby

Convergence (which

the

ciliary

ligaments

more

pupil

light a

action after

consists

nucleus

the

nuclei

ipsilateral

cortex,

a reflex

carries

Postganglionic

suspensory

the

(consensual

visual

object

which

vision.

Westphal

ganglion

•

near

ganglion.

is

nearby

nerve

refers

needed

near

a

reaction,

ciliary

•

on

oculomotor

Accommodation lens

the

Westphal

in

Reaction

focus

modation–convergence

Edinger

reflex.

reaction tries

the

constriction pupil

this

Convergence

someone

distant

→

involve

have

Accommodation–convergence when

supply

eye

contralateral

does

can

Accommodation

area one

consensual reaction

lesion superior

site

is

believed

(but to

also occur

colliculi.

32

PART

Anatomy

III

|

NEUROSCIENCE

Immunology The

eye

is

predominantly

treatment

with

effective

Pharmacology

for

innervated

muscarinic

eye

by

the

antagonists

conditions

(e.g.,

by

the

Eye

parasympathetic

or

nervous

ganglionic

blocking

the

blockers

system,

can

parasympathetic

be

thus

quite

nervous

system).

Biochemistry

Table

III

8

2.

Pharmacology

of

Predominant

Receptor

Receptor

Receptor

Stimulation

Blockade

M3

Contraction

Structure Physiology

Medical Genetics Pupillary sphincter

ms.

receptor

(PANS)

→

Relaxation

miosis

→

mydriasis

(iris)

Pathology

BehavioralScience/Social Sciences

Radial

dilator

ms.

α

receptor

(SANS)

Contraction

(iris)

Ciliary

ms.

M3

receptor

Relaxation

for

body

β

→

Relaxation

accommodation

Microbiology

receptor

(SANS)

epithelium

→

miosis

Contraction

(PANS)

Ciliary

→

mydriasis

→

focus

near

vision

for

far

vision

Decreased

Secretion

of

aqueous

humor

aqueous

humor

production Abbreviations:

ms.,

ic nervous

Table

III

When

In

8

3.

3

parasympathetic

nervous

system;

SANS,

sympathet

focuses

2.

Convergence

3.

Pupillary

general,

on

Reaction

a

nearby

object

after

looking

at

a

constriction

stimuli

from

nucleus

→

(miosis) light

→

Edinger

visual

cortex

Westphal

→

nucleus

superior (1,

colliculus

3)

and

and

oculomotor

(2).

Accommodation: which

Parasympathetic

relaxes

convexity lens,

suspensory (become

round).

focusing

Both

fibers ligaments,

more

thereby

Convergence:

a

medial

This nearby

rectus

contract

allowing

the

increases object

the

ciliary

lens

to

the on

muscles

the

refractive

muscle, increase

its index

retina.

contract,

adducting

both

eyes.

Pupillary sphincter

32

distant

occur:

Accommodation

nucleus

Convergence

individual events

1.

pretectal

the

PANS,

Accommodation

an

object,

muscle;

system

constriction: muscle

Parasympathetic →

miosis.

fibers

contract

the

pupillary

of

CHAPTER

Table

III

8 4.

Clinical

pupil light

Robertson

•

(pupillary near

|

VISUAL

PATHWAYS

Correlates

Pupillary

Argyll

8

No

Abnormalities

direct

or

consensual

accommodation •

Seen

•

Lesion

light

reflex;

convergence

in

intact

neurosyphilis,

diabetes

dissociation)

Relative

afferent

(Marcus

Gunn)

pupil

of

afferent

diagnosis •

Shine not

•

limb

made light

in

constrict

Shine

with

of

pupillary

swinging

Marcus

light

reflex;

flashlight

Gunn

pupil

→

pupils

do

fully

light

in

normal

eye

→

pupils

again

in

constrict

fully •

Shine

light

immediately

apparent

dilation

stimulus seen

Horner

Adie

syndrome

pupil

•

•

carried in

by

(uncal)

• herniation

a

lesion

of

syndrome

apparent

enophthalmos,

Dilated

Ciliary

pupil to

and

eye

→

because

that

CN

often

II

is

weaker;

oculosympathetic of and

that

reacts

miosis,

sluggishly

with

ptosis,

hemianhidrosis

to

often

associated ganglion

seen

loss

of

light, in

knee

but women

jerks.

lesion

intracranial herniation dilated

the

consists

accommodation;

Increased uncal

affected

pupils

through

pathway;

and

both

MS

Caused

better

Transtentorial

of

pressure →

pupil,

CN “down

III

→

leads

compression and

out”

to →

eye,

fixed

ptosis

32

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Site

of

To

detached

lateral

body,

retina

geniculate

pretectal

nucleus

These up

Pharmacology

Biochemistry

Physiology

Medical Genetics

Pathology

axons the

will

optic

make

nerve

BehavioralScience/Social Sciences Choroi

Light

Microbiology Rod

Cone

Outer

Inner

nuclear

nuclear

layer

layer

Nuclei

Pigment

of

rods

epithelium

Ganglion

Vitreous

layer

humor

Bipolar

and

cells

cones

III Figure 8 2.

Figure

III 8 2. Retina

Retina

NOTE At Photoreceptor

Rods:

•

Achromatic

•

Low

•

Night

1

kind

the

optic

cross

and

temporal

Cones:

3

sensitive

vision,

part

motion

tract. of

retina. receives

kinds

Red,

green,

blue

lateral reflex

•

Chromatic

•

Bright

•

Object

recognition

camera,

the

light

nucleus

sensitive

NOTE

Like the

a

visual

field,

information and

the

from

At the the

330

nasal

optic

the

inverts nasal

of

contralateral

image

retina

receives

visual

receives

of

field,

information

field.

optic each

the

temporal

retina visual

chiasm, half

to

the the

temporal

nasal

project

so

from

the

lens

retina

nerve cross optic

fibers and tract.

from

do

The

the

not

the

geniculate gaze, of

contains

retina

and

inverts from

from

a

nasal

nucleus. to

the

the

pretectal

hypothalamus

at

tract

eye

information

the

optic

nerve

contralateral

cross

optic

Because

of

the

ipsilateral

information •

60% into

retina

optic light

chiasm, project

the

like

Most tract

for

for

fibers the

circadian

light

nerve nasal

in

also reflex, rhythms.

in

project and

3).

into

of

reality

each the

half

8

from the

to to

the the

retina

from

the

ipsilateral the

each

tract

each

temporal

contralateral nasal

temporal

optic

of Fibers

the

fibers part

and

fibers

nasal III

pass

camera,

hemifield,

hemifield.

area

instead

the a

the

(Figure

optic

from

temporal

Optic

and

remixed fibers

from

tract

chiasm

images a

fibers

optic

retina

retina project

superior suprachiasmatic

receives to

the

colliculi

for

CHAPTER

Visual

Field

8

|

VISUAL

PATHWAYS

Defects

Visual

Fields

Temporal

Temporal

Nasal

Defects

Ganglion

Retinae of

Left

left

eye

of

Anopia

cells retina

nasal

hemianopia

1 3 Optic 2

Bitemporal Red

heteronymous

nucleus

hemianopia

Optic

chiasm

Optic

tract

4

Crus Right

nerve

Substantia Medial

cerebri

nigra lemniscus

5

Meyer

homonymous

loop

hemianopia LGNu MGNu homonymous

MGNu Right

SC,Br

SC,Br

superior PULNuPULNu

quadrantanopia

Superior colliculus Pretectal nucleus

6

Edinger preganglionic homonymous

Oculomotor

nucleus

Edinger Westphal projecting nucleus

Westphal nucleus

centrally

Right Cuneus

inferior

Optic

quadrantanopia

(in

retrolenticular of

homonymous

radiations

internal

limb capsule)

Right

Lingual

gyrus

7 hemianopia macular

with CalSul

sparing

Figure

1,

III

2 Optic

8 3.

nerve,

Visual

Pathways

3 Chiasm,

4 Tract

NOTE Visual

information

in lateral Fi⯑u⯑e 1,

2

Optic

⯑⯑⯑⯑⯑⯑⯑⯑ Visual nerve,

3

Chiasm,

Pathways

projects 4

fibers to

the

from forming lingual

lower Meyer’s

retina loop,

courses which

gyrus.

Tract

33

PART

III

|

NEUROSCIENCE

Anatomy

Immunology CLINICAL

Some

Pharmacology

Biochemistry

Causes

of

1.

Optic

2.

Internal

3.

Pituitary

Lesions

neuritis,

central

carotid

retinal

artery

adenoma

artery

occlusion

aneurysm

(begins

Craniopharyngioma Physiology

CORRELATE

as

superior

(begins

as

quadrantanopia)

inferior

quadrantanopia)

Medical Genetics 4.

Vascular

5.

Middle

6,7. Pathology

cerebral

artery

Posterior

cerebral

collateral

blood

(MCA)

artery

occlusion

occlusion

Macula

is

spared

in

7

due

to

BehavioralScience/Social Sciences

NOTE Microbiology Lesions

to

the

visual

radiations

are

more

Most

fibers

some

also

gaze), common

than

lesions

to

the

optic

tract.

from

the

project

and

visual

the

radiations.

•

•

Visual

The

lateral

from

the

visual

from

→

body

(striate

lateral

geniculate

reflex),

the

(circadian

rhythm).

Brodmann

area

→

the

retina

(upper gyrus

upper

retina

(LGB);

colliculi

The 17)

lingual

body

superior

of

LGB the

(reflex

projects

to

occipital

lobe

the via

contralateral

visual

field)

contralateral

visual

field)

(lower

gyrus

(LGB)

gives

is a

rise

cortex,

the

lower

loop)

cuneus

and

maintain

the

from

lobe

tract

(light

cortex,

(Meyer

geniculate

cortex

laminae

(striate

information

optic

to

area nuclei

lobe

parietal

MCA.

project

pretectal

information

temporal

→

tract

the

cortex

Visual →

from

suprachiasmatic

primary optic

optic

to

the

supply

to

laminated

axons

Brodmann

a segregation

structure

that area

of

inputs

that

terminate

17)

from

of

on

the

the

receives cells

occipital

input

in

the

lobe.

ipsilateral

and

primary

The

LGB

contralateral

retina.

The

axons

from

radiations,

CLINICAL

the

striate

cuneus

and

the

calcarine

gyrus, Unilateral MS,

optic

where

there

inflammatory lesion

33

due in

is

lesions an

the

are

immune

demyelination

typically

scotoma fibers

nerve

presents to

involvement

nerve

from

the

fibers

the

macula.

The

pass

carry from

deep

the

route

from

fibers

of

reach

the

on

the

input

from

LGB the

lower the Meyer lingual

the

LGB loop gyrus

visual

the

through then

cuneus

gyrus,

medial

fibers

bank

in

the

of

the

medial

in

upper

contralateral loop

posteriorly

the

cortex.

in

lower lobe

the

visual

into course

into

superior

reach

field),

the bank

The

receives the

radiations, visual

sulcus

17)

the

visual

lateral

visual the

cuneus

the

temporal

through

the

field), gyrus.

which take

of

lingual

radiations,

contralateral to

optic

radiations.

cortex,

anteriorly and

on

visual

coursing

as

calcarine area

lies

the

the

known The

Brodmann

which of

parietal

coursing

striate

or

calcarine

(i.e.,

the

are tract.

fibers

retina

Meyer turn

cortex

cortex

the

upper

fibers (i.e.,

striate

The

through

lateral

the

geniculocalcarine

The

directly

retina

to

the

inferior

radiation.

Significantly, from

gyri. receives

visual

the

project or

(primary

lingual

lies

the

that

cortex

cortex,

which of

which nerve.

a central of

the

in

related of

with

seen

LGB radiations,

divides

the

CORRELATE

the

visual

carry a

input

circuitous lobe.

parietal

The lobe

to

CHAPTER

LESIONS

OF

Lesions

of

scotoma.

the The

THE

VISUAL

retina

that

macula

is

8

|

VISUAL

PATHWAYS

PATHWAYS

include

destruction

quite

sensitive

of to

the

intense

macula

light,

produce

trauma,

a

central

aging,

and

neuro

toxins.

Lesions

of

sensory

limb

is

shined

an

optic

nerve

of

light

into

shined

the

the

into

the

opposite

of

meningioma,

results

crossing

defect

All

lesions

past

result

in

lesion

of

This

is

a

a

the

loss

of

the

called

a

each

light

the

peripheral

nasal

retina

optic

tract

results

homonymous

but

of

a

in

both

not

a

loss

of

when

when

pituitary

the

light

light

tumor

is

or

temporal

damaged.

contralateral

from

and

The

fields

resulting

because

visual

field

hemianopia.

produce input

eye constricts

reflex).

result

are

that eye

vision

heteronymous

chiasm

in

affected reflex)

direct

often of

visual

right

the light

of

chiasm,

bitemporal

of

(consensual

a loss

from

(anopsia)

pupil

(absence

optic in

fibers

is called

eye

the

blindness The

eye

blinded

Compression

the

produce reflex.

the

defects.

contralateral

in

a

loss

hemianopia;

of in

Lesions

visual input

this

of

field.

from

the

example,

left

a

the

For

left

optic

tract

example, visual

a field.

homonymous

hemianopia.

Lesions

of

the

lateral

geniculate

mous

hemianopia)

Lesions in

field.

For

results

a

to

loss

of

loss

of

in

a

loss

Lesions

inside

of of

Lesions

the

the

of

presence

the

optic intact

the

fibers

of

in the

temporal

from

the

than

field

the

the

medial

primary

from

visual a

vision

cuneus

fibers

input

in

visual

of

radiations

with

the

(central)

fibers

of

from

input

visual

resulting

Lesions

lesion

to of

quadrantanopia).

macular

lateral

visual

inferior

radiations,

those

input

common

visual

lesions

defects

optic

(a

tract

Meyer

if all

loop,

in

upper

left

in

visual

are

in

upper

fibers

the

right

quarter

the

temporal of

visual

of

the

tract

or

involved.

quarter

the

optic homony

fibers

usually

contralateral

to

contralateral

lobe,

the

visual

radiation

field

quadrantanopia).

restricted

result

the

more

produce to

visual a

superior

are

and

similar

example,

in

left

Lesions

the

radiations body

restricted

result

(a

visual

lingula

radiation

in

lower

quarter

are

equivalent

to

homonymous

those

the

parietal of

of

the

the

hemianopsia,

lobe field

(an

visual

except

that

is spared.

gyrus

are

are sparing.

similar

inside

visual

cortex

to

terminate

in is

to

macular

to The

or

reflexes

equivalent

with

tracts

pupillary

the

contralateral

cortex

contralateral

radiation,

macular

the

lesions

of

pupillary because

the termed

lesions

restricted

to

the

parietal

sparing.

the

light fibers

pretectal

area. cortical

Meyer’s reflex of

the The

loop is spared pupillary combination

fibers in

except lesions

light

for of

reflex of

the

the leave

blindness

blindness.

33

9#

Diencephalon

LEARNING

OBJECTIVES

❏

Interpret

❏

Demonstrate

❏

Use

scenarios

on

thalamus

understanding

knowledge

of

of

hypothalamus

epithalamus

DIENCEPHALON

The

diencephalon

can

epithalamus,

and

be

the

divided

into

4 parts:

the

thalamus,

the

hypothalamus,

the

subthalamus.

Thalamus The

thalamus

auditory, control nuclei regulation

serves and

areas before of

as

the

gustatory

major

sensory

information

such

as

the

basal

they

reach

their

states

of

consciousness.

relay

that ganglia cortical

for

ultimately and

the

cerebellum

destinations.

ascending

reaches also Other

tactile, the

synapse nuclei

visual,

neocortex. in participate

Motor thalamic in

the

33

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Table

III

9

1.

Thalamus

Thalamus—serves

as

areas

(basal

states

of

ganglia,

a

major

sensory

cerebellum)

relay

also

for

information

synapse

in

the

that

ultimately

thalamus

reaches

before

the

reaching

the

neocortex.

cortex.

Motor

Other

control

nuclei

regulate

consciousness.

Pharmacology

Biochemistry Thalamic

Nuclei

Input

VPL

Output

Sensory

from

body

and

Somatosensory

cortex

from

face,

taste

Somatosensory

cortex

limbs Physiology

Medical Genetics

Internal

medullary

lamina

VPM

Sensory

VA/VL

Motor

info

from

BG,

Motor

cortices

cerebellum Pathology

BehavioralScience/Social Sciences

AN

LGB

Visual

from

optic

tract

First

MD

VA

degree

visual

degree

auditory

cortex

MGB

VL

Auditory

from

inferior

First

colliculus

VPL

cortex

Microbiology Pulvinar

VPM

AN

Mamillary

nucleus

mammillothalamic

MD

LGBMGB

(Dorsomedial

TB

IV

9

1.

Cingulate

tract)

of

nucleus).

Damaged Figure

(via

in

Involved

Wernicke

gyrus

Papez

in

Korsakoff

(part

circuit)

memory

syndrome

Diencephalon Pulvinar

Helps

integrate

somesthetic,

visual,

and

auditory

input

Midline/

Involved

in

arousal

intralaminar Abbreviations:

AN,

geniculate dial

body;

anterior VA,

nuclear

ventral

group;

anterior

BG,

nucleus;

basal VL,

ganglia; ventral

Major

CORRELATE

Thiamine

deficiency

degeneration

in

of

thalamus

and

the

the

hippocampus,

alcoholics

results

dorsomedial

geniculate VPL,

body;

MD,

mediodorsal

ventroposterolateral

nucleus;

nucleus;

VPM,

MGB,

medial

ventroposterome

of

of

the

Anterior

nuclear

Input

bodies,

vermis

CLINICAL

the

cerebellum.

pain

nuclear

syndrome

group.

aching

pain

Involvement lemniscal

part

sensitivity

to

contralateral

affects

Patients

present

in

contralateral

of

the

of VPL and

loss

of

column

increases presents vibratory

burning, or

dial

body.

Thalamic

pain

syndrome

medications.

Inputs

and

Outputs

(part

of

the

mammillary

Papez

bodies

output

is

to

the

of

limbic

circuit

via

of

the

limbic

system)

mammillothalamic

cingulate

gyrus

via

and

temporal

tract the

anterior

and limb

from of

nuclear is from

group the

cortex

(part

the

amygdala, and

prefrontal

cingulate

cortex,

gyrus.

The

most

important

lobe; nucleus

output

is to

is the

dorsome

nucleus.

Ventral

nuclear

Motor

Nuclei

group

as sense

and

is

the

system)

medial

gait anterior

nucleus

(VA):

Input

to

VA

is

from

the

globus

resistant nigra.

analgesic

the gyrus;

prefrontal

Ventral ataxia.

Their

capsule.

Input

ventral

with limbs

dorsal

pain

the

and

group

is from cingulate

Medial

CORRELATE

Thalamic

Nuclei

in

nucleus

mammillary

and

Thalamic

internal

336

lateral nucleus;

nucleus

CLINICAL

to

LGB, lateral

Output

is

to

the

premotor

and

primary

motor

cortex

pallidus,

substantia

the

CHAPTER

Ventral the

lateral

nucleus

dentate

(VL):

nucleus

(Brodmann

of

area

Sensory

Input

the

to

VL

cerebellum.

is mainly

Output

is

to

from

the

the

primary

globus

pallidus motor

9

|

DIENCEPHALON

and

cortex

4).

Nuclei

Ventral

posterolateral

nociceptive

(VPL)

information

Output

is

parietal

lobe.

Ventral

to

primary

and

(Brodmann

Medial the

Lateral of

the

2)

of

body

cortex

Midline

and

Midline

and

in

the

occipital

information

to

nuclei

from the

tract.

areas

VPM

is

primary

3,

from

the

1,

and

2)

of

the

ascending

somatosensory

cortex

from

auditory

primary

is

from

information

auditory

the

radiations

optic that

that

ascends

cortex.

tract.

Output

project

to

is

the

in

primary

the visual

Nuclei

intralaminar and

and

spinothalamic

lobe.

Intralaminar

formation,

to

visual

somatosensory and

lobe.

is is

Input or

to to

parietal

Input

conveying

lemniscus (Brodmann

is

Output

(nucleus):

VPL

Input

the

(nucleus):

geniculocalcarine

(striate)

mediating

and

to medial

Output

colliculus.

geniculate

form

1,

body

inferior

nucleus:

pathways. 3,

geniculate

from

the

cortex

(VPM) taste

areas

Input in

somatosensory

posteromedial

trigeminal

nucleus: ascends

the

receive

input

spinothalamic

cingulate

desynchronization

gyrus. of

from

tract.

the

the

brain

Intralaminar

stem nuclei

These

nuclei

appear

to

EEG

during

behavioral

be

reticular send

pain

important

in

arousal.

Hypothalamus The

hypothalamus

connections pituitary

is composed with

gland,

widespread the

autonomic

of regions system,

numerous of

nuclei the

and

nervous the

limbic

that

have

system,

afferent including

and

efferent

the

system.

33

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Table

III

9

2.

Hypothalamus,

Epithalamus,

Hypothalamus—helps

maintain

Hypothalamic

Nuclei

hypothalamic

and

Feeding

Ventromedial

Suprachiasmatic

and

body

region

in

the

autonomic,

endocrine,

and

limbic

systems

Produces

hypothalamic

pophysial

tract

region

Temperature

Preoptic

area

Dorsomedial

before

circadian

of

puberty

inhibiting

factors

inhibiting

gives

rise

to

subthalamic flinging

movements

savage

and

factor)

hyperthermia system

poikilothermia

hormones;

arrested

(inability

to

thermoregulate)

contains

sexual

sexually

development;

dimorphic

lesion

after

nucleus puberty

is one

→

behavior

habenular

nucleus of

tuberohy

system

gonotrophic →

and

impotence

→

body

encephalopathy

balance polyuria

nuclei.

The

pineal

body

secretes

melatonin

rhythm.

Subthalamus—The (contralateral

pineal

nervous

and

Wernicke

nervous

→

water

polydipsia

(prolactin

→

lesion

of

or

Stimulation

Epithalamus—Consists

lesion

input

regulates by

in

behavior

retinal

oxytocin;

and

parasympathetic

release

amenorrhea

and

dopamine

sympathetic

Regulates Lesion

produce

savage

direct

characterized

releasing

regulation;

Stimulates

receives

hormone

regulation; the

obesity,

damaged

that

Temperature

hyperphagia,

insipidus,

hippocampus;

neurons

starvation

rhythms,

diabetes

Stimulates

Posterior

→

antidiuretic →

Input BehavioralScience/Social Sciences from

Has

Anterior

lesion

Synthesizes

Arcuate

→

circadian

Lesion

Mamillary

lesion

center;

Regulates Medical Genetics

paraventricular

33

roles

Lesions

center;

Satiety

Supraoptic

Microbiology

has

Biochemistry Lateral

Pathology

homeostasis;

Functions

Pharmacology

Physiology

Subthalamus

or

involved both

in extremities)

basal

ganglia

circuitry.

Lesion

→

hemiballismus

with

a

CHAPTER

Major

Hypothalamic

Regions

or

Zones,

and

Their

CLINICAL

Nuclei

Paraventricular

terminalis

nuclei

Dorsomedial

inhibit

from

from

the

the

prolactin anterior

pituitary.

nucleus Lesions

Preoptic

projections

secretion

commissure

DIENCEPHALON

nucleus arcuate

Anterior

|

CORRELATE

Dopaminergic Lamina

9

nuclei

result

discharge)

in and

galactorrhea

(milk

amenorrhea.

Posterior A Anterior

hypothalamus M

hypothalamus

(sympathetic)

P (parasympathetic)

CLINICAL Descending

Suprachiasmatic

nucleus

Lesions

hypothalamic

occur

CORRELATE

of in

the

mammillary

korsakoff

bodies

syndrome

and

are

fibers Supraoptic

usually

nucleus Mammillary

Optic

body

Ventromedial

tract/chiasm

nucleus

deficiency

nucleus

Median

eminence

both

amnesia Anterior

pituitary

(adenohypophysis; from

oral

Rathke’s

with

associated

alcoholism. in

Arcuate

associated

Korsakoff anterograde with

thiamine with

chronic

syndrome and

results

retrograde

confabulations.

derived ectoderm

of

Posterior

pouch)

pituitary

(neurohypophysis;

ophysis;

outgrowth

of

Magnocellular in and

neurons

paraventricular supraoptic

nuclei

Parvocellular in

Releasing

and

inhibiting

hormones

CNS)

arcuate

neuron nuclei

Infundibulum Oxytocin Superior

and

vasopressin

hypophyseal

(ADH)

artery Inferior

Hypothalamic

hypophyseal

hypophyseal

portal

artery

system Anterior

pituitary

cells

Hypophyseal

Drain

III Figure 9 1.

Figure (B)

Secretory

(B)

into

III 9 Organization 1. (A) Organization (A) Secretory MechanismsMechanisms

veins

cavernous

of of thethe of of thethe

sinus

Hypothalamus Hypothalamus Adeno Adeno

(Sagittal (Sagittal Section)

Section)

and and Neuro Neuro Hypophysis Hypophysis

33

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Anterior The

region paraventricular

and

antidiuretic the Pharmacology

hormone

supraoptic

(ADH)

hypothalamus

and

nuclei

and

course

synthesize

oxytocin.

in

the

the

Axons

neuropeptides

arising

from

supraopticohypophysial

these tract,

nuclei

leave

which

carries

Biochemistry neurosecretory

granules

into

Lesions

capillaries.

characterized

by

to of

the

posterior

the

polydipsia

pituitary

supraoptic (excess

gland,

nuclei water

lead

where

to

they

diabetes

consumption)

and

are

released

insipidus,

which

polyuria

is

(excess

urination). Physiology

Medical Genetics Visual

input

from

the

suprachiasmatic 24

Pathology

hour

retina

nucleus. light

dark

by This

cycle

way

of

the

optic

information

(circadian

tract

helps

terminates set

in

certain

body

the rhythms

to

the

rhythms).

BehavioralScience/Social Sciences Paraventricular

Posterior

nucleus

nucleus

Dorsomedial

nucleus

Thalamus

Microbiology

Preoptic

area

Anterior

nucleus

Pineal Suprachiasmatic

Supraoptic

Optic

nucleus

Midbrain

chiasm

Arcuate

gland

nucleus

Cerebral

aqueduct

nucleus Pons

Infundibulum

Hypophysis

Ventromedial Mammillary

nucleus

Figure Figure

III

Tuberal

region

Cells

in

which

9

the

section.)

34

gland. of

the

The

nucleus in veins

Releasing acidophils

Hypothalamic

Hypothalamic

capillaries portal

pituitary

9 2.

The

arcuate

enter

hypophyseal

activity

III

2.

to

releasing

hormones

tuberoinfundibular reach

hormones and

Nuclei Nuclei

produce the

body

basophils

the

and

tract

secondary and

capillary

inhibitory in

the

and

through

plexus

in

factors anterior

inhibitory

pass

pituitary.

influence

factors, the the the

(See

anterior secretory

Histology

CHAPTER

The

ventromedial

Lesions

of

Posterior The

mammillary The

terminates

Anterior The

satiety

center

hypothalamus

nuclei

system.

and

is a

ventromedial

and

result

in

regulates

food

|

DIENCEPHALON

intake.

obesity.

region

limbic

are

in

anterior

located

the

the

mammillary

tract

anterior

nuclear

bodies

originates

group

of

in

the

and

the

are

part

of

mammillary

the

nuclei

thalamus.

zone

hypothalamic the

in

mammillothalamic

hypothalamic

mediates to

hypothalamus

the

9

zone

response

to

senses

dissipate

an

heat.

elevation

of

Lesions

of

body

the

temperature

anterior

and

hypothalamus

lead

hyperthermia.

Posterior The

hypothalamic posterior

hypothalamic

mediates

the

(i.e.,

posterior

zone

conservation

poikilothermy

tal

zone

of cold

senses

heat.

blooded

hypothalamus

has

a

decrease

Lesions

of

organisms).

a body

of

the

body

temperature

posterior

An

individual

temperature

that

and

hypothalamus with

varies

lead a lesion

with

the

the

lateral

of

to the

environmen

temperature.

Lateral

hypothalamic

The

lateral

mus

hypothalamic

produce

Preoptic The

zone zone

severe

is a

feeding

center;

lesions

of

hypothala

aphagia.

area preoptic

area

influence

the

pituitary.

Before

is

sensitive

to

production

of

puberty,

sex

androgens

and

hormones

through

hypothalamic

estrogens,

whereas

their

lesions

here

other

regulation

may

areas

of

arrest

the

sexual

anterior

develop

ment.

After

puberty,

hypothalamic

lesions

in

this

area

may

result

in

amenorrhea

or

impotence.

CLINICAL

EPITHALAMUS The

epithalamus

posterior

•

is

commissure

The

pineal

the

posterior

ventricle. cytes •

The of

•

the

part

of

which

body

is

the consists

a

small,

contains

synthesize pineal

circadian

of

and

gland

plays

attached

serotonin, a

role

in

subthalamus

and

region the

a

glial

stalk cells

to but

of

the

roof

•

above of

neurons.

the

third

Pinealo

cholecystokinin. development,

and

the

In

young

cause

nuclei.

situated

no

•

the

habenular

structure

and

growth,

the

regulation

males,

Pineal

tumors

of

flow

CSF

regulates

the

activity

of

the

pathway. is

reviewed

with

the

pineal

gland

through

a

and

and

in of

may

obstruction intracranial of

pretectal

tumor

pupillary

cause

increased

midbrain

and basal

may

Compression

impairment

lesions

puberty.

pressure.

syndrome,

light

pineal

precocious

pineal

rhythms.

Environmental

The

body

by

and

retinal–suprachiasmatic–pineal •

pineal

in

vascularized

pinealocytes melatonin,

located

the

highly

commissure It

diencephalon

CORRELATE

the

area

results

in

Parinaud

which

there

is

conjugate reflex

upper by

vertical

a

gaze

abnormalities

ganglia.

341

10

Cerebral

LEARNING

es,

❏

Answer

❏

Solve

problems

concerning

language

❏

Solve

problems

concerning

blood

surface

of

referred

to are

the

cerebral

as

gyri;

general

cortex

and

divided

prominent the

the

is

features

and

the

dominant

hemisphere

supply

highly

spaces

according

the

sulci

on

hemispheres.

temporal

lobes

temporal

dicular

to

the

The

central

convoluted

separating

with

the

prominent

gyri,

gyri

lateral

fissure.

The

parietal

lobes,

but

its

the

medial

are

On

separated an

artificial

parietal horizontally

lobe

by

occipital

a

into

a

The

central

lobe

extends on

aspect

lobe. the

of

sulcus

(of

Rolando)

cuneus

it

and

the called

sulci

bulges

or

sulci.

Lobes

that

the

are

eminenc of

fairly

the The and

the

constant

the

of the

cingulate

inferior

and

the

parietal

the

gyrus. occipital sulcus lingual

and

temporal

are

and The sulcus

divides

the and

hemisphere

frontal

and

perpen

frontal the

divisions

frontal

roughly

from aspect

parieto

an

situated

separates

calcarine

the

the separates

is

hemisphere, the

understanding

partially

lateral

the

to

separates

posteriorly

from

lobe.

key

Sylvius)

sulcus

Posteriorly,

occipital

superior

are

(of

posteriorly, sulcus

boundaries

cingulate

limbic from

surface fissure

further

lobes.

indistinct.

lateral

lateral

rostrally; lobes.

to

the

The

parietal

of

about

humans.

Two of

questions

FEATURES

cerebrum in

Cortex

OBJECTIVES

GENERAL

The

#

parietal cingulate separates the

occipital

lobes is part the lobe

gyrus.

34

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Central F: frontal

lobe

Postcentral gyrus

P:

parietal

gyrus

lobe Superior

Pharmacology

T: temporal

Biochemistry

lobe

Superior

parietal

lobule

occipital

F

Inferior

lobe

frontal

gyrus

P O:

sulcus

Precentral

Middle

parietal

lobule

frontal

gyrus F

Supramarginal Physiology

Inferior

gyrus

Medical Genetics

O

P

gyrus

T

T: Lateral

sulcus

Superior

temporal

Middle Pathology

frontal

BehavioralScience/Social Sciences

gyrus

temporal

Inferior

gyrus

temporal

gyrus

Pons

Cerebellum

Medulla

oblongata

Microbiology Figure III 10

Figure

III 1.

Fornix

10 1. Lateral View Lateral View

of the of the

Right Cerebral Hemisphere Right Cerebral Hemisphere

Cingulate

Precentral

gyrus

sulcus Interthalamic

Central

adhesion

sulcus

Cingulate Septum

gyrus

pellucidum Postcentral

Interventricular

Corpus

Anterior

Third

commissure

callosum

Thalamus

ventricle

Lamina

gyrus

foramen

Splenium

terminalis

Hypothalamus

Parieto

occipital

Cuneus

gyrus

Calcarine Optic

sulcus

chiasm Lingual

Tuber

sulcus

gyrus

cinereum Pineal

body

Pituitary Cerebellum Mammillary

body

Cerebral

aqueduct

Pons Fourth

Figure Figure

III

III

10

10

About (Figure structures

344

2.

Medial View 2. Medial

90%

of

the

III

10

5).

and

of the View

cortex The

together

Right of

Cerebral Hemisphere the Right Cerebral

is composed olfactory comprise

of

cortex the

Hemisphere

6 layers,

and allocortex.

ventricle

which

form

hippocampal All

the

formation of

the

neocortex

neocortex are

3 contains

layered a

CHAPTER

6

layer

cellular

different Brodmann used

arrangement,

locations. divided synonymously

but

On

the

the

cortex

with

the

basis

of into

actual these 47

functionally

structure

varies

variations areas,

in

but

specific

only cortical

considerably

the

cytoarchitecture,

a few

Brodmann

10

|

CEREBRAL

CORTEX

between

numbers

are

areas.

MCA L

ACA

M

A

E

T

D

E

I

R

A

A

L

L

Figure

III

10

3.Figure Motor

Homunculus III 10

Gyrus

(Area

3. 4)

in Precentral Homunculus Motor Gyrus Frontal

Lobe

(Area

4) inFrontal PrecentralLobe

(Coronal

(Coronal

Section)

Section)

ACA

MCA

Figure

III

10

4.

Sensory

Figure

III

Gyrus

(Areas

10

Homunculus 4. 3,

in Postcentral

Sensory 1,

2)

(Coronal

Gyrus

Homunculus Section)

Parietal

Lobe

(Areas in

(Coronal

3, 1,

2)

Parietal

Lobe

Postcentral Section)

34

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Efferent

NOTE

Afferent

cortical The

internal

granular

layer

termination

of

the

Pharmacology projections.

In

primary

is the

site

form

internal that

a

form

Physiologycorticobulbar

the

corticospinal

Molecular

of

Gennari.

gives

rise

The to

II.

axons

External

granular

layer

External

pyramidal

and Medical Genetics III.

Pathology

layer

Biochemistry cortex, these

visual Line

layer

tracts.

fibers

thalamocortical

distinct

pyramidal

cortical

of

I.

fibers

fibers

IV.

BehavioralScience/Social Sciences

V.

Internal

granular

Internal

pyramidal

layer

layer

layer

Microbiology

VI.

Multiform

layer

(layer

of

polymorphic

cells)

Figure

LANGUAGE

AND

Most

people

brain

has

right

handed in

bilaterally, sided

cortex

is III

left

handed, hand

and

a few,

language

implies

left

left

left

the

also

people

strong

the

In

are

handed

with

that

circuits.

functions

Most

although

which controlling

language

hemisphere.

and

supplied 6 and internal

of

the

the

of

Willis.

circle

whereas

the

of

is

Willis

posterior

side

vast

of

the

majority

of

predominantly

show

handed

language

preferences,

show

functions.

by

parts

communicating

arteries,

which

ganglia,

and

of

the

2

internal

10

7).

On

carotid

the

arise

carotid the

and

part

of

is situated

the

terminal and arteries.

from

the

the

just part

anterior

The of

inferior

the

basilar

the

vertebral of

mammillary carotid

of

all

and

of

arteries brain, to

optic

the

posterior the

cerebral

form

chiasm,

bodies.

and

supply

the

arteries;

arteries

anterior,

the

anastomose

front

the

cerebral

Willis,

2

artery in

internal

middle,

the

surface)

lies

below of

and

(or

circle

posterior

circle

arteries

base

arteries

anterior part

formed

posterior

The

circle

the anterior

and

cerebral cortex,

basal

diencephalon.

internal

terminates

III

The

proximal

the

by

10

branches

enters

34

right

HEMISPHERE

SUPPLY

(Figures

The

are

speech

speech

BLOOD The

the

Six Layered Neocortex 6 Layered Neocortex

DOMINANT

developed

people,

functions right

80%)

highly

organized

10 5. The III 10 5. The

THE

(about more

III Figure

carotid skull by

through dividing

artery

arises the

into

from

carotid the

anterior

the canal.

bifurcation It

and

enters middle

of the

the

common

subarachnoid

cerebral

arteries.

carotid space

and and

CHAPTER

Just

before

carotid

splitting artery

orbit

into

gives

through

the

rise

the

to

optic

middle the

and

anterior

ophthalmic

canal

and

cerebral

artery.

supplies

arteries,

The

the

eye,

the

ophthalmic the

|

CEREBRAL

CORTEX

internal

artery

including

10

enters

retina

and

the

optic

nerve.

The

middle

artery. the

cerebral

It

artery

supplies

superior

the

inch

anterior

of

cerebral

pole,

which

artery

also

basal

ganglia.

of

the

the

by

the

of

parietal part

of

the

CLINICAL

and

internal

Occlusion

the

the

middle

in

lower

and

of

results

occipital

cerebral

capsule

CORRELATE

are

by

lobe The

the

carotid

supplied

temporal

of

internal

Exceptions

are

artery.

limb

the

hemisphere.

which

cerebral

posterior

of

the

lobes,

posterior

and

branch

surface

inferior

the

genu

terminal

lateral and

and

supplied

supplies

larger

the

frontal

artery,

are

is the

bulk

the

An

spastic

face

the

the

and

middle

cerebral

paresis

of

upper

contralateral

(e.g.,

conduction)

contralateral

and

anesthesia

and

upper

limb.

Broca,

may

the

limb

face

aphasia

artery

Wernicke,

result

when

of

or

branches

of

Anterior the

left

middle

cerebral

artery

are

affected,

seen

with

cerebral and

artery

Superior parietal

lobule

left

sided

neglect

blockage

of

cerebral

artery

may

branches

of

be

the

right

a

middle

Superior frontal

to

the

right

parietal

lobe.

gyrus The

middle

cerebral

proximal

Posterior Frontal

cerebral

of

the

also

visual

supplies

the

radiations

as

pole they

artery

Middle

parts

artery

cerebral

artery

emerge of

Meyer’s

loop.

temporal rejoin

Temporal

from

nucleus

the

These

lobe the

the

lateral

thalamus fibers

before

rest

of

geniculate

and

course

course

looping

the

in into

the

posteriorly

visual

radiation

to fibers.

pole Occlusion

of

Meyer’s

the

loop

branches

fibers

in

that the

supply

temporal

lobe

Inferior temporal

results

gyrus

in

a

contralateral

superior

quadrantanopia.

Figure

III 10 Figure

6. The III 10 6.

Distributions The Distributions

of of

the Cerebral the Cerebral

Arteries:

Arteries: Part

Part

1

NOTE

1

The

The

anterior

artery.

cerebral

It

communicating

to artery,

anterior

cerebral

lobes,

which

limbs.

The

corpus

artery

Occlusion

of

the

contralateral

lower

incontinence

may

transcortical

apraxia

portion

of

hemisphere the

right

the

internal

the

the and

anterior

hemisphere.

be

and

of

of

the

left

callosum. dominant) The

results

anterior

of

this

limbs A

the

the

usually may

been

cerebral

the

the

circle

the

frontal

for

the

of

•

•

parietal lower

fifths

lateral

artery

surface and

upper

(MCA)

of

the

supplies:

frontal,

temporal

lobes

The

and

parietal

the

parietal,

Willis.

and

four and

carotid

anterior

pelvis

anterior frontal

internal

by

in

spastic

paresis

contralateral occurs

result

transcortical has

the

cerebral

of

the

posterior

internal

limb

and

genu

of

the

capsule

the

cortex

on

•

the

most

of

the

basal

ganglia

hemisphere.

artery

but

the

of

the

anesthesia

present,

of areas

supplies

1 inch aspect

of

surface cortical

of artery

part

medial

also

cerebral

limb

branch cerebral

anterior

sensory

artery

lateral

terminal

anterior

approximately

the

corpus (language

smaller

the

supplies

cerebral and of

the

opposite

motor

anterior

aspect

is the

completing

include

callosum

superior

artery

is connected

middle

only

artery

with

from

involvement

apraxia

occurs

disconnected

from also

of

lower

supplies

the

limb.

Urinary

bilateral

damage.

of

the

because the the

the motor anterior

A

anterior left cortex limb

of of

capsule.

34

PART

III

|

NEUROSCIENCE

Anatomy

Immunology NOTE

Pericallosal

The

anterior

artery

and

lobes;

Biochemistry

callosum

4/5

limb

internal

Corpus

parietal of

Posterior

callosum;

Physiologyanterior

Medical Genetics

of

Cuneus

posterior

Superior

cerebral

(PCA)

cerebral

artery

capsule

artery Pathology

artery

Splenium

of

anterior

corpus

Callosomarginal

supplies

surface

frontal

The

cerebral

(ACA)

medial Pharmacology

artery

cerebellar

pole

Orbital

artery

Anterior

artery

supplies

Frontal

cerebral

artery

BehavioralScience/Social Sciences

occipital

lobe;

temporal

lobe;

splenium;

lower

Anterior cerebellar

inferior

Inferior

temporal

Basilar

artery

artery

midbrain

Vertebral

Microbiology Posterior CLINICAL

gyrus

artery

inferior

cerebellar

artery

Internal

carotid

artery

2

2

CORRELATE The

most

aneurysm

common site

in

circle

of Willis

is

where

the

cerebral

an

III Figure 10

Figure

10 7. III The

7. Distributions The Distributions

ofof

the the

Cerebral Cerebral

Arteries: Arteries: Part

Part

anterior

communicating joins

the

artery anterior artery. Circle

Middle

cerebral

of

Willis

Anterior

communicating

Anterior

cerebral

Internal

carotid

Superior Posterior

cerebellar (lateral

communicating

pons) Posterior (medial

cerebral midbrain)

Basilar

Vertebral

Paramedian

(medial

Anterior

inferior

cerebellar

Anterior

spinal

(medial

medulla)

Posterior cerebellar

Figure

34

III

Figure 10

8.

III

10 8. Arterial

Arterial Supply

Supply

of

of the Brain the Brain

pons)

(lateral

pons)

inferior (lateral

medulla)

CHAPTER

10

|

CEREBRAL

CORTEX

Anterior Cerebral

Middle

Artery

Cerebral Artery

Internal Carotid Artery

Figure III 10

Figure

Lateral

III 9.

view

10 9. Anteroposterior Anteroposterior

View View

of Left Internal Carotid of Left Internal

- Left

Lateral

Calculation Wernicke

finger

view

Spatial

recognition

Carotid

- Right

Prosody

perception centers

area Broca

Angular

area

gyrus

Medial

viewInferior

Splenium corpus

Anterior

of callosum

cerebral

artery

Figure

view

Posterior artery

IIIFigure 10

10. III

10Territories 10. Territories

cerebral

Middle

cerebral

artery

Supplied Supplied

Cerebral Arteries byby the theCerebral

Arteries

34

PART

III

|

NEUROSCIENCE

Anatomy

Immunology The

posterior

artery.

The

internal The Pharmacology

Biochemistry

carotid posterior

Medical Genetics

Pathology

Microbiology

artery

and and

the

occipital

the

hemisphere,

Occlusion the

Sciences Table BehavioralScience/Social III 10 1. Cerebrovascular

artery

is formed

and

passes

carotid

lobe

and

the

contralateral

on

posterior the

The

the 2/3

of

field

the

the

posterior

the

circle

of

and

lateral

on

basilar the

cerebral by

the

supplies

of

the

artery.

joining

artery

surfaces

lobe

the of

Willis

cerebral

temporal

the

the

hemisphere,

medial

surface

of

nucleus.

results

macular

of

termination

join

subthalamic

artery

with

the

posterior

inferior

and

cerebral

visual

to

bifurcation

near

complete

thalamus

posterior

terminal

arises

posteriorly

circulations.

cortex

and

the

artery

arteries

temporal

of

by

communicating

communicating

vertebrobasilar occipital

Physiology

cerebral posterior

in

a

homonymous

hemianopia

of

sparing.

Disorders

Disorder

Types

key

Concepts

Cerebral

Thrombotic

Anemic/pale

Embolic

Hemorrhagic/red

infarct;

usually

atherosclerotic

complication

infarcts infarct;

plaques;

Hypotension

“Watershed”

Hypertension

Lacunar most

Hemorrhages

Epidural hematoma

middle

areas

and

infarcts;

heart

artery

deep

basal

or

most

cortical

ganglia,

atherosclerotic vulnerable

to

layers

internal

most

capsule,

emboli

affected

and

pons

affected

Almost

always

Rupture

of

Lucid

from

cerebral

traumatic middle

interval

meningeal

before

loss

artery of

after

skull

consciousness

fracture

(“talk

and

die”

syndrome)

Subdural hematoma

Subarachnoid hemorrhage

Usually Rupture

Ruptured

hemorrhage

35

of

by

Common

trauma

bridging

berry

Predisposing adult

Intracerebral

caused

veins

aneurysm factors:

polycystic

causes:

(drain

is Marfan

kidney

disease,

hypertension,

brain

most

to

dural

frequent

syndrome,

sinuses)

cause Ehlers

hypertension,

trauma,

Danlos smoking

infarction

type

4,

CHAPTER

10

|

CEREBRAL

CORTEX

Voluntary contralateral horizontal

gaze

Frontal

eye

(area

field

Premotor

Primary

cortex

cortex

(area

motor

Central

(area

4)

sulcus

(Rolando)

6)

8)

Primary

somatosensory

cortex

(areas

3,1,2)

Somatosensory association

cortex

Visual

association

cortex

Broca’s

area

(areas

Primary

44

Lateral

&

45)

visual

Angular

sulcus

Primary

(areas

41

Figure

Frontal large

42)

Figure 10 11.

III

part of

include

III Cerebral

of

the

eye

10

11. Cortex:

Cerebral Functional

Left

(Dominant)

immediately

motor

map

the

muscles

of

Cortex: Functional Areas of Left (Dominant)

22)

Areas Hemisphere

of

Hemisphere

aspect

of

the

the

the

pelvis

It

the areas

(area

(area

44

is

contains

ventrally

for the

and

to These

cortex Broca

cortex. and

related

body.

in

an

6), and

the

the 45).

precentral

orderly

skeletal

body.

most

On

of

motor

the

is

the

premotor

sulcus,

regions

hemisphere. for

4),

of

areas

primary

of

sulcus

side

area

represented are

central

speech

central

side

are

the

the

opposite

motor the

to

head

representation

Premotor

the

is considered

dorsally,

to the

(Brodmann

and

contralateral

the

proceeding

motor

8), 4

on

anterior

of

rostral

cortex

(area area

gyrus,

lateral

cortex primarily

motor

field

Traditionally,

then,

frontal

movements,

primary

frontal

the

closest

neck,

medial

lower

to

upper aspect

the

limb, of

the

lateral and

fissure;

trunk

hemisphere

on is the

limb.

cortex

Just

anterior

larly

active

premotor results movements. patient

&

area

(area

Lobe

control

the

39)

Wernicke’s

auditory

cortex

The

gyrus

(area

(Sylvius)

A

cortex

to

area

prior cortex

in

an

to

4

is

the

the

is involved

apraxia,

a

to

cortex of

in

the

disruption

Individual is unable

premotor

activation

movements

(area

the are

6).

4 neurons,

planning of

movements perform

area

of

motor

patterning intact, in

correct

it

here

is thought

activities. and

and the

Neurons so

there

particu

that

the

Damage

execution is

are

no

of weakness,

here learned

motor but

the

sequence.

35

PART

III

|

NEUROSCIENCE

Anatomy

Immunology CLINICAL

Prefrontal

CORRELATE

Lesion

of

the

Frontal

Eye

The

Field

cortex

prefrontal

cortex

a quarter The

frontal

Pharmacology cortex

eye

in

area

is

gaze.

the

intact

deviation

for

here eye

the of

eyes

motor

in

an

organizing as

inability

adjacent

the

Lesions

opposite after

such

in

in

syndrome.

toward

general

the

side

of

the

Microbiology patient paresis. opposite from

the

Lesions

conjugate slow BehavioralScience/Social Sciences

may

have

The

intact

hemisphere the

paralyzed

involved a

in

the

contralateral frontal

eye

deviates limbs.

planning

the

intellectual

premotor

cortex

lesion,

the

spastic field

in

the

eyes

Prefrontal

the

of in

is

premotor

area

human

and in

and

brain.

This

emotional

involved

represents area

is

of

behavior,

aspects

planning

CLINICAL

CORRELATE

produce

what

of

its

participation

in

In away

of

the

side

social

motor

about

involved

in much

aspects.

the

stimulus

reflex,

touching

which

allows

as the

an

or

the

of to

reflexes causes

the

hand

for

results

anything

Expressive

area

is just

anterior

to

motoneuron

innervation

of

or

dominant

hemisphere

is

to

Brodmann

areas

nonfluent,

or

words

to

written a

question

town.”

The

all

all

other

a

result

in

the

suppressed to

to

reflex

in

turn

suckle.

In

closing the

adults.

toward

of

the

the

grasp

the

fingers,

hand.

45.

such

as to

that speech.

“What

are their

hand

of

This

speech

and

reflects

a

do

for of

ability

a can

left

understand When

reply

similar be

used by

their

pressed

“Went

way

frustrated verbalize

the

together

can

might

in

and to

piecing

nothing.

they

in

a motor,

lesion

almost

writing

area

corresponds

in

this

affected

upper

produces

difficulty with

today?”

aware the

area

say

used

keenly

lack

nuclei.

Broca

also

provides

motor

to

you

that

motor

normally

did

region

Patients

is usually the

Patients of

but

write

although

tasks.

for

Damage

language

ability

nerve center

aphasia

spoken

cortex

(agraphia)

normally an

in

expressive

thoughts

orally

or

writing.

Broca and

area might

lower

face,

larger,

the

limb.

head

decreased

CORRELATE

motor

cranial

expressive

because

the

the

and

expressive

aphasias,

aphasia, in

44

produce and

in

are

the

touches

associated

and

that

is a aspect

Aphasia

Broca

on

in that

usually

also

a nipple

there common

speech,

lesions

searches

grasp

is

slow

cheek

mouth

palm

infant

Apathy

grasp

the

lobe

distracted;

Another

Prefrontal

touching

frontal

easily

perspective.

faculties,

suckling

reflex,

the

is

indifference).

intellectual

interactions.

infantile

suckling of

of

and

and

emotional

slowing

is called

concentrate

foresight,

severe a

emergence the

cannot

initiative,

(i.e.,

abulia,

area

patient

CLINICAL

35

the

the

Area

prefrontal

The lack

with is

front

of

is apathy

cortex

in cortex

the

lesion.

If motor

located

cerebral

and

the

is

entire

to

toward Medical Genetics the activity in

the

horizontal

unopposed

is

the

contralateral

field

be

of

Biochemistry This cortical

8.

movements

result the

front

Because eye

also

in

results

side.

frontal

would

a lesion, Pathology

area

center

A lesion

cortex

lies

Brodmann

make voluntary Physiology contralateral the

field

of

damage be

resulting patient

often

extends

combined

with in

might

a

drooping have

posteriorly a

into

contralateral of

a spastic

the

primary

paralysis the

corner hemiparesis

of

of the of

motor

the

mouth. the

muscles If

contralateral

cortex of

the

the

lesion upper

is

CHAPTER

Parietal

somatosensory

The

parietal

gyrus.

similar

somatotopic

and

trunk

lower

begins

just

postcentral primary

vibration, result

body,

including

Posterior

the

lateral

medially. sense, of

face

and

and

of

left

middle

an

aphasia

CORTEX

with

in

lesions

to

the

and

execution

of

somatosensory

of

what

example, to

to

get

draw

from

Another

his

deficit,

with by

sensation;

rather,

it

that

is

impaired.

usually

damage confined

usually

the

to

movements

(area

into

a

of

of

the

parietal

include in

The

the

a pattern

patient apraxia)

5

and

(also

seems

of

etc.).

areas

apraxia of

deficit

(constructional

areas

5 and is

and

in

loss

of

visual

seen

patterning

to

reflect

of

movements

may

be

or

describe

astereognosis tactile

a lack

unable,

for how

and

is

(inability or

of a

are

the

result

involved

more

common

in

the

the

information

The

body; of

in

to

proprioceptive

somatosensory

damage.

side

directed

is of

hemisphere

is probably which

7

no

astereognosia

right

contralateral

6),

goal

This

next,

There

Apraxia

cortex

then

apraxia

the

posterior

disruption

performance

integration

than

bilateral.

premotor

Wernicke

is

side

work.

touch).

Both

hemisphere

his

lesions

objects

the

diagram

to

the

result

is a

movements.

first,

a simple

recognize

somatosensory

opposite

which

often

Apraxia

organize

done

home

and

7.

and

areas,

cortex).

to

is

5 and

hemisphere

motor

how be

a limb,

CORRELATE

association

learned

should

is

upper pelvis

in

the

and

discriminative

Lesions

areas areas

dominant

premotor

understanding

(i.e.,

the

the

neck,

with

on

2 there

and

concerned

sensations

Brodmann

parietal to

head,

temperature.

somatic

cortex,

hemisphere,

are

and

scalp.

including

posterior

with

postcentral

1,

cortex

ventral

usually the

the

the 3,

motor

here,

of areas

CLINICAL

Lesions,

with areas

primary

body

and

sulcus

Brodmann

aspect

pain, all

association

cortex,

the

These

position

central

Like

of

impairment

parietal posterior

cortex.

on

the

the to

representation

in

association

to

corresponds

somatosensory

represented

cortex

posterior

gyrus

represented

limb

touch,

is

CEREBRAL

cortex

lobe

The

contains

7

|

Lobe

Primary

Just

10

after

contrast,

loss

of

actual

left

astereognosia

is

apraxia

input

to

organization

the of

motor

pattern.

area NOTE

The

inferior

part

dominant

(left)

function area lobe.

of

in 22

in

Areas

convergence

the

parietal

hemisphere,

language the

(the of

visual,

and

known

as

comprehension.

temporal

39

lobe

lobe angular auditory,

but

adjacent Wernicke

At may

gyrus)

also and

and

40

part

of

area,

are

a minimum, include (the

somatosensory

the

temporal

cortical

regions

Wernicke areas

39

supramarginal

and

lobe

area 40 gyrus)

in

in

the Any

that

consists the

parietal

are

regions

blockage

artery

of

of

that

of

the

results

Wernicke,

conduction)

syndrome

will

also

in

or result

cerebral (Broca

Gerstmann in

agraphia.

information.

35

PART

Anatomy

III

|

NEUROSCIENCE

Immunology CLINICAL

Pharmacology

Biochemistry

Receptive

Aphasia

Lesions

in

produce

a

aphasia

Medical Genetics

with

if

as

the

a result

extent

of

using

are condition.

or

the

in

the

patient

may

lesion.

“word

40

The

parietal

with

or

The

Patients

a

their

39

and

meaning.

aphasia of

area

aphasia. language

lacks

speaking

Wernicke

distress

and

Wernicke

spoken on

as

lobe

or

but

words

may

not

deficit

are

lobe

Wernicke be

able

to

is characterized

paraphasic,

often

salad.”

generally

unaware

of

their

deficit

and

show

BehavioralScience/Social Sciences Gerstmann

Syndrome

If the of

lesion

is confined

ability

but

to

ability

to

recognize

of

deficits

is to

in

is

in

frontal

a

arcuate

large

and

word

also

normal,

if an

in

and

it

is

pure

of

(inability

the

to

angular

constellation

underscores begin

loss

(loss

agnosia This

a

(agraphia),

in acalculia

finger

children

to,

of

command

poor the

the

Transcortical

to

deficit

role

count,

of

add,

they

fully

visual

are

repeat

This an

with

this

and

frustrated

Broca

in

are

many

an

an

infarct

area the

conduction paraphrases

comprehension or

to

execute

of

send

a

verbal 100”) disconnect

information

aphasia,

inability

are

at

example

expressive their

a

beginning

is

by

(or

words

inability

an

with

results there

backwards

represents

40

language

cannot “Count

As

and

fasciculus

but

naming.

another.

and

and

as

39,

bundle

fluent,

patient

object

deficit

area

that

the

fiber

is

verbal

(such

22,

longitudinal this

output

Both

asked

which

areas

superior

affecting

verbal

examiner

cortical

aware

the

lesion

demonstrates

one

these

to

patients

execute

a verbal

understand.

Apraxia

Lesions

to

the

may

corpus

result

transcortical

callosum

in

patient

left

hemisphere,

the

right

As

cannot the

primary is area motor

type in

execute

the

in

cortex

the

cortex

to left

is

so

apraxia, to

hemisphere

move in

the

command to

the

corpus

to

is

the the

anterior

cerebral

no

left

as

arm.

communicate callosum.

the

weakness, They

area

Wernicke cannot

move

a

motor

Wernicke the

a command is able using

the

known

there

disconnects

that

of

syndrome

perceived

lesion

execute

without

of

a command

callosal

able

by disconnect

cases

which

motor still

of

other

command, but

patient

caused

another

apraxia.

understand

primary

write

disorientation.

connecting as

pauses.

but

syndrome

Wernicke

A

finding

also

The

to

result

agraphia

problems),

how

the

symptoms:

syndrome

bundle known

patient,

by

the

and with

unique

right–left

39),

fingers.

fiber

this

commands

but

(alexia)

other

of

(area

Alexia

arithmetic and

integration

lobe,

In

artery

3

Gerstmann

fasciculus).

aphasia.

from

language

simple

their

gyrus

Aphasia

There

and

angular

understood.

with

fingers),

the

using

the

be

seen

perform

area

Conduction

are

often

constitutes

subtract

the

may

one’s

cortical

just written

language

lesions

the

to

comprehend

spoken

gyrus

35

temporal

verbalization

Patients

Microbiology

the

depending

fluent

no

in

receptive, comprehend

(alexia)

by

misusing

Pathology

22

cannot

read Physiology

area fluent,

CORRELATE

of area

be right with

the from

executed. arm

because the

left

CHAPTER

10

|

CEREBRAL

CORTEX

Asomatognosia

The

integration

of

formation

of

the

space.

Widespread

parietal

lobe

the

body,

affected

(left) deny

draw side,

face

ignoring

belongs

those

to

vision.

them

Patients

Occipital occipital

lobe

contains

primary

Visual

visual

Area

is

cortex

17,

the

also

they

left.

deny

draw

their

is

deny

deficit,

an

is

intact,

or

wash

they

can

so

true

them If

numbers

that

the

arm into

the

see, bisect

asked

on

left

brought

of

the

to

center.

the

passively

half

undress,

Asking

of only

may

limb

field.

in

right

sensation

deficits,

right

position

contralateral

dress,

visual the

will

Patients

affected

also

essential

for

visual

the

and

is divided

referred

occipital

from

lobe

the

reception

visual

can

be

The

retinal

to

the or

right

leg

their

field

of

anosognosia.

and

recognition

association

the

produce

a

scotoma

(and

spared

because

arteries.

The

posterior

of

visual

stimuli

cortex.

occipital loss

blood

of

result

macular in

Visual

association

cortex

Anterior

to

the

association occipital

lobe

regions

and

receive

from

both

in

fibers

form

processed

separately. system. relays of

primary

This through

the from

the

color,

visual

stream”

are

the

to

color

the

originates of

Blob

zones

the

is mainly lateral

project

are

of

in

the

the

the

entire

lobes.

These

visual cortex,

by

and

input informa are

the

central

inferior

intact.

visual

information

processed

in

produce lesions

temporal

spatial

is

most

cortex

complex

the

fovea

blockage may

areas

geniculate, to

the a

reflexes

association

and

will

cerebral

throughout

integrate

information

layers

middle

area

visual

and

of the

or

this

extensive

visual

depth

17

visual

a branch

in head

pupillary

parietal and

motion,

“cone

cortex.

retina

the

Bilateral but

area

the

containing and

is distributed

of

of

retina

supply

see,

orderly

homonymous

posterior

that

bundle

Gennari.

of of

infarct

of

is

thick

of

an

is represented

fields.

cortex

the

the

back

cortex

striate

and

the

cannot

an

the

artery

parts

Form

of

cortex

versus

by

macula to

striate

posterior

separate visual

the

a contralateral

both

the

patient

or

From

and

from

association

hemispheres.

about

blob

visual

in

a

part

portion

of

input

line in

19).

portion

in the

discrete

corresponding

macula

Blows

gathered

a

and

thalamic

called

to

18

medial

is represented

caused

cerebral of

the

Visual

the

serving lobe.

middle

primary

cortex.

the

the

major

are

brain,

field)

results

supply

representation blindness;

of

fibers

(areas

on

Its

damage

usually

area

the

cortical

17

area

occipital of

in

area

a dual

branches

visual

spot)

lies

sulcus.

gross

that

extrastriate

cortex,

input the

such

sparing, The

the

the

inside

and

calcarine

of

17,

17)

visual

the

Some

a blind

cortical

of

(area

surface

artery.

actual

part

of

area

macular

of

primary

side

therefore

lesion

cerebral

the

cut

of (i.e.,

with

posterior

the

surface

unilateral

hemianopsia

striate

nucleus.

on

surface on

A

as

either

geniculate

visible

manner

field.

into

to on

lateral

that

zones

to

the

field

its

the

cortex

The

retina,

the the

left

of

to

and

for

nondominant

somatic

visual

the

body the

neglect

fail

well

in

important

Lobe

and

lar

on

may

The

tion

in point

memory,

when

no

is

the

40

may

have

things a

from

and

will

of

and or

body

produces

of

39,

Although

their

existence

clock

7,

unawareness

Patients

line

a

of

side.

the

in

information

awareness

areas

asomatognosia.

half

a horizontal

and

in

result as

somatosensory

image”

lesions

known ignore

and

“body

may

patients

but

visual

parvocellu part

of

projects part

of

the to

blob

the

35

PART

Anatomy

III

|

NEUROSCIENCE

Immunology temporal

lobe

complete

loss

thing

Pharmacology

in

an

Motion

and

of

and

21. in

Unilateral the

lesions

result

in

hemifields.

these

recognize

here

contralateral

Additionally, to

Medical Genetics

18

depth

are

the

peripheral

geniculate,

patients

achromatopsia,

Patients

may

also

see

present

a

every

with

prosop

faces.

processed

by part

and

areas

and

color

project

to

through

Lesions

here

result

vision,

and

reading

are

the

of

projects

19.

magnocellular

the

retina,

thick middle

in

a deficit

to

a visual

parts

of

agnosia.

(including show

would

describe

temporal

a

temporal

either

lobe

to

perceiving

visual the

parietal

visual

of

The

the

them

to

voice

of

as

Alexia

Without

lobe

motion;

in

visual

can

all

and, they

syndrome

in

the

bar.

of

name

patient

can

For

patterns

example, and

areas

20

adjacent

specific

and

patient

21

of

occipital

The

to

On

recognize is

an

hearing

identify

the

lobe

deficiency

identities.

immediately

you

the

inability

objects. and

produces

visual

glasses,

in of

faces

stream

deficit.

Lesions

a

and

that

lesions

encompassing

of

information

from

comprehension

a

the

right

the

but

do

color is

the

anomia

the person.

to

only

an the

of

in not

right the

left

understand

or

part

of

corpus

hemisphere. what

with

callosum cortex

the

has

the

been

occipital

lobe

left

occipital

macular

words

mean.

sparing. visual

reaching can

seen.

posterior

the

Patients

the

with

prevents from

to

lobe.)

left

of

colors).

available

parietal

Involvement

occipital

name

to

disconnect

not

the

is

unable

write—occurs

of

anterior

a

what

dominant

hemianopsia the

is

express

read

to of

lobe

infarction

callosum.

homonymous

the

damage are

(inability

occipital

in

lobe patients

example

or

gyrus

not

intact

The

understand

corpus

occipital

another the

is usually

splenium the

centers field

either

angular

affects of

a

This from

syndrome that

Involvement

have

write.

with

blindness).

agraphia—inability the

splenium in

to

with

the

results

to

lobes

alexia

artery

word

information

frontal

of

associated

pure often

able

which

(Recall

cause

deficit (or

curiously,

or

visual

read

order”

are

parietal

cortex

person,

field

destruction

between

agraphia

However,

the

a

cone

recognize

a pair

prosopagnosia,

usually

“higher

cerebral

and

associations

without at

a visual agnosia

some in

to

language see

words

in

areas

fields,

Agraphia

principal

alexia

result

same

of

include

the

inability

object

2 circles

also

form

the

an

involving

the

absence

with

that

patient

inability

The

in

is

the

cortex.

CORRELATE

lobes

agnosia

hemisphere

faces.

left

primary

stream” layers

unaffected.

temporal

patient

lobe

read

the

Visual

objects)

might

but

of

“rod

separate

Agnosia

Damage

A

This

through

zones

in

CLINICAL

in

system.

relays

stripe

the

BehavioralScience/Social Sciences

Visual

35

gray.

inability

in

Striped

Microbiology

20 vision

Biochemistry

lateral

Pathology

areas color

shades

agnosia,

originates

Physiology

in of

the

CHAPTER

Temporal

auditory its

and

Auditory

Heschl,

which

Much

of

42

and

Patients

the

projects

widely

unilateral

field.

Area

and

have 22

lesions

gyrus

both

to

is

on deep

the

a component

of

produce

a

2

within

and

occipital

in

localizing

CORTEX

Wernicke

auditory gyri

the

sulcus.

lateral

by

area

from

22

of

(auditory

both

areas

41

cortices.

auditory

Wernicke

primary

transverse

projection

primary

difficulty

the

the

is occupied

considerable

parietal

contains

located

temporal

some

here

lobe

is

lobe

a

damage but

42)

temporal

receives to

temporal

and

superior which

hemisphere,

the 41

superior

remaining

sensitivity sound

aspect, (areas

cortex),

with

auditory

lateral

cortex cross

the

association

eral

CEREBRAL

cortex

superior

cortex.

and

|

Lobe

Primary On

10

cortex

show

sounds area

in

in the

little the

loss

of

contralat

dominant

aphasia.

Corpus callosum

Lateral ventricle

Anterior limb

Internal

Genu

capsule

Third

Posterior

ventricle limb

Optic radiations

Figure III

Figure

Table

III

10

2.

Internal

10 10III 12.

Capsule:

12. Internal Internal

Arterial

Capsule: Capsule:

Arterial Arterial

SupplySupply

Supply

Internal Arterial

Supply

Tracts

Capsule

Anterior

Medial

limb

br.

Genu

Lenticulostriate br.

striate of

of

Thalamocortical

ACA

Corticobulbar

MCA

Posterior

Lenticulostriate

Corticospinal,

limb

br.

thalamocortical

Note:

The

Abbreviations:

posterior ACA,

of cerebral anterior

MCA artery cerebral

also

supplies

artery;

MCA,

all

somatosensory projections

the

optic

middle

radiations. cerebral

artery

35

PART

III

|

NEUROSCIENCE

Anatomy

Immunology

Pharmacology

Biochemistry

Physiology

Medical Genetics

Pathology

BehavioralScience/Social Sciences

Transcortical

Apraxia

Resulting the

Microbiology

from anterior

Alexia

occlusion

of

cerebral

3.

Left

the

Resulting

artery

arm

moved

in verbal

the

cannot

Language

be

response

area

left

from posterior

Agraphia

occlusion

of

cerebral

artery

in

communication

to

with

command

cortex Left

Without

the

motor (both

sides)

motor

cortex

Wernicke and

Right

area angular

motor

gyrus

cortex 1.

Verbal

command move

Corpus

to the

interpreted

left

callosum

arm

Left

here

process visual 2.

Right

motor

disconnected left in

Anterior

cerebral

cortex the

artery

cortex from

cortex

by corpus

the

Right any

is

Visual

information

cortex

blocked

get

lesion

Result:

callosum

Posterior

cerebral

artery

III Figure

10 III

13. Disconnect 10 13. Disconnect

visual

cortex

information

the

Figure

35

visual

(lesion)—cannot

Syndromes Syndromes

to

language Alexia

from by

right

lesion—cannot area

visual

CHAPTER

Table

III

10

3.

CNS

Blood

Supply

and

Stroke

Arteries

related

System

Primary

Vertebrobasilar

Vertebral

Anterior

(posterior

arteries

artery

10

|

CEREBRAL

CORTEX

Deficits

Branches

Supplies

spinal

Deficits

Anterior

two

spinal

thirds

of

cord

after

Dorsal

Stroke

columns

else

bilateral

See

Brain

spared;

all

Lesions

in

circulation) Posterior

inferior

cerebellar

Basilar

artery

Dorsolateral

medulla

(PICA)

Pontine

arteries

Anterior

Base

inferior

cerebellar

Stem

Chapter

of

Inferior

artery

IV

5.

pons

cerebellum,

cerebellar

nuclei

(AICA)

Superior

cerebellar

Dorsal

artery

cerebellar

hemispheres; superior

cerebellar

peduncle

Labyrinthine

artery

(sometimes

arises

from

Posterior

Inner

ear

AICA)

—

Midbrain,

cerebral

occipital

thalamus, lobe

arteries

Contralateral

hemianopia

with

sparing

macular

Alexia

Internal

Ophthalmic

Central

carotid

artery

retina

Posterior

—

artery

of

without

Retina

Blindness

—

Second

agraphia*

(anterior circulation)

most

communicating

aneurysm

artery

CN

Anterior

—

cerebral

artery

Primary

motor

sensory

cortex

and

III

and

—

Most

anesthesia

of

limb

Frontal

—

with

spastic

paralysis lower

communicating

(often

palsy)

Contralateral

(leg/

foot)

Anterior

common site

lobe

abnormalities

common

site

of

aneurysm

artery

Middle

cerebral

Outer

cortical

artery

Lateral

convexity

hemispheres

of

Contralateral

upper Lenticulostriate

Internal caudate, globus

spastic

paralysis

and

anesthesia

of

limb/face

capsule, putamen, pallidus

Gaze

palsy

Gerstmann Hemi neglect

Aphasia* syndrome*

inattention of

and contralateral

body†

*If

dominant

†Right

parietal

hemisphere lobe

is

affected

(usually

the

left)

lesion

35

PART

III

|

NEUROSCIENCE

Anatomy

Immunology Table

III

10

4.

key

Features

Lobes

Important

Frontal

Primary

Pharmacology

of

Regions

Deficit

motor

and

Frontal

eye

Broca

speech

Lesion

spastic

affected),

fields

area*

deviate

Broca

aphasia

written

and

Pathology

cortex

Parietal

Primary cortex

Superior

parietal

on

area

aphasia):

but

aware right

of

speech

their

lower

syndrome:

of

problem

face

homunculus

can

writing

are

often

understand

slow

and

associated

with

right

weakness.

can

solving,

hemihypesthesia

patient

and

problem;

symptoms

and

Contralateral

somatosensory

Microbiology

and

lobe

nonfluent

language, are

concentrating

depends

side

(expressive, spoken

weakness

Frontal

BehavioralScience/Social Sciences

ipsilateral

patients

arm

(region

apraxia

to

effortful;

Prefrontal

paresis

premotor:

Eyes

Genetics 44,Medical45)

(Areas

After

Contralateral

Biochemistry cortex

premotor

Physiology

Lobes

include

apathy,

(region

poor

judgment,

inappropriate

depends

difficulty social

on

area

of

behavior

homunculus

affected)

Contralateral

astereognosis/apraxia

lobule

Inferior

parietal

(Angular Area

Temporal

lobule

Gerstmann alexia,

gyrus;

pia

39)

Primary

auditory

syndrome

(if

dyscalculia or

lower

Bilateral

and

dominant

quadrantanopia;

damage

→

hemisphere):

dysgraphia,

finger

right/left agnosia,

unilateral

neglect

confusion,

contralateral

hemiano

(nondominant)

deafness

cortex Unilateral

Wernicke (Area

area*

leads

Wernicke any

22)

Hippocampus

to

aphasia

form

of

Bilateral

slight

hearing

(receptive,

language;

lesions

speech

lead

to

inability

loss

fluent

aphasia):

is

fast

and

to

consolidate

patient fluent,

but

short

cannot not

term

understand

comprehensible

to

long

memory

Klüver

Amygdala

Olfactory primary

Meyer

bulb,

tract,

Bucy

Ipsilateral

syndrome:

hyperphagia,

hypersexuality,

visual

anosmia

cortex

loop

(visual

Contralateral

upper

quadrantanopia

(“pie

in

the

sky”)

radiations)

Occipital *In

36

the

Primary dominant

hemisphere.

visual

cortex Eighty

Cortical percent

of

people

blindness are

left

if hemisphere

bilateral; dominant.

macular

sparing

hemianopia

agnosia

term

Limbic

LEARNING

The

Solve

problems

concerning

general

❏

Solve

problems

concerning

olfactory

❏

Demonstrate

limbic

sure,

A

on

plays

a role

aspect

of

Extends

the

the

the

the

limbic

but

rather

system

a

group

of

attention,

such

as

fear,

of

cortical

brain

structures

feeding,

anxiety,

and

happiness,

and

that

mating sexual

diencephalic

plea NOTE

structures

hemisphere.

The

system

lobe,

floor

of

a core

limbic

temporal

system

of

is

the

hippocampal

formation

on

the

3

hippocampus

layered

cerebral

is

characterized

by

a

cortex.

which:

the

inferior

horn

of

the

lateral

ventricle

in

the

lobe

Includes

the

entorhinal

hippocampus,

the

dentate

gyrus,

the

subiculum,

the

anterior

and

adjacent

cortex

limbic

related

structures

Amygdala,

•

of of

features

memory,

feelings

consists

in

along

temporal

•

in

the

medial

based,

emotion,

It

aspect

Other

organ

structure

medial

•

not

modulate

familiarity.

prominent

•

is to

It and

found

understanding

system

together

behaviors.

#

OBJECTIVES

❏

work

11

System

located

rostral

to

the

Septal

nuclei,

include

deep

in

the

the

following:

medial

part

of

temporal

lobe

hippocampus located

medially

between

the

anterior

horns

of

the

lateral

ventricle

The

limbic

tures,

system

is

including

the

mammillary cortical

bodies area)

is

interconnected

with

anterior of

located

and

the

the

and

nuclei

hypothalamus.

on

thalamic

dorsomedial The

of

cingulate

the

medial

surface

of

also

project

to

areas

hypothalamic

the gyrus

each

struc

thalamus

and

(the

hemisphere

the

main

limbic

above

the

corpus

callosum.

Limbic

related

structures

OLFACTORY Central

cranial

of

the

prefrontal

cortex.

SYSTEM projections

a thalamic fascicles

wide

of fossa

of

relay

and

the

central from

the

olfactory

structures

amygdala. processes

the

nasal

The of

cavity

bipolar through

reach olfactory neurons, openings

parts

of

nerve

the

temporal

consists which in

of

reach the

cribriform

lobe

without

numerous the

anterior plate

of

the

36

PART

III

|

NEUROSCIENCE

Anatomy

Immunology ethmoid

bone.

neurons

in

• Pharmacology

The

•

cell

bodies

is

the

olfactory

neurons

neurons,

which

differ

from

other

primary

sensory

these

collected

30

neurons

120

days

mucosa

together

of

in

the

lie

in

are

a

scattered

sensory

in

the

olfactory

ganglion.

continuously

replaced;

the

life

span

of

these

mammals.

nasal

cavity,

the

peripheral

process

of

the

primary

Medical Genetics olfactory

neuron

central

that Pathology

BehavioralScience/Social Sciences

bulb

in

on

the

primary

the

to

the

deal of

of

the

disease

The

results

the

neurofibrillary

from

bulb

membrane.

is

a

6

by

the

and

with

outgrowth entering

before lobe

The

synapsing

layered

information

convergence

temporal

mucous

of the

olfactory

the

brain

olfactory

tract

carries

axons

amygdala.

neurons,

hippocampus,

tangles

nuclei

the

noradrenergic

are

nucleus

and

the

in

of

locus in

is an

caused

by

neurons

injuries

that

olfactory

olfactory

the

are

olfactory

Head

Meynert,

neurons

deficits

primary

cholinergic

the

serotonergic

Olfactory

plaques.

of

CORRELATE

exhibit

amyloid

basalis

neurons

coeruleus,

that

and

affected

in

raphe

the terminate

Olfactory

CLINICAL in

neurons

of

neurons

bulb. plate.

parts

surface

olfactory

olfactory

a great

bulb

reach

cribriform

undergoes the

to

CORRELATE

Alzheimer Microbiology beginning

Other

of

found rests

from

CLINICAL

ramifies

processes

neurons

fibers or

outgrowth

or

fracture

nerve bulb,

as

they of

the

transport

to

problems

neurons

the

cribriform

they

pass

may

injure

CNS

covered

in

by

can the

bulb

by

olfactory

plate through

the

or

the

tear

the

plate

itself.

to

Because

meninges,

damage

to

pathway central

the

CNS.

processes

terminate the

the

to

in

the

olfactory

separation

of

bulb

the

bulb

nuclei. from

Patients

with

present

with

because

Down

syndrome

Alzheimer

in

chromosome

defective

21

commonly middle

age

is one

site

the

plate

cribriform

of

a

may

plate

tear

into

Olfactory

deficits

complete

(anosmia).

the

the

may

meninges,

nasal

be

resulting

in

CSF

leaking

through

the

cavity.

incomplete

(hyposmia),

distorted

(dysosmia),

or

gene.

Papez A

Circuit

summary

Papez

of

circuit.

•

•

NOTE

Axons

The

of

Papez

circuit

oversimplifies

the

the

limbic

system

in

feelings

as

familiarity, understanding

fear,

anxiety, but

it is a the

modulating sexual

pleasure,

useful

starting

role

of

the •

and point

the

The

of

Papez

of circuit

pyramidal

projects

The

mainly

mammillary by

anterior

the

connections the

the

limbic

begins

cells

system

and

ends

converge

is in

to

expressed

the

by

the

hippocampus.

form

the

fimbria

the

hypothala

and,

fornix.

thalamus

limb for

simplified

hippocampal

fornix

mus. The

the

Arbitrarily,

finally,

way

nuclei

the

of

the

the in

mammillary turn,

bodies

project

to

mammillothalamic

project

internal

hippocampus

to bodies,

to

capsule,

the and

through

the cingulum

an

emotional

in anterior

nucleus

of

tract.

cingulate

the

the

gyrus

cingulate and

through gyrus

the

anterior

communicates

entorhinal

with

cortex.

system. The imprint

36

not

olfactory

cells

such

of

are

Primary

Within

primary

ways.

mucosa,

Biochemistry

Physiology

These

2

amygdala the

functions emotional

to response

attach in

memory.

significance

to

a stimulus

and

helps

CHAPTER

Corpus

11

|

LIMBIC

SYSTEM

callosum

Cingulate

gyrus

Thalamus

Fornix

Olfactory

bulb

Mammillary

Hippocampus

body

Amygdala

(deep

to

uncus)

Cingulate gyrus

Thalamus

(anterior

Hippocampus nucleus)

via

Mammillary

fornix

body Papez

Figure

Limbic

Structures •

and

Hippocampal

in

System System

and

and Papez

Papez Circuit

Circuit

(hippocampus,

dentate

gyrus,

the

subiculum,

and

cortex)

•

Amygdala

•

Septal

nuclei

hippocampus

emotional

TheLimbic Limbic

Function formation

entorhinal

The

III 11 III 1. 11 The Figure 1.

Circuit

is

important

significance

in

to

a

learning

stimulus

and and

memory.

The

amygdala

helps

imprint

the

with

anterior

and

attaches

emotional

an

response

memory.

Limbic

Connections •

The of

limbic the

•

The

•

Limbic

•

Central and

system

thalamus cingulate related projections the

is and

gyrus

interconnected the is

structures

mammillary the

main also

of

olfactory

dorsomedial

nuclei

bodies. limbic

project structures

cortical to

wide

area. areas

reach

of parts

the of

prefrontal the

temporal

cortex. lobe

amygdala.

36

PART

Anatomy

III

|

NEUROSCIENCE

Immunology Papez

Circuit

Axons the

of

hippocampal

fornix.

The

hypothalamus. Pharmacology

cells

projects

The

converge

mainly

mammillary

to

bodies

(mammillothalamic

gyrus, (via

and the

the

cingulate

gyrus The

The

to

the

fimbria

and,

bodies

the

projects

entorhinal

anterior to

the

cortex

in

anterior

nuclei

finally,

the

nucleus

project

entorhinal

projects

of

to

the

the

cingulate

cortex

to

the

hippocampus

(via

the

pathway).

Medical Genetics

CLINICAL

•

BehavioralScience/Social Sciences

Anterograde

amnesia:

(including

the

acquire

– Microbiology

new

–

Also

seen

who

have

tion

of

In

in a

patients

a

Korsakoff

medial

temporal

profound

loss

syndrome

deficiency),

related

Wernicke

to

a

which

lobes

of

the

ability

to

patients

the

also

making

palsy,

lesions

an

alcoholics

acute

confusion,

are

dorsomedial

present up

in

follows

presenta and

gait

deficiency).

syndrome, and

(common

often

(ocular

thiamine

Korsakoff bodies

with

stories

to

always of

past

memories

retrograde replace

found

nuclei

the

in

the

thalamus.

amnesia;

patients they

can

no

retrieve.

Klüver

Bucy

syndrome

hippocampus

lead

hypersexual

(rare): to

bilateral

lesions

marked

placidity,

behavior,

and

hypermetamorphosis.

accounts

for

of

increased

the

amygdala

“oral

and

exploration,”

Disease

Alzheimer

disease

increases

with

impairment,

age.

Alzheimer

mood

a bedridden

involve

the

as

well

severely

affected and

an

death.

areas

are

cases

of

basal microscopic

the

hippocampus

dementia;

onset,

About

5

10%

dominant

the

incidence

progressive

aphasia,

hippocampus, (i.e.,

characteristic

memory.

all

insidious

autosomal

neocortex, nuclei

as

of an

disorientation,

eventual as

cholinergic

atrophy,

learning

with

transmitted

forebrain

60% has

alterations,

state and

Lesions

in

the

in

encephalopathy

(also

longer

onset,

with

Wernicke

Korsakoff

Alzheimer

to

resulting

thiamine

confabulate,

•

damage

hippocampus),

mammillary –

bilateral

CORRELATE

information

ataxia)

36

form

mammillary

project

tract).

cingulum).

perforant

Pathology

to

the

Biochemistry thalamus

Physiology

pyramidal

fornix

memory

apraxia, of

and

cases

are

progression

to

hereditary,

early

trait.

and nucleus

subcortical

of

Meynert).

changes. and

temporal

nuclei, These

The

earliest lobe,

including areas and

which

show most are

involved

CHAPTER

Figure

(a) (d)

Corpus

Primary (g)

(j) Posterior

Pons

III

callosum

2. MRI

of Medial

(splenium)

motor

cortex

(h)

Medulla

vermis

11

(e)

Lingual

Mammillary

with

in wall

intracerebral body

(m)

of the

gyrus

somatosensory

(i) Hypothalamus

of cerebellum (l)

(b)

Primary

View

(c)

11

|

LIMBIC

SYSTEM

CNS

Cuneus

cortex of third hemorrhage

(f)

gyrus Midbrain

ventricle (k)

Pituitary

Pineal

36

Index

Acini

A

Amniotic

hepatic,

124

Abdomen aneurysm,

pancreas,

126

anterior

wall,

exocrine,

salivary

85–90

fluid

accumulation,

layers, male

arterial

Actin

extravasation,

and supply,

126–130

canal,

testes

barium

enema,

reflex,

Abducens

cavernous

(CN

sinus,

thrombosis,

219,

Allergies

247

Alpha

281

horizontal

conjugate 281,

299,

304,

305

orbital

muscles,

vestibular

221,

fibers,

Abortions

and

Acalculia,

354

Accessory

duct

Accessory

nerves

hCG

cord, fibers,

functions,

122

XI) 275–277,

284

convergence

reaction,

Acetylcholine autonomic

and system, ganglia cell

somatic

indirect

balance

by

path,

319

kidneys,

140

Anal

triangle,

271

148

Amnesia,

39

Ankle

53

deep 50

glands),

plaques,

172

364 362 and,

362

filaments,

15

tangles, locus nucleus. 338,

238,

caeruleus, See 339,

228

29 38

152

126

of

Nucleus 341

362 308 ambiguus

Willis,

221,

gyrus,

351

360

joints,

205

tendon fibrosus,

Anopia,

331,

reflex,

258

23,

25

333

Anorectal

canal,

Anosmia,

280,

Anterior

cardiac

Anterior

cerebral

135, 360,

aneurysm,

348

occlusion,

347,

radiology,

349

Anterior

136 362

veins,

77

arteries,

354,

347–349

358,

communicating

aneurysm,

221, of

130

45

349,

354,

359

artery,

conversion,

Anulus

circle

348,

mesenteric

lesions,

52

syndrome

364

27,

Angular

bronchioles,

and

226,

Aneurysms

45

disease,

disease,

148 169

epidural,

Angiotensin

51,

129

16

Androstenedione,

52

(mammary

127,

133

junctions,

wall,

51,

105,

132,

insensitivity,

alveolar

Alzheimer

head,

Androgen

superior

Ambiguus

155

circle

membrane

119

152

abdominal,

50–53

155 107–108,

Anchoring

50

hyaline

118

Anastomoses

sacs,

Amenorrhea,

113

sphincters,

273

108

perineum,

Anal

alveolar

raphe

secretion,

material,

272,

238

Anesthesia

50

neurofibrillary

nervous

230

fecal

pudendal,

diseases,

sclerosis,

152

intercostal,

histology,

362

107,

triangle,

ducts,

intermediate

(ACh)

canal,

Anencephaly,

(lungs)

Down

202

228

254–256,

capillary

125

364

tangles,

anal

alveolar

amyloid

328

Acetabulum,

225

228

2 deficiency,

surfactant,

Accommodation

levels,

258–260

reductase

Alveoli

284

45

syndrome,

lateral

portacaval,

260–261

respiratory

281

nuclei,

226, 226,

macrophages,

288

281

lesions,

intake,

motoneurons,

Alveoli

9

Santorini, (CN

spinal

298

364

358

(AFP)

bifida,

reflexes,

294

levels,

of

corticobulbar

297,

293,

339,

134–137

lesions,

5α

285

cervical

297–299

356,

air

122,

361–363

plaques,

female, 336,

fetoprotein

Alpha gaze,

Bucy system,

pancreas

anencephaly,

298,

nuclei,

315

and

107,

360

female

354

spina

functions,

Acid–base

220,

287

358

226

agraphia,

8

105,

neurofibrillary Anal

231

deficiency,

Allantois,

279,

211

lesions,

225,

without VI)

147

(Hirschsprung 109,

356,

ataxia,

Alexia,

220

embryology,

parietal

thiamine

lesions,

Amyotrophic

abuse

gait

275–277,

175

megacolon

plate,

Vater,

Kluver

352–354

173

8

242

congenital,

103,

pregnancy,

of

limbic

(radiology),

without,

130–133 pregnancy,

nerves stem,

hyperplasia,

alexia

ectopic

Amyloid

Adrenal

260

barrier, 201

329 glands

Alcohol

drainage, ectopic

169

Amygdala

339

pupil,

Alar

Abdominal

8–9

170

tubal

muscles,

Adrenal

137

Abdominal

7, 168,

histology,

Ampulla

blood–brain

disease),

173–177

venous

and longus

Aganglionic

137

radiology,

192

14–17

Adductor

Agraphia,

landmarks,

muscles,

306

159

Addiction

91–92

wall

bony

8, proteins,

Adie

90–91

descent,

posterior

basal

38

92–94

inguinal

244,

epiblast, tube

165

fertilization,

(schwannoma),

Adenohypophysis,

region

hernias,

327,

165

85–86

boundary,

inguinal

brain

154,

regions,

diaphragm

from

uterine

anatomy,

121

(radiology),

Acrosome,

89

urine

planes

122

of

165 90

87,

120,

neuroma

Acromion innervation,

121,

glands,

Acoustic

cavity

Ampulla

Willis,

359

arteries 348,

359

301,

348

36

ANATOMY

Anatomy

Immunology

Anterior

cruciate 203,

ligaments

(ACL),

Arachnoid

anterior

drawer

common

sign,

injury,

Anterior Pharmacology

artery, 272,

Anterior

302,

iliac

talofibular

Anterior Physiology

Biochemistry

348

274,

superior

Anterior

spinal,

208

303

spine,

86,

ligament

tibial

arteries

injury,

and

205

fractures, Medical Genetics

201 Anterograde

axonal

243,

Pathology brain

265–267,

system,

263,

282

265–267,

Antidiuretic

262,

BehavioralScience/Social Sciences

277,

Chiari

Arousal

and

282 (ADH),

follicle,

166,

axonal 338–340

338,

340

327,

malformation,

colon,

329

228 336,

of

353,

43

spinal

360

268,

plaque

in

aorta,

138,

272

defecation,

107–108,

innervation,

152,

119 155

heart,

flow,

70

abdominal

aneurysm,

abdominal

126

branches,

atherosclerotic

126

plaque

site,

126

69,

surfaces,

70

of,

descending

aorta,

radiology,

67–68

septal

atrial

septation,

fetal

circulation,

83,

84

abdomen,

174–176

thorax, Aortic

83,

cells, ganglia

66,

mediastinum, hiatus,

64,

65,

82

insufficiency,

aortic

stenosis,

60,

61

74,

flow,

75

73

lung,

cortex,

190

indirect

pathway,

347,

lamina,

Basal

plate,

353,

354,

cells

360

Precursor

Uptake

membrane,

humor, body

glaucoma, Arachnoid 245–247,

74,

Bell

291

Bile,

75 system,

necrosis,

Axillary

arteries,

30–33,

Axillary

lymph

193,

of

289,

183, 186, vertebral

74,

flow,

72,

202

74–76

Bile

canaliculi,

Bile

duct,

137,

138

136 of,

fracture,

male

191 186,

187,

pelvis,

22

spastic,

138

trigone,

136,

Blastula,

7,

138 8 7,

7,

vagina,

150

Blastomeres,

187

151 into

Blastocyst,

184

148

pelvis,

herniation

179–181

column,

123

138

female

neck

8–9

123

105,

exstrophy

187,

disk,

125

embryology,

36

dislocation,

75 73

embryonic

Blepharospasm,

368

291

valve

atonic,

189

192

lesions,

311–313

anatomy,

nerves

injury,

350 304

Bladder

nervous

nodes,

surgical

Axis

225,

system

188,

humeral

218,

palsy,

Bilaminar

Sympathetic

326

217,

348,

278

cells,

auscultation,

110

nervous

head

326

346,

syndrome,

359

Bicuspid

Parasympathetic

plexus,

granulations,

301,

pontis,

blood

nervous

also

328

16

16

pontine

murmurs,

humeral

epithelium,

249

360

43

brachial

114 48,

arteries,

Basis

72

49

gastrointestinal,

15,

292

109,

sounds,

Axillary

17 226

337

heart,

Avascular

Decarboxylase)

respiratory,

336,

valves,

See

358

(Amino

16,

pemphigoid,

medial

357,

290,

plexus,

Autonomic

360

318–319

225,

Basement

351,

system; 351,

322–324

323–324

Basal

Basilar

291,

230–233,

352–354,

transcortical,

ciliary

77

73

sound,

of

107

Aqueous

of,

79

293

loss, of

breath

42

347,

Appendix,

cerebral

heart 185–187,

Aphasias,

APUD

76, 78,

291–293

tests,

Auerbach’s

352

Apraxia,

artery, node,

Auscultation 54,

336 319

323–324

diseases

lesions,

75

system,

auditory

Auricle

vestibule,

hand,”

72,

335, 317,

74–76

thalamus,

75

74–76

of

324,

lesions,

valves 74,

flow,

pitch

73

murmurs,

Apex

(AV)

murmurs,

321

338

64

nodal

hearing 75

324 320,

pathway,

Basket 74,

74,

auscultation,

“Ape

318,

occlusion,

valve

aortic

Apathy,

and,

Atrioventricular

Auditory

80 septum,

semilunar

81,

66

Aorticopulmonary

Aortic

cortex,

sections,

thalamus,

84

Atrioventricular

blood landmark,

superior

blood

317

cerebral

direct

54

173

153

48

bullous

radiological

Aortic

81,

auscultation,

arch

Aortic

63

72

54–56 53,

Atrioventricular

84

58–59,

56–58,

tube,

65

radiology,

glands,

anatomy,

defects,

esophagus

radiology

261

Basal

70

atrial

radiology,

64

260,

subthalamus,

heart coarctation

sign, enema

Basal

embryology

Aorta

veins,

Bartholin

72

borders,

252

238–239

244 of

Barium

blood

sphincters

243,

236,

system

Babinski

of

neuron,

244

251,

B

126

22

anatomy

135

243,

fasciculi,

315

323

bladder,

239

238

neuron,

or of

Azygos

Atria

Anus, 107 Microbiology embryology,

tracts

Axotomy,

gait,

236, of

structure

242

Atherosclerotic

Atlas,

segment,

regeneration body,

and,

244

241–242

initial

50 239,

disorders 243,

histology,

foreign

227,

237

axotomy,

107

264,

Astrocytes,

238–239

neurological

337

355 of

239

polyneuropathies,

microtubules,

175–176

Asomatognosia,

Atonic

168

274,

thalamus,

Aspiration

227,

transport,

axonal

pupils,

radiology,

Athetosis,

hormone of

Arnold

Ataxia

269

stem,

Antrum

Robertson

polyneuropathies,

Axons

252

Argyll

Asthma, sensory

lesions,

26,

Astereognosia,

degeneration,

244

Anterolateral

247

nuclei,

Ascending

88

Axonal

217,

Arcuate

muscles,

spinal

occlusion,

204

205

scalene

Anterior

mater

cranial,

204

8

8 32

152

239

INDEX

Blindness

hypothalamic

cortical

blindness,

night

355,

blindness,

psychic

325

blindness,

Blood–brain

pons,

364

242,

astrocytes,

239,

choroid

242

plexus,

drugs

of

247,

addiction

pericytes,

crossing,

240,

Blood

pressure

Bowel

ischemia

Bowman’s

corpuscle,

Brachial

arteries,

188,

Brachial

plexus,

179–181

injuries,

lemniscus,

medial

longitudinal

flexure,

142–144,

251,

scalene

207,

Brachiocephalic

veins,

radiology,

epithelial

Broad

82

of

217,

218

hematoma,

221,

350

152

motor

system

arterial

344,

supply,

anatomy,

363

vertebral

lung,

44

penis

and

testes,

91

352,

anterior

cerebral

347,

354,

358,

cerebral

cortex,

346–350

cerebral

infarcts,

350, 350,

358,

blood–brain

of

central

nervous

cranial

meninges,

lesion

definition,

225

306

fluid,

245,

Cerebrospinal

(See

also

fascia,

242 228,

embryology,

225,

medulla,

penis,

nodes,

supply,

caloric

test

corticospinal

of

nerves, nerves)

295, 277,

275–281

296

(See

154,

pouch,

150,

154,

153

Cranial

circulation,

of

fibers,

impression,

Cardiac

muscle

Cardiac

tamponade,

gap

junction

molecules, movement,

16

Caudate

79 73,

histology,

79

73–74

69 54

arteries

(radiology),

tunnel,

Cauda

78,

42

veins,

82

190

nerve

syndrome,

15

74,

67

lesions, 190,

sensory

adhesion

78–79

74

trabecula,

Cardiac

median 16

system,

discs,

192

133

conduction

septomarginal

156

142–144

(radiology),

132,

intercalated

Carotid

77–79

humerus

medusae,

Carina,

16

140 141,

193

Cardinal

164

45

corpuscle,

Purkinje

153 153

pouch,

165

Calcium also

51

Cardiac

154 extravasation,

164

15,

91

diseases,

renal

Caput

glands,

Cadherins,

282

341 91

8

Capitate,

C

300–301

308,

64

blood

44

Carpal

function, tract,

44

nodes,

278–280

arterial

306,

kidneys

271–273

muscle,

His,

121

91

metastasis,

Capitulum

perineal

of

49–50

116

pemphigoid,

Bundle

glands,

metastasis,

lung

49

perineal

Bullous

284–287

sections,

46,

urine

ejaculation,

287–289

body,

alveolus,

150,

and

deep

282–284

midbrain,

pineal

Capacitation,

153

ejaculation,

275–277

pons,

of

306

Capillaries

110,

48,

Bulbourethral

anatomy,

metastasis,

thymoma,

43

syndrome,

Bulbospongiosus 227

body,

lymph

superficial 248

stem

cranial

Buck Bulb

salivary

penis,

scrotum,

lymph

glands, cells,

injury

cells,

hydrocephalus,

352,

49

Sequard

Brush

227

ependymal

vesicle

246

fluid)

embryology,

351,

49

histology,

Brown

246

cerebrospinal

Brain

46,

Brunner 245,

332,

cells,

Bronchopulmonary

ventricles anatomy,

357

244

244, 105

parotid

foreign K

tumors,

pancreas,

353

Bronchomediastinal 365

244,

345

36–38

Bronchiole

349,

schwannoma,

of from

histology,

307

320,

337,

292,

297,

embryology,

217–218

239

testes,

cancer

249 244

Schwannoma,

353–355

area,

aspiration

226

diagnosis,

radiology,

242

glioma,

351

355–356

242

225,

345,

Bronchi

crossing,

15

tumors,

metastatic

system,

249

249

system

embryology,

247,

351

336–337,

262,

lobe,

Wernicke

247,

240,

inhibition,

system

craniopharyngioma,

352

system,

parietal

242

addiction

pericytes,

355,

visual 242,

plexus,

drugs

350,

359

239,

choroid

332,

areas,

256,

pathways,

auditory

infarcts,

barrier,

astrocytes,

sensory

359

cerebral

356,

359

functional

area,

91

345

pathways,

Broca

27

360

cortex

motor

posterior

354,

numbers,

cerebral

359

plexus,

45

cerebrospinal

infarcts,

hemorrhages,

scrotum,

spindle

nervous

300–301 Brodmann

venous

area

320

lesions,

metastasis

36

mitotic 276,

42

mesothelioma,

speech

malignancy,

44

internal

Brain anatomy,

lung,

lymphatic

35

and

45

breast,

ligament,

Broca’s

35

appearance,

veins,

subdural

66

lesion,

49

16

metastasis, nerve

35

35

K cells,

cadherins 15,

36

lesion,

appearance,

from

257

172

Bridging

208

nerve

peel

apex

peel

326

36

bronchial

172

orange

triangle,

glaucoma,

172

lung,

histology,

185–187

326

angle

mastectomy

35–36

metastasis,

183–184

branches,

282

256 tract,

mastectomy

253

87

Schlemm,

orange

265–267,

motoneurons,

cancer,

182

of

breast, 279,

308 tract,

anatomy,

189

nerves,

282 278,

Breasts

146

296

fascia,

metastasis,

corticospinal

141,

277,

fasciculus,

formation,

upper

130

125

295,

Cancers 263–265,

spinothalamic

140

biliary, test,

narrow

307

medial

141

nerves,

Canal 302–308

282

kidneys,

at splenic

spinal

Camper

of,

reticular by

renal

collateral

287

282,

242

242 control

capsule,

cervical

249

Calculus, Caloric

diagnosis

249

282

284

lesions,

247,

277–280,

303–305

midbrain,

barrier

about,

fibers,

lesions,

360

loss,

equina, nucleus,

183, 27,

186,

187

193

251, 318,

190 253 320,

321

36

ANATOMY

Anatomy

Immunology

Caval

hiatus,

80

Cavernous

Cerebral

sinuses,

thrombosis, Cecum,

219,

220,

247

220

Biochemistry 118

adhesion,

15,

Cell

junctions,

16–18 systems

follicles,

microtubules,

167

Pathology autonomic

BehavioralScience/Social Sciences system, 30–33, 225,

nervous 230–233

(See

nervous

system;

also

nervous

system)

Parasympathetic

infarcts,

basal

ganglia

tumor

cells,

craniopharyngioma, glioma,

249

239

metastatic

tumors,

Schwannoma,

lesions,

306

sensory

244,

244

definition,

225

diseases,

237

congenital

origins,

vesicles,

225,

and

228

10,

12,

cells,

239–240

immune

neurons,

system

and

320, cord,

microglia,

240

349, 83,

245,

365

hydrocephalus, lumbar

245,

Cerebrospinal

246

(See

fluid) 227

ependymal

cells,

242

hydrocephalus,

228,

Central

retinal

artery

Central

sulcus

(of

occlusion,

332

Rolando),

Centromeres

in

Cerebellar

343,

4,

277–279,

309

outflow,

310,

and

lesions,

5

314,

305 284

anatomy,

enlargement,

Cervical

parietal

Cervical

vertebrae,

315

cerebral

hemispheres,

circuitry,

313–315

cytoarchitecture, thalamus,

344

310–315

264,

of

322, 9

213

cavity, (eye),

Choroid

plexus,

9 326, 242,

227,

309 315

245–247,

barrier, cells,

247,

249 249

225

embryology,

Cloacal

membrane,

ducts,

Cochlear

nuclei,

18 161

292

15 circulation 332,

350,

355,

artery,

105, 189,

Colon,

107–108

127,

129

190 of

ankle,

ganglia,

ducts, fascia,

359

129

head, limbs,

Colles’

139,

205 30

141,

145

153

aganglionosis,

103,

109

embryology midgut

boundary,

midgut

rotation,

material,

107 98

118 110,

111

peritoneal

membranes,

radiology,

173–176

Colonic efferentes,

291,

305

motor

histology,

ductuli

292,

ligament

fecal

Cilia,

67–68

291

285,

Collateral

3–5

50

136

aorta,

290,

Collateral

243

disease

10, the

88

Cochlear

Chromosomes,

pulmonary

155

96

of 22,

Chromatolysis,

obstructive

147 151,

Cloaca

colonic

330

312

136,

Collecting

323

Choroid

Chronic

310, 313–314

genitalia,

upper

11

187

7, 8

Clitoris

pancreas

73

186,

312,

marginal

114 72,

261 192

fibers,

Collateral

30

cell

214

Climbing

Colchicine,

40

stomach,

tympani,

Chorion,

249

271

213

macula,

tendineae,

(COPD),

313,

palate,

lesions,

22

ganglia,

Chorea,

336

embryology,

in,

218

170

cells

Chorionic

lip,

Cleft

Coccyx,

253 pleura,

motor

Chromaffin

309–310

27,

259,

zygote,

Coarctation

leukocytes

Cervical

Chief

362

341

space,

151,

215,

29

tumors,

blood–brain

Cerebellum

245–247,

248 27,

subarachnoid

Chain

Cleft

female

fractures, 228,

Chordoma,

peduncles

anatomy,

also

Chorda

122

meiosis,

242,

255,

tract

184,

of

embryology,

body

Chordae cells,

245–247

249

puncture,

Cervix,

248

351

Centroacinar

source,

polymorphonuclear

fluid,

embryology,

as

plate

84

246

cerebrospinal

218,

49

252,

reflex,

circuitry,

245–247,

pineal

anatomy,

217,

249

plexus

circulation,

ventricles

pons,

of,

cribriform

spinal

input

granulations,

chemistry

249

249

radiology brain,

(CSF),

arachnoid

235–240

and,

hand,”

Cleavage

fluid

15

(radiology),

“Claw

278

287

choroid

of

276,

306

Cerebrospinal

227

supporting

histology

peduncles,

213

diseases,

268

knife

Clavicle

350 359

77

spinocerebellar

Clasp

266

256

341

49–50

267, 262–264,

348,

76,

nucleus,

dorsal

340,

346–348,

papillae,

fibrosis

Clarke’s

systems,

338,

221,

liver cells,

364

363

301,

artery,

cystic

346

motoneurons,

midbrain,

225

Willis, site,

350

lesions,

malformations,

ectoderm

Clara

227

Cerebral 225–229

257

346

upper

embryology,

Cirrhotic

363,

362,

rhythms, of

324 256,

hemisphere,

language,

circuit,

Circumvallate

tract,

embryology,

361,

Circumflex

pathways,

dominant

244

276

system,

aneurysm

350

328

gyrus

Circle

350

18,

328

326,

anatomy,

Circadian

360

cells,

epithelium,

Papez

346–350

hemorrhages,

muscles,

Cingulate

360

357,

supply,

body

limbic

353–355,

lobe,

48

49

Ciliary

360

48

170

18

columnar

Ciliary

brain

355–356,

lobe,

cerebral

360

351

lobe,

corticospinal

Microbiology cerebrospinal

370

344–346

arterial

Sympathetic

cancers

lesions,

neocortex,

temporal

15, system,

46,

351–352,

18, and,

microtubules,

ciliated

areas,

242

transport

308

lobe,

parietal

system

248

ovum

respiratory

functional

occipital

15

nervous

syndrome,

246

343–346

frontal

Medical Genetics

245,

cortex

anatomy,

16–17

ovarian

344,

circulation,

cells,

Kartagener

287

Cerebral

13–14

junctions,

glial

fluid

ependymal

227 306,

midbrain, 16

transport

Central

344

228,

embryology, lesions,

126–128

Cell

gap

278,

hydrocephalus, 98

artery,

Cellular Physiology epithelial,

276,

cerebrospinal

107

embryology, Pharmacology fecal material, Celiac

aqueduct

anatomy,

aganglionosis disease),

103,

100

(Hirschsprung 109,

23

bodies,

INDEX

Common

bile

duct,

104–105,

hepatopancreatic

125

ampulla,

105,

107,

122,

125 carotid

arteries,

embryology,

209

fibular

nerves,

195,

196

127,

128

artery,

Common

hepatic

duct,

Common

iliac

105,

arteries,

Communicating

See

Gap

junctions syndrome,

Complete

androgen

Conduction

Corpus

luteum,

Corpus

spongiosum,

of

Congenital

sinuses,

218,

219,

247

adrenal

hyperplasia,

annular

pancreas,

heart

hernia,

and

atrial

of

patent

aorta,

of

62,

of

60,

61, the

inguinal

nervous

system,

lip,

Costal

parietal

Costal

surface

63

gaze,

Connexons,

89,

296–300 III

pupillae,

Conus

arteriosus,

Conus

medullaris,

Convergence

326

27,

251,

253

accommodation

reaction,

Coracoid

anatomy,

276,

anatomy,

IX

332,

light field

visual

pathway,

reflex,

defects,

326,

327

325,

stem,

275–278,

cavernous

sinus,

cavernous

sinus

horizontal lesions,

287 219,

220,

211

conjugate

gaze,

306,

307,

297,

muscles,

221,

297,

298,

light

reflex,

326,

327

pupillary vestibular

Coronary

arteries,

Coronary

sinus,

heart

embryology,

Coronoid

process

166,

168

IV

76–78 72,

77, 54,

of

ulna,

fibers,

293,

298

275–277,

stem,

stem,

275–278,

XI

294

220,

cavernous 192

sinus

thrombosis,

304

293,

294

279 283

211 281 303

283

tongue

innervation,

213

stem,

275–277,

279

fibers,

motor

288

nucleus,

283

211

innervation,

79

303 283 mediastinum,

66,

67

accessory spinal

corticobulbar

cord, fibers,

275–277,

284

288

281

247 281

220 nuclei,

embryology,

303, 306

nucleus,

281,

superior

287 219,

287

291

294,

275–277,

motor

nuclei,

lesions,

58

292,

system,

cervical

sinus,

279, 290,

244,

functions, cavernous

305

281 281,

nuclei,

326

trochlear brain

78

304,

213

division,

lesions,

287

299,

glossopharyngeal

heart

orbital

7

stem,

embryology,

329

nuclei,

follicle,

innervation,

291,

vestibulocochlear

dorsal

326

graafian

289, 285

corticobulbar

radiata

fertilization,

281,

tongue

brain

220

280

280,

287 289

X vagus

247

thrombosis,

288,

211

283,

lesions,

oculomotor

279,

fibers,

functions,

326

298

294

275–277,

embryology,

331–332

297,

293,

305

281

dorsal

333

297–299

304,

221,

nuclei,

brain

280 280,

visual

192

159

stem,

vestibular

277

222

220

facial

lesions,

362

299,

fibers,

functions, 360,

Corona

enzymes,

muscles,

cochlear

277

Cornea,

acrosome

orbital

schwannomas,

36

(radiology),

glands

280 280,

functions, 35,

Bulbourethral

247

gaze,

298,

285

lesions,

41

287

220,

thrombosis,

conjugate 281,

functions, 40,

279,

281

embryology,

41

219,

211

nuclei,

brain

embryology,

328 ligaments,

40

optic

brain

54

sinus

VIII

pupillary

91

17

Constrictor

See

276,

lesions,

147–148

88,

305,

42 recesses,

functions, 136

system,

39,

lung,

nerves

eye

cavernous

corticobulbar

recess,

lesions, II

275–277, sinus,

brain

pleura, of

functions,

214

tendon,

304,

I olfactory

215

stem,

cavernous

VII

glands.

Cranial

136–137

reproductive

302,

67

anatomy,

38,

282,

38

Costomediastinal

brain

agenesis,

Cooper

63

214

palate,

327,

68

notching,

226

system,

Conjugate

59, 92

apparatus,

261,

346

Costal

226

pharyngeal

Conjoint

vessels,

defects,

260,

Costodiaphragmatic

63

great

hernia,

bifida,

renal

62,

285–286

vestibular

groove,

303–305

horizontal

315

247 289

283

lesions,

257,

Costal

228

anencephaly,

cleft

63,

280,

functions,

314,

288,

211

embryology,

282

efferents,

Cowper septal

indirect

cleft

67–68

63

ventricular

277–279,

271

307

arteriosus,

Fallot,

transposition

269,

284

lesions,

63

arteriosus,

257,

220,

fibers,

abducens brain

282

neocortex,

truncus

tetralogy

spina

80

58–59,

the

ductus

persistent

stem,

102–103

defects,

coarctation

renal

38,

circulatory

septal

307

287 219,

280

nuclei, VI

315

294

275–280,

medulla,

288–289

293,

sinus,

functions,

tracts

cerebellar

abnormalities,

156

346

pons,

102

diaphragmatic tube

fibers,

medulla, 147

154,

360

efferents,

256,

brain

stem,

lesions,

Corticospinal

abnormalities

150,

355,

306,

221

fibers,

embryology,

168–169

164

anatomy,

Confluence

muscles,

cavernous

166,

neocortex,

326

287

orbital

corticobulbar

blindness,

lesions,

356

156

164

cerebellar

280 280

nuclei,

brain 154,

Corticobulbar

355–356

agnosia,

fovea,

148

354

330

stream,

visual

155 150,

Cortical

insensitivity,

aphasia, 325,

gut

201

344

V trigeminal

erection,

Compartment

320, 356

cavernosum

erection,

126

junctions.

318, 354,

vestibular

penis,

125

functions,

365

clitoris,

hepatic

169

lesions,

276,

Corpus

198

166,

347,

radiology,

Common

cone

callosum

lesions,

211

Common

Cones,

albicans,

Corpus anatomy,

Common

injury,

Corpus

284

211

37

ANATOMY

Anatomy

Immunology

XII

hypoglossal

brain

stem,

275–277,

corticobulbar

fibers,

embryology, Pharmacology

288

281

lesions,

281,

Biochemistry 302,

284

tongue

innervation, stem,

foramen

syndrome,

BehavioralScience/Social Sciences

285–286 nervous

peripheral

system,

nervous

32,

system,

Craniopharyngioma, Cranium,

27,

33

hemorrhages,

217–218

orbital

muscles,

respiratory Cremasteric

muscle

cremasteric

and

fascia,

91,

260

reflex,

Cribriform

88,

89,

91

215, system,

361,

terminalis, meiosis,

Cryptorchidism, Crypts

of

Cumulus

4,

91,

lesions,

115,

tract, 331,

117,

267,

truncus

pulmonary left

shunts,

of

of

Cystic

artery,

Cystic

duct,

Cystic

fibrosis,

127,

59,

63

great

62,

15

Cytoskeletal

elements,

Cytotrophoblast,

mellitus

Decerebrate

of

39,

52

65

the

pyramids,

256,

257,

311–312

hernia,

80

parietal

innervation,

79,

referral,

pleura,

80

spinal

40

and,

38

106

of

lung,

42

28,

of

215

intestine, glands, intestine,

functions,

140

119

55,

ductus

164 134 162,

pupillae,

foregut histology, peritoneal

154,

156

91

162 54–56 106–107

delivery,

duodenal

326

150, cord,

venosus,

115–117

3

163

anatomy,

digestion,

(DHT),

60

211

deferens

120–121

112

56

arteriosus, arches,

Duodenum, bile

147

arteriosus

Ductus

reabsorptive

238

161

circulation,

spermatic

125

225 362

embryology,

efferentes,

vasectomy, functions,

and,

204

Gartner

male 212,

267,

levels,

tangles,

signs,

histology,

sequence,

262

tract,

neurofibrillary

embryology,

227

253,

disease

ejaculation,

335–341

252,

fetoprotein

Ductus

74–76

262–266

271

patent

defects,

254

259

pharyngeal

surface

lemniscal

syndrome

fetal

38

valvular

26

spinocerebellar

Ductus

174–175 hernia,

270

28

sensory,

Duct

98

nerve

receptors,

Ductuli

outlet,

in

39,

97,

252

259

Drawer

hypoplasia

hiatal

233,

ganglion

Alzheimer

80

81,

stomach,

Dilator

of

269,

32,

horn,

alpha

Dihydrotestosterone nuclei,

sections,

root

Down

265

271 95,

column–medial

Dorsal

80

80

small

260

as

239

282

265

ligaments,

268,

64,

264,

263–265,

28,

sensory

mothers, 227,

embryology,

salivary

280

cerebellar

340

79–80

sliding

cord

reflexes,

diabetic

columns,

system,

dorsal

338,

277–280,

282

252–254

reflexes,

hiatus,

large

228

260

rigidity,

Decussation 271,

malformation, rigidity,

Decorticate

372

of

stem,

mesentery,

anatomy,

138

insipidus,

277

lemniscus,

254

sensory,

dorsal

150

Diabetes

system,

263

138

bladder,

kidney Walker

horn,

16

Digestion

7–9

embryonic

Dorsal

138

pelvis,

DiGeorge

14–15

D

Deep

muscle,

Diabetes

bile

Dandy

vulgaris,

embryology,

Cytokinesis,

Dorsal

dorsal

16–18

anatomy,

14

dorsal

lemniscus,

root

Diencephalon

transport,

of

medial

denticulate

bladder,

Diastole

49

lesions

Dorsal

Diaphragmatic

125

brain

287

thoracic

48

cells,

63

in

rami,

radiology, vessels,

263–265, medial

lesions

Dorsal

pulmonary

61–63

63

stem, stem

303–305

Desmosomes,

lemniscal

263–265

spinal

277–280

Endocrine

346

column–medial

as

282

Neuro

48

anterolateral fibers,

284

pain

59

128

105,

epithelial

61, the

62, causing,

58,

Fallot,

transposition

Clara

arteriosus,

hypertension to

anatomy,

diaphragmatic

365

tetralogy

173

hypothalamic

apertures,

conditions

right

enema,

diaphragmatic

radiology,

persistent

107

173–176

aortic

268

332

333

Cyanotic

colon,

Diaphragm,

168

26

145

319

brain

84

neuropathies,

118

314

141,

hemisphere,

brain 312,

5

tubule,

(Diffuse

Dopamine, Dorsal

205

64

83,

infants

110, 166,

Cuneocerebellar gyrus,

5

148

Lieberkuhn, oophorus,

Cuneus

aorta,

spastic

362

72

in

Descending

cells

262,

279,

ligaments,

male

362

ankle,

4,

145

Dominant

238

Denticulate

atonic

olfactory

Crossover

236, nucleus,

Detrusor

215

fractures,

Crista

208

pemphigus

plate

cranium,

of

muscles,

5

92–93

meiosis,

System),

231

4,

hernias, in

convoluted

119

disease,

247

meiosis,

inguinal

Diuretics,

155

ligament

218, in

296

Distal

Hirschsprung

Deltoid

pons,

46

cells

DNES

152,

midbrain,

221–222

pathways,

155

107–108,

and

lesions,

veins,

Diploid

Disjunction

119

brain

Diploic

Direct 153

258–259

sphincters,

barium

220–221

199

90 152,

reflex,

Descending

218–219

89,

Deltoid

209 sinuses,

meninges,

tendon

radiology,

venous

196,

innervation,

Descending

244

supply,

dural

pouch,

radiology,

225

215–216

Microbiology arterial

ring,

perineal

Dentate

287–289

parasympathetic as

inguinal

Deep

Dendrites,

283–284

pons,

Deep

meconium

217

219 195,

Diplopia,

innervation, Medical Genetics

nuclei

Pathology

218,

nerves,

198–199

anal

211

midbrain,

veins,

Defecation,

213

275–277

medulla,

fibular

pudendal

303

302–308

jugular

face

Deep

Deep

nuclei,

lesions, Physiology embryology,

Deep

injury,

211

functions,

brain

279

125 116 atresia,

103

boundary, 110,

107 111,

membranes,

114–118 10

system,

INDEX

radiology, ulcer

173, and

Dural

sac,

Dural

26,

fetal artery,

127

27

venous

Dura

176

gastroduodenal

sinuses,

217,

218–219,

247–248

247

arachnoid dural

Dust

granulations,

217,

sinuses,

218–219,

venous

spinal,

26,

cells,

circulation, week,

54–56

247

system rotation,

95,

midgut

rotation,

99

organ

development,

252

gastrulation,

53

95–97,

3, 4,

91,

18 syndrome,

retrograde

18,

axonal

spermatozoa

48

transport,

flagella,

vagina, 15,

239

159

Dysdiadochokinesia, 323

Dysmetria,

315

Dystonia,

tubules, 136,

and

323

E

inner

ear

auditory

system,

auditory

atrial

septation,

fetal

circulation,

hearing embryology, middle

tube

derivatives,

heart

tube

septation,

third

212

diseases,

vestibular

system,

pharyngeal epiblast

12,

derivatives,

pectinate

12,

gut

tube,

pregnancy, levels,

8, 170

Endocardial

9 nuclei,

accommodation,

287

327, light

Eisenmenger

328

reflex,

complex,

Ejaculate,

163,

327

59

164

Ejaculatory

ducts,

ejaculation,

150,

156,

163

164

embryology,

as

136,

147

of kidney,

122

pancreas,

101

pectinate

line,

median

nerve

258

lesion,

musculocutaneous radial

nerve

radiology, ulnar

lesion,

lesion,

186

185

nerve

Electrolyte Emboliform Embryoblast,

balance

186 by

nucleus, 7,

kidneys, 312,

140

embryonic

291, 165,

115,

95

Epiblast,

170,

117,

114, 48,

Ependymal derivatives,

294 171 119

cells, 8–9

13,

type,

13,

Duchenne

palsy,

of

16

14

penis,

183–184

164

hypothalamic

lesions, and

139,

Esophageal

atresia,

Esophageal

hiatus,

341

B12,

113

145 37 80

hiatal hiatal

338,

vitamin

hernia,

hernia,

Esophageal

varices,

Esophageal

vein

80

106 132,

133

anastomoses,

132,

133

49 242

36–38 gut

tube,

portacaval

anastomoses,

radiology,

82,

left superior

117

Estradiol

96

110–112

atrium

132,

and,

64

mediastinum,

66, fistula,

from

133

84

tracheoesophageal

cells

respiratory,

mesentery

tissue

histology,

136

290,

gastrointestinal,

80

146

14

14–15

123

junctions,

primitive

136

Enteroendocrine

8–9

elements,

embryology, 36

sinus,

Enterocytes,

314

145,

16–18

alongside,

Esophagus

95

Endometrium,

Embryology diaphragm,

urogenital

Endolymph,

lesion,

96

system,

bladder,

192

210

tube,

94

respiratory

nerve

139,

15

13–14

sliding

pouches,

epithelia,

185

tissue

esophageal 108

gut

molecules, specializations,

Erythropoietin,

229

derivatives, reflex,

Erb

59

10

101,

primitive

Elbow tendon

57,

12

74

Erection

12,

pharyngeal

134,

surface

Erythrocytes

gastrulation, liver,

adhesion

cell

tight

247

74

derivatives,

164

Ejaculation,

219,

Endoderm

326,

derivatives,

cell

heart,

8–9

functions

229

10,

13–14

polarity,

50

Endocrine

sac

cytoskeletal

cushions,

12,

16

36

hepatocytes,

218,

Endocardium,

Westphal

pupillary

Emphysema,

135

21

veins,

99–101

341

derivatives,

connective

134–135

disk,

Emissary

96

36

column,

Embryonic 210

yolk

134–136

97,

vertebral

108

grooves,

primitive

225

10–12

septum,

97,

10

layer

histology,

system,

95

Winslow),

membrane,

respiratory,

225

urorectal

338,

gastrulation,

52

60

system,

(of

148

germ

59,

pain,

foramen

embryology

134

urinary

10,

line,

pharyngeal

deep

57,

29

29

86

basement

225

surfactant,

weeks,

53,

kidneys,

system,

Edinger

211

10

12,

8–9

eighth

27, 27,

referred

Epithalamus,

36–38 and

209

Epithelia

10,

system,

respiratory

10

nervous

Ectopic

229

arch origins,

gastrulation,

hCG

origins,

to

60–63

225–226

week,

anesthesia,

Epispadias,

59

laceration,

27

puncture,

Epiploic

56–63

artery

218 26,

foregut

72

septation,

system,

neurulation, 10,

54,

350

space

lumbar

53

29

218

meningeal

epidural

septation,

kidney,

293–296

Ectoderm derivatives,

middle

136

cranial,

arteriosus

heart,

291

space,

Epigastrium,

tube,

second

292

211, ear

epidural

54–56

corticosteroids

291,

220–221,

56–59

heart

respiratory

293

loss,

hematoma,

Epidural

heart

ectoderm

17

291–293

tests,

27,

Epidural

spinal,

nervous

stereocilia,

134,

162 anesthesia,

210–215

ventricular 290–292

17

Epidural

89

147

neck,

truncus

Ears anatomy,

tissue,

162

164

vasectomy,

95

heart

315

Dyskinesias,

head

94,

connective

mesonephric

Kartagener

156,

ejaculation,

147

extraperitoneal

cilia,

74

Epididymis,

microvilli,

tube,

9

10

Epicardium,

101–102

10

gonads,

Dynein

96

98–99 gut

mesoderm,

gastrulation,

foregut

primitive

10

extraembryonic

peritoneum, 247

ectoderm,

7–8

gastrointestinal

mater

cranial,

first

granulosa

67 37,

cells,

38 167

Estrogen granulosa ovary

lutein embryology,

cells,

169

3

37

ANATOMY

Anatomy

Immunology

Eustachian

tube,

Eversion

loss

Expressive

290,

in

291

foot,

aphasia,

External 89,

199

muscle,

91 nucleus,

External

iliac

External

spermatic

126,

200,

fascia,

Extraembryonic Extrahepatic Physiology Extraperitoneal

biliary

89,

See

atresia,

Lower

91

tendon

injuries, radiology, neck

Upper

limbs

control,

nystagmus,

296–300

meiotic

Fovea,

326

Frequency

170

division,

test,

vestibular, orbital

BehavioralScience/Social Sciences

295 294,

muscles,

vestibulo

visual Microbiology

Fibular

221–222

Filiform

stem

reflex,

282,

integrity,

field

defects,

visual

pathways,

visual

reflexes,

293,

295,

294

296

326,

papillae,

Filum

326–329

agnosia,

First

arch

First

jejunal

Flaccid F

354

syndrome, artery,

embryology, prechordal facial

plate,

paralysis,

289,

corticobulbar oral salivary

glands, colliculus,

Facial

nerves

120–121

(CN

279,

fibers,

embryology,

288,

287

281,

nuclei, tongue

291,

218–219 91 263–265,

263–265,

nucleus,

312,

vitamins 199,

201,

269 269,

314 in

liver,

125

pelvic

Female

anatomy,

pseudointersexuality,

151,

155 147

Femoral

arteries,

200,

Femoral

hernias,

94,

triangle,

injuries,

198

lumbosacral

pollicis

Flexor

withdrawal

sheath,

Femoral

triangle,

Fundus

(uterus),

papillae,

190 190

271

312

294

Foramen

ovale

atrial

septation,

fetal

circulation,

195,

196

201

g

head,

202

reflex

activity,

254–255,

258–260

aminobutyric

acid

(GABA),

213

Gap 217

junctions,

ovarian

56–58

54–56

16–17 follicles,

Gastric

glands,

Gastric

pits,

167 110,

110,

Gastroduodenal

57

artery,

Gastroepiploic 57

113

113 127,

artery,

Gastrointestinal

128

128

system

embryology supply,

collateral

187–190 circulation,

tendon

189,

reflex,

190

258

181 182,

183

rotation,

95,

midgut

rotation,

99

organ

development,

95–97,

gut

tube,

94,

95

glands

95

liver,

artery,

126 95

duodenum

boundary,

respiratory

system

122–125

pancreas, salivary, 36–38

121–122

132

108–109

regional immune

131,

exocrine, 120–121

107 origins,

95–97 vein,

96

98–99

primitive

227 94,

foregut

peritoneum,

derivatives,

splenic

and

317–319

Forearm

rotation,

Femurs of

tone

histology,

201

271

259

169

54,

secundum,

254–256,

260–261

muscle

216,

Foramen

100

4, 5 motoneurons,

166,

212,

primum,

102

membranes,

lesions,

199

Foramen

celiac

89,

198,

magnum,

Foregut,

201

101,

Gametogenesis,

140

247

125

Gamma

kidneys,

217,

104–105

reflexes,

cecum,

deep

aponeurotica,

peritoneal

310,

198–199

274

embryology,

260 309,

injuries,

dorsalis,

histology,

preventing,

Foramen

152 213

315

plexus

Gallbladder,

213

Foramen

125

111

97

268,

lumbar

190

development,

drop,”

151,

papillae,

tabes

reflex,

by

105,

360

abnormalities

Galea

system,

Follicular

48

superficialis,

balance

351

106,

fascia,

Gait

18

lobe,

Forebrain,

necrosis

18,

longus,

sensory,

201

plexus,

Femoral

273

profundus,

innervation,

201

nerves

femoral

avascular

digitorum

Flexor

arterial

205

Female

Femoral

Flexor

“Foot

Oviducts

89,

gracilis,

198,

159

digitorum

progesterone 103

sinuses, 88,

soluble

305

247

cuneatus,

Fastigial

304,

213

See

inguinalis,

(stomach),

167–168

217,

venous

Fasciculus

299,

101,

tubes.

cerebri,

Fasciculus

spermatozoa,

285

ligament,

Fallopian

15,

Foliate

innervation,

Falciform

microtubules,

Fluid

289,

283,

271,

syndrome,

vestibular

289

281

lesions,

(gallbladder),

Fundus

ataxia,

Flexor

352, 345,

G 257,

Flocculonodular

211

functions,

Feet,

VII)

275–277,

corticobulbar

Falx

112

279

stem,

dural

288

histology,

Facial

Falx

299

syndrome,

269,

303

weakness,

Kartagener

9

fibers,

cavity

brain

8,

352

lobe homunculus,

Fusion 261,

360

351

Fundus

Flagella

214

351–352,

Fungiform

129 260,

272–274,

Face

215

paralysis,

Flaccid

253

169

351

351,

motor

27,

165,

268

344,

frontal

213

terminale,

Finger 330

203

hearing,

360

lobe,

lesions, ligaments,

and

cortex,

Frontal

206

72

296–298

352,

anatomy,

collateral

Fimbriae,

331–333 325,

68–69

58,

sound

field,

cerebral

205

56,

ataxia, eye

lesions,

radiology,

296

ocular

brain

203,

of

Frontal

See

321

363

291

Friedreich

168

54–56

pericardium,

Fibula,

55,

290,

development.

Fibrous

296

Pathology caloric

374

ovalis,

8

circulation,

Fetal

362, 151

Fossa

Embryology

movement

Fat

8,

7,

344

section,

circuit,

posterior,

pregnancy,

276,

ganglia

Papez

168

second

anatomy,

basal

202

embryology,

Eyes

258–259

206

fractures,

Fetal

brain

reflex,

203–205

ectopic

102 Medical Genetics tissue, 89

limbs;

Fornix 203–205

Fertilization,

9

connective

Extremities.

201

87,

mesoderm,

87,

Biochemistry 268

267,

arteries,

202

joints,

deep

oblique

cuneate

joint,

knee

352

abdominal

Pharmacology External

hip

198,

bile

differences, functions,

transport

110–111 110

of

IgA,

12

101–102

INDEX

gut

associated 110,

lymphatic

116,

ileum,

109,

112

patches,

innervation, intra

110,

116,

118

retroperitoneal

mucous

organs,

cells,

stomach,

110,

99

See

95,

97,

101,

102

Hair

dysfunction

conjugate

315

gaze,

3

embryology,

3,

4,

91,

extraperitoneal

female

136,

147

connective

mesonephric

system,

151,

pelvis,

150,

urogenital

134,

152,

152–153,

Gerstmann

syndrome,

353,

Gestational

trophoblastic

“Hand

Glial

cells,

Glial

fibrillary

360

disease,

9

(radiology),

Globose

cells

Haustra,

nucleus,

192

protein

312,

239

314

140

corpuscle,

275–277,

motor

See

also

See

281, 283

tongue

innervation,

“Glove

and

Goblet

cells cells,

large

48

intestine,

respiratory

116,

intestine, cells,

Golgi

tendon

Gonadal

supply,

blood

flow,

fetal,

(GTOs), 126,

colchicine, follicles, cells

circuitry,

(cerebellum),

cells,

130 15

166,

311–314

Granulosa

259

168 311–313

drainage, 74,

cells,

75

152

38

80

92–93 hernia,

virus,

25

239

Hilar

nodes,

lymph of

106

24,

triangle,

axon,

92,

93

44 238

hepatic,

104,

123

227

colon

77–78

boundary,

78–79 74 74,

78,

95

inferior

mesenteric

artery,

inferior

mesenteric

vein,

primitive 79

trabecula,

gut

rectum, 73,

79

fetal

circulation,

56–59

Hip

54–56

heart

tube,

heart

tube

derivatives,

heart

tube

septation,

54,

72

septation,

135–136

necrosis

injury, 60–63

132

95

202

dislocation

56–63

168–169 septation,

joints,

femur,

166–168 arteriosus

septum,

avascular

53

94,

96

urorectal septation,

tube,

129 131,

107

septation,

embryology atrial

107

derivatives,

discs, fibers,

ventricular

and,

hernia,

Hesselbach’s

75

system,

truncus lutein

71,

vagina,

Hindgut

septomarginal

organs

into

hypoplasia

Hindbrain,

70

Purkinje

105,

80

disk,

Hilum,

79

intercalated

311–313

rectum

hiatal

Hillock

72–73

projections,

Vater,

94

Herpes 54–56

69–71

surfaces,

103

of

125

hiatal

Herniated

76–77 72–73

conduction

115–117

arteries, and

119 48

or

femoral,

292

70

auscultation,

system,

Golgi

239

122,

sliding

flow,

100,

ampulla

pulmonary

292

blood

100,

ligament,

inguinal,

venous

brush

small

227,

ligament, 104

esophageal

291,

surface

weakness,

122–123

diaphragmatic, 292

causing,

104 101

Hernias

system

291,

123

124

bladder

innervation,

stocking”

174–175

Hepatogastric

293

chambers,

213

hilus,

radiology,

107,

tests,

131–133

122,

Hepatopancreatic

Auditory

borders,

303

nuclei,

215

loss

arterial

283

system, flow,

cavity,

Cranium

anatomy,

281

lesions,

214,

131–133

100

peritoneal

103,

Heart

211

functions,

Granule

146 IX)

279

nucleus,

embryology,

Graafian

(CN

5, 158

173

55

portal

central

127

124

foramen,

liver

209

sensorineural,

142–144,

nerves

stem,

dorsal

140

141,

4,

123,

circulation,

blood

123,

122

(radiology),

Hepatocytes,

210–215

lesions

Glossopharyngeal

vein

187

abnormalities,

conductive,

139,

185,

meiosis,

supply,

Hearing

134 anatomy,

system,

portal

liver

133 104,

105

Hepatoduodenal

auditory

kidney

portal

Hepatic

118

Hearing. 321

Glomeruli circulation,

Hepatic

zones,

congenital

(GFAP),

317–319,

embryology,

in

embryology,

pallidus,

lobules,

hepatic

Head

239–240 acidic

Hepatic

183

benediction,”

arterial

fossa

flexure

190

132, 101,

value,

ducts,

193

of

Haploid

354,

189,

flow

Hepatic

181 182,

radiology,

326

Glenoid

circulation,

100,

blood

epiploic

sensory,

155

arteries,

fetal

338

17

anastomoses,

Hepatic

187–190

innervation,

136

154

triangle,

Glaucoma,

89

155

153,

292

293

supply,

collateral tissue,

tubules,

pelvis,

291,

323, 16,

108

rectal

Hand arterial

brain

Hemorrhoids,

290

vestibular

sex,

Genitalia

renal

tube

343–344

341

system,

322,

Hemidesmosomes,

cells

endolymph,

296–300

determining

blood

gut

cortex,

nuclei,

auditory lesions,

Globus

Primitive

114

12

331

118

liver

Habenular

10

cerebellar

Hemianopia,

H

ligament,

Gastrulation,

male

116,

infection,

9,

Hemiballismus,

110,

cerebral

(GALT),

118

75

53

pylori

Hepatic

103

Gastrosplenic

Gout

of

cells,

Hematopoiesis,

98

Gastroschisis,

Genes

tube.

74,

failure

Helicobacter 241 tissue

69

74–76

auscultation, Heart

92

116,

patches,

Gyri

192 153

lymphatic

110,

mediastinum,

murmurs,

syndrome,

associated

Gut

78

glands, 91,

Peyer’s

119

77,

(radiology),

Barre

109,

113

cavity,

peritoneum,

vestibular

116

115–117, 111,

peritoneal

tubercle

Greater

73–74

middle

vein,

Greater

Gut

glands,

goblet

histology,

233

cardiac

Guillain

99

production

Brunner

352 32,

Gubernaculum,

109–110 vs.

reflex, rami,

Great cells,

Peyer’s

Grasp Gray

116

Langerhans

Gaze

tissue,

118

innervation,

of

head

of

202 and

sciatic

nerve

199 195–197

59

37

ANATOMY

Anatomy

Immunology

Hippocampus

radiology,

lesions,

360

anterograde

amnesia,

Kluver

Bucy hippocampal bodies,

237

Papez

circuit,

362–364

364 361, 363 Biochemistry

336

disease,

109,

231

adhesion

cell

surface

molecules,

cytoskeletal

elements,

mole, 9, 11

liver,

pancreas,

glands,

small

120–121

intestine,

stomach, heart,

Nissl

substance,

Schwann

241,

ovaries,

167–170 154

testes

and

accessory

170,

vagina,

glands,

46,

49

339–341

lesions,

system,

361,

364

365

diverticulum,

ileal

Iliac

337–341

31,

232,

269,

274,

305 abnormalities, outlet

chorionic

placenta,

329

syndrome,

kidney,

and

110,

282,

gonadotropin 9,

(hCG)

crest

and

116,

vessels,

Immune

system

Inferior

mesenteric

vein,

Inferior

olivary

Inferior

pancreaticoduodenal

Inferior

phrenic

Inferior

sagittal

Inferior

vena

fracture,

185,

187,

192

infant

130

arteries,

arteries,

cava,

128,

system,

110

of

125

IgA,

canal,

lymphatic

tissue,

109,

191 165,

168,

169

91

inguinal

ring,

89,

contents, triangle,

92,

93

90–91 inguinal

Inguinal

ligament,

ring,

87,

89,

90

92–94 86–88,

triangle, vs.

91

201

femoral of

and

90

90

contents,

hernias,

hernias,

heart

94

valves,

74,

corticosteroids,

75

52

15

Intercalated

discs,

Intercalated

ducts

Interlaminar

247

90

Inguinal

Intercostal

219,

174–177

73,

salivary

126 217,

130–132

muscles,

Integrins,

90

116,

74

exocrine, glands, spaces,

122 120 38

spaces, flava,

22 27,

29

118 118 cells,

patches, passive

129, 132

279

sinus,

Infundibulum,

ligamenta

Peyer’s

196 126, 131,

nuclei,

Infraspinatus

lumbar

191

195, artery,

pancreas,

Langerhans 187,

29

202

associated

116,

91

197

plexus,

Insufficiency

Radiology

transport

110,

89,

nerves,

mesenteric

Insulin

nerve,

ileum,

186,

puncture,

ligament,

See

303

292

Inferior

inguinal lumbar

Imaging.

gut

118

137

Ilioinguinal

lesions,

198

femoral

173

muscle,

11

Humerus dislocation,

114–118 103

activity,

bile

pregnancy,

111,

gastrointestinal

207

137

169

shaft

gluteal

superficial

98

Iliofemoral

193

syndrome,

thoracic

epigastric

Inferior

inguinal

129

diverticulum,

Iliacus

140 Hamate,

Horseshoe

Inferior

male

immune

228

hypothalamus,

128,

107

radiology,

304,

287

female

103

artery,

histology,

139–146

240

Homeostasis

pupillary

system,

Inguinal

embryology,

Holoprosencephaly,

kidneys,

peduncle

midbrain,

radiology,

282

315

Ileum,

system,

levels

stem

52

37

129

338–341

Ileocolic

13

1 virus,

Human

282

39,

276–278

auditory

deep

Ileal

49–50

46–49

urinary

Horner

277–280,

I

46,

types,

of

344

functions,

Hypotonia,

45–46

trachea,

colliculi,

boundaries,

bronchioles, overview,

cerebellar

Inferior

39

syndrome, fistula,

lumbosacral

50–53

bronchi,

Hook

213

60

syndrome,

distress

Inferior

287

radiology,

system

alveoli,

303

fibers,

37 arteriosus,

tracheoesophageal

284

limbic

171

171

respiratory

288

303–305

brain

156–165

93

172

distress

respiratory

337–341

lesions,

penis,

respiratory

hemispheres,

pons,

116,

ductus

injuries,

endocrine

6 92,

development,

XII)

276

midbrain,

242

4,

hernias,

immunity,

patent

148

lesions,

3,

inguinal

passive

279

302,

innervation,

systems

uterus,

281,

tongue

235–237

cells,

reproductive

102

211

descending

235–239

211

Infants

281

nuclei,

214

291

95

(CN

fibers,

284

241–242

170

341

gonads,

lung pain,

275–277,

cerebral

8

premature

nuclei,

system

neurons,

stenosis,

nerves

anatomy,

73–74

axons,

150

8,

338,

290,

240

7,

9

foramen,

Indifferent

Hypothalamus

110–114

nervous

prostate,

CNS,

zygote,

embryology, 308

86

stem,

levels,

Impotence,

306,

172

with

pregnancy,

hCG

248

referred

Hypospadias,

114–118

of

Incus,

pyloric

lesions,

110–111

Implantation ectopic

8–10

functions, 121–122

link

Incisive

the

embryology,

differences,

salivary

of

glands,

microglia

Indirect

corticobulbar

exocrine,

regional

47

39

291

brain

112

trachea,

11

228,

Hypoglossal

122–125 cavity,

323 of

syndrome,

hindgut

118–119

192

148

Hyperacusis,

125

intestine,

Microbiology oral

HIV

92,

Hypogastrium,

110–112

gallbladder,

tissue

levels,

187,

disease,

hCG

Hypoblast,

14–15

322,

Hydatidiform

BehavioralScience/Social Sciences 108–109

system,

esophagus,

large

16–18

186,

rings

Hypertrophic

15

specializations,

Pathology gastrointestinal

376

membrane

Hyperplasia

13–14

cell

mid

cartilage

Hyaline

Hydrocephalus,

Medical Genetics

13

epithelia,

head

Hyaline

Hydrocele,

103,

fracture,

disease,

Parinaud

Histology Physiology definition,

mammary

neck

Huntington

formation,

deficiency,

Hirschsprung

364

syndrome,

limbic Pharmacology Negri

thiamine

192

surgical

112 110,

immunity,

116,

puncture,

27,

Intermediate

filaments,

Intermediate

mesoderm,

29 15,

17

3,

10

118 116,

172

Intermediate

zone

of

spinal

cord,

252,

25

INDEX

Internal

abdominal 89,

oblique

arcuate

Internal

capsule

arterial

fibers,

Internal

320,

tract,

257

thrombosis, cerebral

iliac

arteries,

Internal

jugular

mammary

Internal

pudendal

Internal

spermatic

drainage,

43,

218,

artery,

artery, sphincter,

vertebral

65,

91

disks,

Intervertebral

Intracerebral

26

350

fibers,

256,

motoneurons,

reflexes,

258

pressure,

Intraperitoneal

326

tail,

Intrinsic

organs

factor,

Lateral

ligament

Lateral

medullary

Lateral

menisci,

17

Lateral

mesoderm,

Lateral

plantar

Lateral

pontine

Lateral

sulcus,

versus, 98,

99

99

medial

meniscus,

364

258–259

ligament,

bronchial

reflex,

259

203,

205

339,

fossa,

152 muscle,

ejaculation, Ischiofemoral

of

tumors,

Left

gastric

artery,

Left

gastric

vein,

Left

gastroepiploic

Left

renal

ramus,

202 155

Langerhans, of

Ito

125

121,

uterus,

Labia

minora,

165,

122 169

Left

to

147 172

Lacunar

ligament,

Laminae

of

Lamina

propria

109, small obstructive,

Jejunum,

107

digestion,

radiology,

lymphatic

tissue,

cells,

116 98 110, 173,

dominant 111, 176

114–118

Large

110

intestine,

Laryngotracheal

347,

352–354,

hemisphere

septal

59,

diverticulum,

defects,

and,

346

36

68

63

convergence

reaction,

328 240–241

237

149

disease,

322

cells interstitial

tissues,

157,

secretion, flava,

3,

27,

160,

161

160

29

arteriosum of

the

aorta,

circulation,

55,

ductus

66,

Ligamentum

capitis

Ligamentum

teres

Ligamentum

venosum,

reflex,

68

56

arteriosus,

anatomy,

60

70 femorum,

of

liver,

202 55,

55,

56,

104

56

277

system

anatomy,

361,

functions,

361,

olfactory

system, circuit, See

363 363 361–363 362,

Lower

alba,

Upper

limbs

85 85

Gennari,

346,

355

gyrus

lesions,

333

Meyer’s

loop,

radiology,

363

limbs;

semilunaris, of

Lingual

118–119

63,

326

bodies,

Linea

360

60, 59

muscle,

Linea

112

63 63

hypertension,

ani

Limbs. 115

59,

arteriosus,

Parkinson

Line

aphasias,

58, 58,

eye,

Papez

118

intestine,

Langerhans

109,

Language

embryology, histology,

105

mucosa,

112

associated

J

GI

128 130

defects,

ductus

Limbic

116

177

shunts

septal

of

(radiology),

126–128

noncyanotic,

Light 23

of

duodenum, esophagus,

Jaundice,

87

vertebrae,

76,

130

artery

artery,

right

heart

155

embryology,

gut

147

artery,

compression,

Ligamentum

embryology,

(LAD)

132

vein

Ligamenta

49

122

35

129, iliac

testosterone

L

Lactation,

ligament,

Isthmus cells,

153

164

Ischiopubic

artery,

patent

Ischiocavernosus

artery, descending

common

testis

364

48

304–305

351

79

Leydig 336,

199

344,

colic

fetal majora

303

syndrome,

Left

Lewy

205

ligament,

metastatic

Labia

205

204

Leukodystrophies,

205

204,

cells,

cells,

269

10

thoracic

Levator

syndrome,

Kupffer

ankle,

accommodation

206

(K)

32,

292

nerves,

ventricular

204

collateral

356

30,

syndrome, 203,

coarctation

stretch

88

Ischioanal

of

anterior

Lens

cruciate signs,

355,

28,

291,

Left

328 spine,

system,

332,

284

patent

113

muscle 326,

360,

reflex,

drawer

212 192

gray

327,

Kulchitsky

peritoneum,

cysts,

pulmonary

syndrome,

tendon

Korsakoff

105

retroperitoneal visceral

238

184

203–205

radiology,

106

pancreas

lemniscus

atrial

transport,

joints,

tibial

organs

duodenum,

Lateral

as

anterior

254–256

258–260

Intraocular

177

paralysis,

deep

matter,

injuries

muscle

gamma

176,

Bucy

Knee

146

137

anterograde

Kluver

365

Intrafusal

Inverse

fast

129

145,

15

Klumpke’s 22–24,

128,

139,

97

140

calculi,

Kinesin,

59

hemorrhage,

radiology,

77

mesentery,

175–176

renal

body,

horn

77,

139–146

radiology,

geniculate

Lateral

136

functions,

ureters,

76,

22–24

arteries,

27

314

foramina,

Intestinal

26, 282

Lateral

Left

134–135

by,

epicondyle,

Lateral 136–137

38,

homeostasis

plexus,

312,

140

embryonic

histology, 138

septum,

Intervertebral

15,

140

agenesis,

endocrine

35

arteries,

Interventricular

49

filaments,

abnormalities,

dorsal

89,

venous

nucleus,

323

tumors,

circulation,

renal

Lateral

48

139,

embryology,

ophthalmoplegia,

Interventricular

67

35

fascia,

urethral

Interposed

137,

blood

152

thoracic

Internuclear

45,

artery,

Internal

170

intermediate

congenital

Internal

Internal

as

anatomy,

247

Internal

cells,

cervical

pons,

322,

211

Lateral

auditory

48

Kidneys

66

drainage,

and, ring,

metastatic

Keratins

126

sinus

146

18,

transport Fleischer

K (Kulchitsky)

332

veins,

venous

lymphatic

complex,

bronchial

Internal

247

syndrome,

ovum

349 defects,

219,

217

Kayser

346–348

field

219,

sinuses,

Kartagener 220

46

embryology,

K

219,

cortex,

Larynx,

218

321

220

radiology,

216

vein,

sigmoid

arteries sinuses,

visual

foramen,

Juxtaglomerular

318,

carotid

cavernous

dural

280

357

ganglia,

corticospinal

Islets

Jugular

syndrome,

supply,

basal

Ischial

88,

jugular

Internal

Iris,

muscle,

91

331,

332

365

37

ANATOMY

Anatomy

Immunology

Lingula

of

Lithiasis,

left

lung,

biliary,

Liver,

bladder,

125

103–104

embryology, Pharmacology

43

97,

ventral

zones,

internal

arcuate

36

medulla,

282

95, 97, Biochemistry

internal

124 122–125

lobules, Physiology peritoneal

123,

storage,

125

caeruleus,

Long

nerve,

Lower

testes,

91

35,

182

141,

scrotum,

91

joints,

43–45 116

arterial

108

43–45

superior

65

mediastinum,

67

200–201

feet,

198,

199,

femoral hip

Macrophages, Macula

201,

205

triangle,

joints,

(eye),

circulation,

201

355,

202

hemianopia

and

gait,

lumbosacral

plexus,

segmental,

195–197

joints,

Macula

203–205

radiology, Lumbar

arteries,

Lumbar

plexus,

253

nerve,

parietal

puncture,

27,

Lumbar

splanchnic

ejaculation, Lumbar

138

crest

and

Lumbosacral

plexus,

collateral

puncture,

29

195–196

nerves,

injuries,

also

Papez

42–43

aspiration

of

auscultation, cancer, apex

nuclei,

of

Marcus lung,

42

362,

embryology,

45

primitive

gut

pulmonary

95,

hypoplasia,

histology,

96

lymphatic

43–45

39–41

tracheoesophageal also

Luteinizing Lymphatic abdominal

artery,

fistula,

Surfactant

38

Meckel

168

system 90

Medial

130 lesion,

35,

210,

186–187

Median

sacral

Median

umbilical

219,

artery,

thoracic

anterior,

64

280

inferior,

63 pleura,

68–69

(See

40

also

diverticulum,

40

angle,

63,

63,

Medulla,

64,

66

65–67

282–283 276,

277,

279,

280

hemispheres, nerves,

344

275,

277,

279,

103

medullary

syndrome,

302–303

365 4, 5 in

microtubules

See Meniere

231 ligaments, body,

203 292

Meningeal dural

280

227

of follicle,

cytokinesis,

mitotic 167,

tubule, plexus,

109,

spindle,

110 septal

361

336

also

Alzheimer disease, dural

venous

disease 295 layer,

sinuses,

15

158

364 system,

15

168

ventricular

thalamus,

Hirschsprung

Heart)

64–65

limbic

geniculate

38

parietal 66,

amnesias,

286

collateral

42

lung,

Memory

280

and

136

of

cavity,

Membranous

220

126 ligament,

63–69

Meissner’s

220

193

193

surface

ovarian

211

190 190,

183

seminiferous

sinus,

disease, Medial

192, 182,

microfilaments

nerves

Meconium

hormone,

wall,

37,

129,

nerve

56

185–187

Meiosis,

329

embryology,

nuclei,

183, 183,

radiology, pupil,

305

55,

179–181

tunnel,

medial

213

304,

ligaments,

plexus,

carpal

cranial

280

lesions,

nerves

306–307

199

syndrome,

cerebral

286

functions,

drainage,

Median

302–303

204

syndrome,

embryology,

thrombosis,

45–53

umbilical

anatomy,

280

cavernous

38

211

211

Maxillary

tube,

210,

nerves

Gunn

Maxilla

36–38

pontine

Medial

superior,

365

Mastectomy

diseases,

Medial

sternal

363–364

297

294

nerves,

pneumothorax,

344

embryology,

Marginal

44

plantar

middle,

341

339

tongue,

45

capillary

See

43

43

metastasis,

pleura,

body,

338,

339,

circuit,

lesions, foreign

midbrain

Medial

posterior,

functions,

anatomy,

Medial

293,

203,

mediastinal

embryology,

Lungs

172

276,

Mandibular

193

menisci,

adult

bodies,

Mandible

198–199

Cancers

296,

300

syndrome,

Mediastinum,

Breasts

radiology,

197

Medial

Mediastinal

211

lesions,

lumbar

154

291

glands,

anatomy, 22

107

153, 147

See 290,

Mammillary

164

150,

pseudointersexuality,

See

nerves,

vertebrae,

Lunate,

29

105,

anatomy,

Mammary

medullary

sensory,

16

embryology, 98

fibers,

Medial

radiology,

293

papilla,

pelvic

Malleus,

90

peritoneum,

Lumbar

system),

gaze, 298,

287

lesions,

Malignancies.

251,

ilioinguinal

355

adherens,

Male 126

sparing,

(MLF)

282

297,

syndrome,

duodenal

Male

206

macular

279,

284

brachial

(vestibular

Major

350,

333

Macula

199

332,

with

lesions,

197

sensory,

iliac

198–199

53

359

331,

injuries

51,

326

collateral

innervation

knee

alveolar,

205

conjugate

vestibular

mediastinum,

ankle, fasciculus

282,

pons, duct,

of

278,

midbrain,

91

posterior

145

210

longitudinal

lesions,

280

302–305

ligament

horizontal

fibers,

287

Medial

116

line,

282,

Medial

44–45

271

282

284

anatomy,

M

supply,

embryology, Microbiology

pons,

lungs,

thoracic

205

27

277–279,

midbrain,

limbs

ankle

378

plexus,

ileum,

BehavioralScience/Social Sciences

Henle,

and

testes,

186–187

of

penis

venous

stem,

lesions,

pectinate

308

thoracic

Pathologylesions, Loop

Medical Genetics

100

174–175

vitamin Locus

44

duodenum,

membranes,

radiology,

vertebral

lung,

drainage,

124

263–265,

metastasis

122–123

histology,

brain

breast, mesentery,

lemniscus,

cancer 101

embryonic

Medial

36

101 hepatocytes,

138

breast,

217 218–21

defect,

59

INDEX

Meninges

Microvilli,

cranial,

217–218

spaces

of,

spinal,

218, 217

of

Menstrual

27,

knees,

29

203

missed

in

339,

341 10

phase,

Mesangial

cells,

medial

287

227

95,

histology,

97,

98,

101

108

intra

vs.

retroperitoneal

mesoappendix,

organs,

99

107

peritoneum,

98–100

Mesocolon,

98

Mesoderm 10,

12,

pharyngeal

229

arch

derivatives,

extraembryonic, face,

211

9

365

substantia

nigra,

cardiac

Middle

cerebral

heart,

10

endocardial

cushions,

hematopoiesis,

332,

radiology,

349

Middle

colic

Middle

meningeal

134

nervous

system,

Middle

suprarenal 94,

210

39 gut

respiratory

tube,

94,

system,

spleen,

96

36

107

Mesometrium,

210

Mesonephric embryology,

(Wolffian),

3,

4,

136

Mitotic Mitral

of

Gartner,

Mesonephros,

147

vein,

131,

spermatozoa,

in

152

of

132

Mesothelioma,

45

cytokinesis,

mitotic

15

spindle,

15

of

gallbladder

GI

serosa,

15

covered

by,

125

73,

levels,

Metanephric

mass,

Metanephros,

134,

135

134

Metencephalon, Meyer’s

309

loop,

331,

7,

9,

Mossy

fibers,

Motor

cortex

basal

332

cerebral lesions,

333,

14–15,

Microtubules,

237

transport,

237–239 and,

parotid

of

317–319,

324

332 glands,

121

74–76

74,

stretch

241

salivary

heart,

75

reflex,

258–259

Muscularis

externa,

108–110,

Muscularis

mucosa,

109,

112 110,

115

nerves plexus,

183,

179–181

184

186,

187

183 328 227

sheath initial

disorders

segment, of

subacute

lobe,

239

238 159

237

351, areas,

360

238

myelination, combined

240–241 degeneration,

273,

radiology,

365

274 neuron

351

homunculus, gyrus,

345, 256,

257

optic Schwann

lesions, reflexes, autonomic

vitamin

motoneurons,

254–256,

271

260–261

Myocardial

nerves,

30,

230

Myotatic

238 240

325 cells

B12

forming,

165,

113 76

histology,

reflex,

240

deficiency,

infarction,

Myometrium, system,

236, forming,

Myocardium

258–260 nervous

structure,

oligodendrocytes

351

system

alpha

15

cytoskeleton,

spermatozoa,

227,

18

protein,

pathways,

precentral

Motor and,

neuron

and

Myelin

312–313

cortex

motor

neuropathies

colchicine

lesions,

Myelencephalon,

functional 15

15,

329

nerve

Murmurs

axon

frontal

240

axonal

(MS), pupil,

Mydriasis,

11

310,

3,

347

Microfilaments, Microglia,

111,

(MIF),

afferent

sensory,

8

ganglia

stomach,

sclerosis

lesions,

79 11

152 Morula,

of

factor

optic

injury,

pregnancies,

hCG Mesovarium,

114

3, 4

inhibiting

brachial

73

74–76 band,

infection,

cells

Musculocutaneous

75

109 Molar

48

119

auscultation,

9

microtubules,

74,

Moderator Mesothelium

pylori

ducts,

Muscle

72,

H.

255

108–111

secreting

Mumps

8

flow,

tract,

and

relative

valve

murmurs,

254, system,

4, 160

159

syncytiotrophoblast,

auscultation,

252,

intestine,

Multiple

spindle

blood

tau

128

134–136

Mesosalpinx,

cilia,

artery,

328

7,

252–255 28,

GI

Mullerian

134–136

duct

of

288–289

271

escalator

unilateral

zygotes,

ducts

root,

Mullerian

mesenteric

in

also

113

mesenteric

none

152

259–261, horn,

Mucosa

98

in

(See

255–257 fibers,

ventral

103 96,

351

336

lower,

ventral

large

activity,

345,

335, and

Mucous

microfilaments

21,

130

reflex

259

258–260

gastric

microtubules

column,

126,

107 95

327,

and

271

cortex)

Mucociliary

Mitosis

102

vertebral

208

arteries,

Mitochondria

primitive

209

304,

258–260

lesions,

350

254–256,

homunculus,

upper

129

muscles,

duodenum,

Miosis,

359

arteries,

derivatives,

superior

arches,

tone

thalamus,

95

superior

pharyngeal

128,

boundary,

rotation,

12

353,

hematoma, scalene

muscle

reflexes,

347–349

347,

artery,

Middle

260–261

reflexes,

78

302,

226

corticobulbar

malrotation,

9

kidneys,

pleura,

57

77,

284

282,

346 225,

Motor

arteries,

261,

307

lesions,

motor

271 282,

motoneurons,

41 vein,

occlusion,

colon

53

287

271

269,

260,

embryology,

86

reflections,

Middle

257,

254–255, 278,

256,

277–279,

257,

gamma

lines,

Midgut,

214

gastrulation,

287–289

syndrome,

radiology,

epidural

derivatives,

stem,

neocortex,

277,

227 midbrain

pleural

embryonic,

287–289 275,

Midclavicular 107

256,

brain

306–307

286,

Mesenteries colon,

anatomy, 150

255, tracts

lesions,

276–278, nerves,

146

nuclei,

Mesencephalon,

150 149,

41

embryology,

8

145,

Mesencephalic

corticospinal

305,

cranial

pregnancy,

progestational

prostate, 138,

line,

anatomy, 338,

the

neurons,

138

Midbrain

cycle

amenorrhea,

system,

sphincters,

Midaxillary

cortex

motor

of

urethral

29

cerebral

nervous

hyperplasia 27,

puncture,

Meniscus

18 138

autonomic

anesthesia,

lumbar

first

247

25–27,

epidural

17,

Micturition,

73–74 170,

171

258–259

37

ANATOMY

Anatomy

Immunology regeneration

N Narrow

angle

NAVEL

contents

glaucoma, of

326

femoral

canal,

Neck supply,

cervical

209

parietal

embryology,

scalene

triangle,

thoracic Physiology

207,

outlet,

38,

syndrome,

Night

208

and

207

Medical Genetics

Argyll

axon

237

Neocortex,

Nitric

344–346

of

embryology, Pathology

135

histology,

BehavioralScience/Social Sciences

atrial

236,

blocks 27, 38 152 system.

system; Neural

See

Central

Peripheral

crest

colonic

nervous

system

cells

aganglionosis,

103,

derivatives,

12,

endocardial

cushion

ventricular

septal

59,

gastrulation, tube

formation,

derivatives, system

Schwann

cells,

pharyngeal

210,

arteriosus

Neural

plate,

Neural

tube,

225

240

arches,

fold,

30,

ambiguus,

225,

60,

61

cuneatus, gracilis,

Nucleus

pulposus,

225,

226, 10,

Neuroendocrine

cells

gastrointestinal,

229 12,

225,

48,

Neurofibrillary

test,

Neurohypophysis,

238, 2),

244

inclusions microglia

free

in,

production,

tangles,

protein,

240

238

235–239 241–242

356

237

275–278, sinus,

degeneration,

273,

15

247

211

276,

277,

280,

306,

307,

orbital

muscles,

221,

light

reflex,

297,

298

field

disc, nerves

anatomy,

fibers, system, 280, bulb, anatomy,

326,

293,

294

361–363 360,

362

276,

II)

field light

332,

333

defects, reflex,

pathway,

Optic

neuritis,

Optic

tract

lesions,

optic thalamus,

277

222

280,

visual

276,

280

lesions,

visual 361–362

363

327

326

332

326

(CN

anatomy,

visual

298,

340

331–332

330,

325,

pupillary 297,

defects,

pathway,

Optic

329

344

339,

functions, gaze,

321

hemispheres,

Optic

eye

287

brain

220,

219

333

brain

nuclei,

deficits,

veins, chiasm

visual

220

conjugate

Olfactory

240–241

III) 287

219,

280

olfactory

274 neurofilaments,

stem,

(CN

218,

280

visual

nerves

vestibular

combined

219

220

280

lesions,

sinus,

219, 220

hypothalamus,

horizontal

pupillary

235–237

disorders,

sinus,

cerebral

344

functions,

lesions,

238

substance,

nerves

286

Optic

360

347

359

anatomy,

embryology,

240

196

326 40

arteries,

functions,

355–356,

thrombosis,

237

radical

neurofibrillary

pneumothorax,

thrombosis,

198

cavernous

cytokines,

microglia

glaucoma,

cavernous

195,

lobe,

Oculomotor

240

239

seen

Open

315

nerves,

lesions,

brain

scars,

6

angle

occlusion,

296

167

167

Open

nuclei,

anatomy,

diseases

astroglial

subacute

295,

294–296

Occipital

237

238,

degenerative

development, 5,

Ophthalmic

24

166,

6 5

Ophthalmic

lesions,

injuries,

362

339

potential,

myelination

282

168

Oogonia

lesions,

Neurons

inclusions,

282 280,

25

vestibular,

Occipital

Nissl

280, 271,

23,

cerebellar

Obturator

15,

4, 4,

Ophthalmic

(type

Neurofilaments,

axons,

263,

229

49

Neurofibromatosis

166–168

meiosis,

283

O

tangles,

histology,

21

114

pulmonary,

action

23

296

caloric

6

ovulation,

meiosis,

166,

168

oogenesis,

follicular

263,

24,

Nystagmus,

226

5,

oogenesis,

Nucleus

226

225,

10,

303

Nucleus

54

7 development,

meiosis,

embryology,

279,

95,

103 veins,

325,

331–332 326,

327

326

332

333 field chiasm,

defects, 330

335,

33

331–332

103

103

Oocytes

63

15

herniation,

septation,

Neuroectoderm,

380

Nucleus

211

Omphalocele,

Oogenesis,

12,

column

100, 100,

mesentery,

Omphalomesenteric

226

pulposus,

lesions,

neurons,

225,

envelope,

53

postganglionic

Neural

68

12

embryology,

plate,

Nuclear

225–226

embryonic

follicular

germ

95

ligament, ligament,

fertilization, 11

neural

57,

12

system,

truncus

63,

225–226 development,

10,

defects,

chordoma,

nucleus

nervous

60, 59

229

214

heart

arteriosus,

layer

mesentery,

101

101

63

hypertension,

vertebral

tau

59,

pulmonary

nervous

109

59 face,

63

58,

Notochord

nervous

embryonic 100,

ventral

58,

29

intercostal,

38,

101

hepatogastric

shunts,

ductus

99,

hepatoduodenal

240

defects,

right

patent

epidural,

pudendal, Microbiology Nervous

to

agenesis,

100

141–146 left

renal

98

lesser,

164

conditions septic

bursa,

dorsal

Ranvier,

Noncyanotic

and

greater,

erection,

362 240

Omentum,

243 for

360,

276

Omental

238

oxide

Nodes

Nephrons

Nerve

Olive,

207

bodies,

280 280,

136

235–237

hillock,

I)

277

Oligohydramnios

Robertson

329

325

chromatolysis, Negri

functions,

225–226

substance,

(CN

276,

Oligodendrocytes,

327,

blindness,

Nissl

237

239

274,

Neurulation,

215

tract

anatomy,

lesions,

227,

pupils,

abnormalities,

Olfactory

238

Neurosyphilis

40

244

238 236,

protein,

210–215

congenital

243,

236,

Neuropathies,

Biochemistry

pleura,

of,

cytoskeleton,

201 tau

arterial Pharmacology

of,

structure

97,

INDEX

Oral

cavity

Paramesonephric

embryology,

8,

histology,

9,

glands,

120–121

of

Oval

window,

219 291

290,

eye

291

165

outflow,

embryology,

3,

fertilization,

7

follicular

151, 4,

152

147

166,

167–168

oogenesis,

4,

meiosis,

glands,

anal

penile

7

tubal anatomy,

pregnancy,

165, 7,

8, 168–170

cells layer,

of

ovulation,

female

168

male

Oxyntic

cells,

Oxytocin,

113

338,

114

of

heart.

See

Sinoatrial

pleura,

(SA)

anal 98,

anterolateral medial

sensory meniscus

peritonitis,

reflections,

tear,

in

primitive

gut

lesion,

thalamic

shoulder,

tube

structures,

265,

266,

pain

syndrome,

embryology,

214

Pampiniform

venous

Pancreas,

269 336

plexus,

Patau

anastomoses,

105,

127,

129

deep

102

embryology,

97,

foregut,

95,

exocrine

gland,

radiology,

101,

102

Patent

duct

of

hepatopancreatic

Wirsung, ampulla,

105, 105,

125 Paneth Papez

cells, circuit,

anterior Papillae Papillary

110, 362,

thalamic of

tongue,

muscles,

111,

115,

117

363–364 nuclei,

122

107,

122,

Pedicles

73

tendon

infants,

reflex,

116,

supporting of

diaphragm,

Pelvic

kidney,

Pelvic

splanchnic

group, 23,

36

63,

68

disease,

muscularis

externa, cavity,

89,

of

32, 138

164

109

116

101

98

testes,

33

female

92

origins,

primitive nerves,

103,

98

mesodermal

152

137

innervation,

27

109

99, 97,

Peritoneum,

as,

tract

109–110,

descent 149,

30

nerves

embryology

24

149

erection,

GI

embryology,

72 node

vertebrae,

Pelvic

cranial of

Peritoneal

muscles, lymph of

60,

239–240

235–240

neurons,

and

innervation, (PDA),

cells,

neurons,

Hirschsprung

108

30–32

244

225–229

and

spinal

228

system, 243,

postganglionic

172

258–259

arteriosus

line,

30 system,

225

histology

121

206

brim,

penile

120,

nervous

regeneration,

Peristalsis

Pelvic

bladder

213 72,

336

106,

Pectoral

of

glial

323

holoprosencephaly,

ductus

system, nervous

embryology,

341

203

Pectinate

175

Pancreatic

immunity

Pectinate

121–122

218–219 system

nervous

definition,

353

308,

glands,

syndrome

radiology,

96

345,

322,

salivary

Patella,

nervous

axonal

306,

disease,

Passive

91

217

32–33

262–264

homunculus,

Parotid

layer, sinuses,

sympathetic

syndrome,

Parkinson

dural venous

257

356 gyrus,

Parinaud

105–106

annular,

tract,

sensory

95

155

165

parasympathetic

353,

postcentral

80

innervation, to,

autonomic

360

344

lesions,

diaphragmatic

41

353–355,

152

155

Peripheral

corticospinal

pain

spinal

lobe,

anatomy,

205

triangle,

dural

40

153

152

Periosteal

39–40

Parietal

265

98

referred

Palate

system,

membrane,

pudendal

97,

291 165

female,

99

39

242

290,

trauma

pleurisy,

Pain

240,

Perineum,

retroperitonealization,

pleural

node

origins, 217

Perineal

organs,

69

74

Perimetrium,

151

308

tamponade, wall,

Perilymph,

99

Pacemaker

gray,

Pericytes,

98

secondary

114

mesodermal

150

165

152–154

68–69

cardiac

98

pelvis,

154,

triangle,

cells,

heart 113,

341

154

Pericranium,

retroperitoneal

P

30

338,

165

extravasation,

Pericardium, ganglia,

148

lesions,

accumulation,

Periaqueductal

98

peritonitis,

340

338–340

stomach,

pelvis,

147

abnormalities,

histology,

68–69

169 166,

136,

164

fluid

41

89,

embryology,

156

154,

164

erection,

39

peritoneum,

infundibulum,

107

10

pericardium,

8, 170

150,

embryology,

Peptic

motor

Parietal

7,

16

91

urine

line,

Parietal

fertilization,

ejaculation,

212

169

169

vulgaris,

urogenital

166–169 preventing,

120

215

mesoderm,

progesterone

cancer,

164

Paravertebral

Ovum

anatomy,

gland

Paraxial

ovulation, Ovulation,

110

nuclei,

195–197

154

hypothalamic

erection,

Paravertebral

169–170

153,

Pemphigus

138

Paraventricular

169

fertilization, histology,

8

plexus,

150,

Penis

sphincter,

embryology,

ectopic

232

138

ectopic,

ampulla,

231,

155

congenital

bladder,

Parathyroid

Oviducts

33,

155

202

lumbosacral

339

spastic

6

231

79

micturition,

4, 5

230,

116

innervation,

internal

167–170

30,

328

system,

hypothalamus,

development,

histology,

heart

151–152, joint,

male,

32,

326,

111,

salivary

anatomy,

hip

138

innervation,

peristalsis,

female

system,

innervation,

gastrointestinal

Ovaries anatomy,

female, 32–33,

innervation,

craniosacral

290,

Pelvis

system,

nervous

bladder

218, Corti,

4 36

nervous

autonomic

211

veins,

3,

nodes,

231–232

221–222

embryology,

Organ

lymph

Parasympathetic

muscles,

Orbit

ducts,

Parasternal

112

salivary Orbital

214

gut pelvis,

tube,

39 97

151

intra

vs.

retroperitoneal

male

pelvis,

150

organs,

99

38

ANATOMY

Anatomy

Immunology

membranes,

100

peritonitis, serosa

of

GI

Peritonitis,

tract,

Biochemistry 62, 63

arteriosus, 110,

116,

apparatus,

118

lip,

cleft

palate,

214

first

arch

210,

215

Pharyngeal

fistula,

Pharyngeal

grooves,

BehavioralScience/Social Sciences

cyst, fistula,

DiGeorge

212

212,

fistula,

215

213

diaphragm,

79 triangle

and,

207,

mediastinum,

208 66,

67

mater 217,

spinal,

26–27,

252

(posterior occlusion, 338,

anatomy,

276,

circadian

rhythms,

341

365

tumors,

306,

Piriformis Pisiform,

341

and

276,

cavernous

hearing,

290,

291

344

ovulation,

168

radiology,

365 field

39–40

recesses,

pleural

reflections, cavity,

41

39,

41 40

40

40

350,

palate,

Primary

sex

(eye),

rotation, 94,

221,

midgut,

301,

346,

359 ligaments,

drawer tibial

sign, arteries

and 30,

nervous

fractures, 225,

230,

system,

32,

95

nervous

system,

30,

31,

232 136

Douglas,

8,

98 95,

Primitive

pit,

Primitive

streak,

Primum

atrial

Process

vaginalis,

10 cells,

phase 169 and

151

artery,

nucleus,

344

motor

neurons,

plate,

8–10

cortex,

352, 363

339

100,

101,

104,

127,

128

255

263,

tracts, 356

Prostaglandins, 256,

257

261,

288,

Prostate 314

139 gland

ejaculation,

164

embryology, 360

histology, hyperplasia,

lemniscal

264

spinocerebellar

cortex,

8

152

column–medial

Prosopagnosia,

motor

cycle,

134

dorsal

314 cortex,

nuclei,

uterus,

hepatic

Clarke reticular

gyrus

primary

59

of menstrual

arcuate

the

58,

148

Proprioception

pontine

cerebral

defect, 92,

Progesterone,

Pronephros,

3

septal

Progestational

of

99

10

germ

Prolactin

97,

10

231

225,

97

retroperitonealization, node,

296–299

system,

103

Primitive

Proper 38,

95

201

33,

96

development,

Prolapse

formation),

limbic

204

232

(paramedian

Prefrontal

203, 204

neurons,

sequence, of

95,

96,

Primordial

cruciate

Prechordal

350

102–103

95

secondary

348,

96

95

94,

rotation,

359

Willis,

94,

96

356,

arteries

3

tube,

hindgut,

malrotation,

326

31

95

347–350

355,

30,

abnormalities,

organ

communicating

posterior

cords,

gut

septation, system,

ganglia,

214

foregut

266

359

Posterior

upper 41

265,

arteries,

chamber

cerebellum,

reflections,

pneumothorax,

169

262,

lemniscal

Posterior

Precentral 45

pleural

382

gonadotropin,

vein

39

277

motor

derivatives,

332,

of

nuclei,

derivatives,

cerebral

PPRF

chorionic

portal

60

syndrome,

291

derivatives,

123

10

170

distress

Primitive

124

missed,

arteriosus,

congenital

column–medial

Potter

8

133

levels,

37

ductus

Primary

262–264

Pouch 7,

132,

system,

first

development,

Prevertebral

gyrus

231, 332

306

201

Hepatic

sympathetic

mesothelioma,

Pleurisy,

104,

gonadotropin

growth,

Presbycusis,

132

See

231,

Placenta

pleural

vein.

340

defects,

embryology,

200,

parasympathetic

220 339,

305

169

infants

respiratory

304,

225

228

11 cycle

Pretectal

Postganglionic

sinuses,

hypothalamus,

Pleural

triad,

Portal

Posterior

anatomy,

Pleura,

Portal

Posterior

sound

304–305

syndrome,

123,

occlusion,

198

Pituitary

human

lobules,

circle

193

visual

Portal

aneurysm, 308,

syndrome,

of

hypertension,

358, 340,

341

radiology,

Pitch

Portal

344 338,

lung

52

occlusion,

277,

31,

11

patent

angle

Posterior 341

285–287

anastomoses,

artery)

303

body,

lesions,

cerebellar

277,

syndrome,

Kohn,

dorsal

inferior

30,

9

myometrium

syndrome,

anterolateral

247

33,

228

chorionic

Premature

365

of

and,

menstrual

344

275,

pontine

Postcentral

cranial,

37

227

pontine

226,

9,

284–287

nerves,

bifida,

levels,

102

and,

hemispheres,

Portacaval

nerves

superior

276–279,

arteries,

Pores

214

hCG

molar,

Popliteal

215

32,

8, 170

human

fistula

Pontocerebellar 214,

diverticulum,

scalene

102 103 stenosis,

levels, 226,

luteum

ectopic,

pyloric

radiology,

abnormalities,

thyroid

spina

Pons

medial

210–211

system,

fetoprotein

anencephaly,

146

atresia,

lateral

215

embryology,

congenital

239

226

embryology,

210,

sequence,

pharyngeal

alpha

transport,

pancreas,

cranial 215

nervous

corpus

cerebral

215

pouches,

Philtrum,

273

145,

anencephaly,

210

pharyngeal

Pineal

cells,

anatomy,

215

pharyngeal

PICA

272,

hypertrophic

215

231

system,

230–232

tracheoesophageal

cyst,

230,

231

sympathetic

axonal

annular

211

213

Pharyngeal Microbiology

230,

168

30, nervous

Pregnancy

Polkissen

Medical Genetics

214

syndrome,

tongue,

Phrenic

virus

duodenal

Pathology Pharyngeal

Pharynx

Polio

6,

neurons,

parasympathetic

Polyhydramnios

arches,

face,

215

214

Pharyngeal

body,

retrograde

abnormalities,

cleft

Preganglionic

142–144

Polar

poliomyelitis,

210–212

116

52 40

Podocytes,

truncus

congenital

115, 51,

Pneumothorax,

113

patches,

Pharyngeal

Pia

108

anemia,

Peyer’s

circulares,

Pneumocytes,

98

Pernicious Pharmacology Persistent

Physiology

Plicae

98

136 164 15

267–268

system,

INDEX

male

anatomy,

perineal

150,

154,

pouches,

Proximal

convoluted

renal

142,

141,

145

Quadratus

147 muscle

lumborum

(radiology),

anterior

surface,

2 deficiency

hypothalamic

lesions,

oogenesis,

338,

148

341

6

pineal

lesions,

Sertoli

cells

341 in

salivary

arteries,

188,

Radial

dilator

muscles,

Radial

glia,

Radial

nerves

tubercle,

86,

Pubofemoral

189

plexus,

328

anal

external

urethral 150,

149

dislocation, shaft

187,

sphincter,

108,

119,

sphincter,

fracture,

Pulmonary

152

185,

187,

arch,

nerve

lesion,

320,

spinal

cord,

aorta,

circulation,

persistent heart

68

left

55

truncus

radiology,

83,

63

and

joint,

hypoplasia,

Pulmonary

lymph

Pulmonary

neuroendocrine

38, nodes,

136

fecal

Pulmonary

flow,

72 54

329

constriction,

327,

reflex,

326,

cells

318,

Pyramids,

mothers,

103,

material,

106,

stenosis, 276,

79

vagina,

152

36–38,

also

111

156,

161 147

formation,

278,

279

vestibulo 257,

314,

66,

lamina,

271,

280

brain

circadian

rhythms,

histology,

330

315

341

333 field

defects,

pathway,

331–332

325,

326,

amnesia,

67

330

364

organs 106

parietal

versus,

99

peritoneum,

98

secondary

retroperitonealization,

97,

99

Ribs in gut

shoulder,

tube

80

structures,

95

intercostal

spaces,

radiology, convergence

reaction,

spleen Right

reflex,

Right

277

system,

258–260, lesions

lesions, light

stem

260

352 reflex,

ocular,

271 and,

282,

integrity,

326, 293, 295,

327 294 296

afferent

pupil,

82,

106

artery,

common gastroepiploic

Right

lymphatic

Right

to

left

cyanotic,

128, iliac

Right

as

38

83

laceration, colic

129

artery

(radiology),

artery, duct,

127,

177 128

43–45

shunts 58,

59,

61–63

fetal

foramen

ovale,

fetal

foramen

secundum,

persistent Relative

314, 16

315

327

pupillary

308

efferents,

intraperitoneal nerves,

pain

prefrontal 102

95

Lungs

Retroperitoneal

87–89

nucleus,

motor

52

133

laryngeal

motoneuron

hypertrophic,

256, 303

78,

39 39,

118

accommodation

74,

50

45–53

testes,

visual

Reflexes

321

160

Uterus

system

visual 135

sheath,

310–313

4,

Retina

151

231

anastomoses,

light

(heart), 320,

stomach,

decussation, lesions,

328 327

(cerebellum),

fibers

pyloric

8,

aganglionosis,

primitive

311–314

of

diabetic

of

Reticular

133

107

diaphragmatic

abnormalities,

Pylorus

132,

into

Referred

Pupil

Putamen,

syndrome,

cerebellar

354

portacaval

Red

embryology,

3,

Testes;

distress

Reticular

pouch,

Recurrent

Penis;

bronchioles,

embryology,

192

herniation

Rectus 70

154

Respiratory

duodenum,

anatomy,

156–165

factor,

Ovaries;

Retrograde

veins

153,

Respiratory

Rete

anastomoses,

colonic

also

See

85

aphasia, vein

150, inhibiting

embryology,

349

308

embryology,

75

74–76

Purkinje

artery,

(radiology),

Rectum, cells,

72

murmurs,

circuitry,

171

glands,

171

pelvis,

lesions,

flow,

Purkinje

64

192–193

Rectouterine

44

valve

74,

blood

vagina,

histology,

nuclei,

Rectal

(PNE)

semilunar

auscultation,

155

accessory

170,

Respiratory

carotid

109,

Pulmonary

light

atrium,

206

limbs,

49

heart

left

plane,

Receptive 59

and

uterus,

infants

81–84

Radius

84

Pulmonary

151–152,

67

internal

Raphe

hypertension,

blood

84

notching,

upper

arteriosus,

Pulmonary

heart

60

70

81,

160

147

365

83,

transpyloric

arteriosus,

anatomy,

48,

system 349,

esophagus

52

ductus

136

154

Mullerian

211

patent

134, factor,

167–170

penis,

35,

66

brain,

thorax, fetal

136, pelvis,

male

nervous

knee embryology,

89

173–177

costal

the

tubules,

ovaries,

183

mastectomy

abdomen,

137

of

tissue,

91

inhibiting

vagina,

See

capillaries,

coarctation

4,

192

aortic

138

arteries

alveolar

147–148

connective 3,

female

182,

central

vessels,

abnormalities,

191

Radiology

152

Pudendal

Urinary

147

Mullerian

186–187

155

perineum,

Kidneys;

systems

testes

external

146

176

146

gonads,

179–181

mid

sensory,

164

pelvis,

139,

congenital

187 head

radiology,

202

137

ejaculation,

142–144,

histology

Radical of,

See

embryology,

nerve

course

system.

Reproductive

88

muscle,

Pudendal

141,

38

140

(radiology),

extraperitoneal

185,

humeral

155

ligament,

Puborectalis

pelvis

Renin, 239

192 Pubic

corpuscle,

Renal

240

humeral

6 88,

Renal

and, 130,

mesonephric

160

symphysis,

121

transport,

Radial

lesions,

spermatogenesis,

glands,

axonal

brachial

seminiferous

tubules,

Pubic

virilization,

126,

system

parotid

Puberty reductase

137

arteries,

Renal

137

136 hypoplasia

Renal

virus

retrograde

5α

muscle,

176, Rabies

on

360

R

177 ureters

331,

agenesis,

pulmonary

143

Pseudointersexuality, major

Renal

Q Quadrantanopia,

tubule,

corpuscle,

Psoas

156

153

truncus

54,

55

arteriosus,

57 62,

63

329

38

ANATOMY

Anatomy

Immunology

pulmonary

hypertension

tetralogy

of

Fallot,

transposition Rinne

test,

Robin Pharmacology Rods,

325,

of

vessels,

62,

63

Biochemistry

356 264,

315

of

ligaments 151,

histology,

of

hip,

the

202 Medical Genetics 90,

uterus,

152

male

290,

Rubrospinal

tract,

291

Saccule,

290,

system,

Sacral

hiatus,

Sacral Microbiology

plexus,

293,

251,

Sacrum,

22,

Salivary

glands,

Saltatory

Sartorius media,

290,

Scala

tympani,

290,

291

Scala

vestibuli,

290,

291

thoracic Scalp

291

triangle,

207,

outlet

venous

Scanning

Scarpa

fascia,

urine Schwann

82,

83

35,

154,

regeneration,

formation,

neuron

structure,

243,

240

195,

injuries,

198–199

sciatica,

25

214

septal

97,

271

263,

venarum, venosus,

defect,

58,

sys

264 267–268

290, 290,

291 291

295 293,

294

263, cord

nuclei,

and,

183,

190

293–296

lemniscal

lesion,

Septomarginal

269

pellucidum,

Septum

primum,

57,

256,

257 315,

322–324

lower

motoneurons,

Motor

system

supply,

209

venous

sinuses,

sys

218–219

220–221 217–218

muscles,

221–222

pathways,

Sliding

hiatal

Small

intestine,

46

hernia,

106

114–115 115–118

tobacco

lung

cancer,

45 metaplasia,

nucleus,

49

279,

283

303

of

cortex, Disse,

122,

262–267 123,

torticollis,

Spastic

bladder,

Spastic

paresis,

Spastic

weakness,

125

323

138,

272

260,

261, 257,

347 261,

269,

157,

158

307 Spermatic

cord,

Spermatic

fascia

90–91

external,

87,

89,

internal,

89,

91

91

Spermatids meiosis,

363

trabecula,

Septum

73,

315

215–216

Spasmodic

264

361,

312,

288–289

tract,

also

267–268

column–medial tem,

Septal

See

Space

182–183

system,

309,

259–261,

and

263

syndrome

191

322–324

fibers,

Somatosensory

336

tunnel

72 cuff,

258–260

lesions, 258

limbs,

56,

317,

257,

Solitary

365

335,

54,

functions,

squamous

tracts,

79

innervation

ganglia,

lesions,

78,

rotator

muscle

Smoking lemniscal

213

59

of

respiratory

262,

76–78 72,

72

53,

muscles

orbital

361–362

neurons,

247

54,

meninges,

tracts,

130

node,

hemorrhages,

255

initiation,

spinal

system,

(SA)

dural

199

nucleus,

dorsal

99

15

test,

265

vibratory

retroperitonealization,

ducts,

Sinoatrial

arterial 264,

271

column–medial

vestibular

Secondary

Semicircular

artery,

histology,

carpal

165

92

canals,

282

226

dorsal

upper

147

Semicircular

277–280,

263–265,

system,

80

255–256

columns,

Clarke

tongue,

palate,

384

limbs,

thalamus,

atrial

nodal

277

stem,

264–269,

spinocerebellar

91

hydrocele,

system,

lemniscus,

225,

sensory

accumulation,

219,

Sinoatrial

corticospinal

364

252–254

radiology,

Secondary

vestibular

horn,

reflex

embryology,

caloric

lemniscus,

160

173

reflexes,

spinocerebellar

196

21

cancer,

Selectins,

medial

tem,

Scrotum

Secundum

dorsal

306

326

Sclerotomes,

360,

pain,

129,

corticobulbar

proprioception

244,

nerves,

fluid

brain

4, 160

107

cerebellar

lemniscal

medial

in

3, 158,

190

sinuses,

Skull,

olfactory

244

236

Schwannomas,

stem

in

lesions,

165

242

myelin

colon,

basal

295

356,

263–265,

lesions

lower

241,

239

362

263–265

embryology,

87

histology,

360, 264–269

355,

lesions

dorsal

187

cells

axonal

Sclera,

315

extravasation,

arteries,

Sigmoid

Skeletal

282

217

scapula,”

353

227, 280,

column–medial

brain

207

160

191

Sigmoid

SITS

dysfunction,

stem,

157,

referred

cuff,

Sinus

292

lesions,

325,

158,

factor,

tubule,

circulation,

upper

drainage,

“winged

cord

262,

syndrome,

(radiology),

345,

lesions,

brain

193

Scapula

Sciatic

dorsal

208

dysarthria,

Scaphoid,

360

polyneuropathies,

visual,

inhibiting

rotator

Sinus

vestibular

201

Scala

351

353–355,

291,

160

157,

160

Sigmoid

homunculus,

spinal

199

muscles,

345,

lobe,

olfactory

240

protein,

barrier,

radiology,

282 291–293

cortex,

axonal

120–121

nerve,

263,

282

265–267,

auditory,

88

Saphenous

262,

deficits

11

conduction,

system,

277,

system,

sensory

253

teratoma,

binding

collateral

269

stem,

parietal

22

Sacrococcygeal

Scalene

294

68–69

160

diaphragmatic sensory

cerebral

cells,

58

108–110

Shoulder

156 157–158

lesions,

pericardium,

Sertoli

seminiferous

161

systems

auditory

291

vestibular

160,

265–267, BehavioralScience/Social Sciences

Serous

57,

tract,

Mullerian

147

anterolateral

Pathology S

GI

inhibin,

spermatogenesis,

brain

of

blood–testis

156

157–158,

anatomy,

314

secundum,

Serosa

androgen 150,

tubules

Sensory

window,

Septum

valve

163

anatomy,

embryology,

the

semilunar

semilunar

164

histology,

ligaments

Aortic

vesicles

Seminiferous

191

See

Pulmonary

Seminal

male

sign,

Round

great

215

cuff,

valves.

valve;

330

Romberg

Round Physiology Round

the

Semilunar

59

63

ejaculation,

stream,

Rotator

61,

293

sequence,

rod

causing,

79

5

seminiferous

276

spermatogenesis,

58

spermiogenesis,

tubule,

6, 158 6,

15

271,

273,

INDEX

Spermatocytes

Spinal

meiosis,

5, 158

seminiferous

tubule,

157,

spermatogenesis,

158

4, 6,

8

tubule,

Spermatogonia pre

28,

cauda

meiosis,

5,

158 157–158

spermatogenesis,

as

6, 157–158

equina,

ductuli

8

ejaculate,

161

163, 164

Spinocerebellar

epididymis,

162

lesions,

8

Spinothalamic

fertilization, flagella,

18 syndrome,

seminiferous

18,

tubule,

spermiogenesis,

6, 159 of

Sphincter

Oddi,

urethrae

Spina

bifida,

Spinal

cord

107,

122,

muscle,

226,

125

149

nerve

anatomy,

origin,

gray/white

matter,

257,

276

251,

252,

cancers,

244,

central

nervous

138

system

embryology,

225,

inferior

limit

lesions,

271–274

diagnosis

in

of,

27

307 259–261,

269

217

motor

tract,

256,

motoneurons, 257,

259–261,

neurons,

reflexes,

255,

277

269,

Stapedius,

256,

271

83,

sections,

269–270

sensory

systems

anterolateral,

262,

263,

265–267,

column–medial system,

lesions,

262,

263–265,

262,

vertebral

ligament,

267–268 32,

protecting, 23,

233

and

hCG

Stellate

cells

Stenosis

of

Stensen’s

(liver),

311,

74,

ganglia,

63, muscles,

64,

66 208

disease,

95 114

323

Sulci

of

heart,

Superficial

317,

323,

reflex, cerebral

352 cortex,

343–344

70 fibular

nerves,

195,

inguinal

ring,

perineal

fascia,

Superficial

perineal

pouch,

87,

199

colliculi, 306,

89,

90

153 152,

innervation,

153

155 276–278

308 287

gluteal

nerves,

197

198 plexus, mesenteric

radiology,

175,

195, artery,

196 126,

128,

129

176

mesenteric

vein,

131,

132

176

Superior

olivary

Superior

pancreaticoduodenal

Superior

196,

199

Superficial

lesion,

338

338

Superficial

127, 100

322,

nucleus,

of

110–114 membranes,

319

287

322,

radiology,

infection,

108–110

338

Sulci

Superior

121

191

317,

Parkinson

Superior

83

tract,

278,

lumbosacral Louis),

106

251

GI

midbrain,

injuries,

162 (of

120, glands,

nigra

Superior

75

121

(radiology),

peritoneal

9

350

glands,

muscles,

midbrain,

valves,

Sternocleidomastoid

pylori

313

125

heart

ducts,

embryology,

of

Superior

(cerebellum),

17,

106

67

121

pudendal

291

angle

histology,

levels,

211

cells

21

102,

290

Stellate

H.

101,

221,

salivary

injury,

abortion

Stomach,

tracts,

97,

3

290,

Sternal

95,

105

65, 208

86

salivary

Suckling

132

45,

207,

218

subthalamic

130

356

tail,

Sternum

263

outflow,

canal,

277

271

spinocerebellar

vertebrae

lemniscal

264–269,

neurons,

sympathetic

344,

Stereocilia,

277 dorsal

269,

128

175

embryology,

84

space,

lesions,

131,

85,

Subdural

173

gene,

Stapes,

271

258–260

radiology,

and,

Spontaneous Sry

127,

ischemia

pancreas

257,

plane,

Substantia

100

43, and,

hematoma,

Subthalamus,

vein,

254–256

drainage, triangle

Subscapularis

102

208

66

Subdural

basal

106,

Splenorenal 254–256

corticospinal

lesions,

flexure

Splenium,

motoneurons,

gamma

artery,

Splenic

Splenic

system

alpha

Splenic

95,

106

radiology,

versus,

motor

174

lacerating,

radiology,

264–269

25–27

cranial

radiology,

bowel

257,

systems,

meninges,

225

207,

veins,

Submucosa mesentery,

189

209

Submandibular

embryonic

188,

triangle,

Sublingual

23

102

membranes,

ribs

adults,

system,

sensory

definition,

226

vertebrae,

29

82

Subcostal

303–305

27,

neck,

Subclavian

282

290–292

peritoneal

247,

211

and

120,

dorsal

249

282,

97,

246,

27

arteries,

scalene

of

218

circulation,

27

lymphatic

processes

106

26,

scalene 277–279,

287

Spleen,

puncture,

radiology,

265

ganglion,

limit,

lumbar

embryology,

263,

287

Spiral

217,

fluid

inferior

head

fibers,

embryology,

atonic/spastic,

262,

282

265–267,

350

218

space,

Subclavian

271

284

Spinous

271

269

bladder

motor

275,

269,

29

269

unilateral,

251–255,

266,

system,

277–280,

midbrain,

accessory

26,

284

lesions,

228

24,

265,

sensory

stem,

221,

space,

Subarachnoid

267–268

tracts,

pons,

hemorrhage,

spinal,

midbrain,

105,

274

subarachnoid

24

foramina,

hypothalamic

Spermiogenesis,

30–32

211

degeneration,

249

tracts,

pons,

162

273,

25

265–267, brain

combined

Subarachnoid

268

48

157

6, 159

vasectomy,

Sphincter

disk,

anterolateral

Kartagener

embryology,

cerebrospinal

intervertebral

ejaculation,

290

process

33

225

29

herniated

164

22,

32, 27,

system,

column,

exiting,

efferentes,

system,

nervous

vertebral

capacitation,

system,

nervous

127

317–319

Subacute

nervous

peripheral

106 erosion,

219

vascularis,

Styloid 26

artery

sinus,

Stria

ligaments,

hernia,

and

Striatum,

27

sympathetic

Spermatozoa

hiatal

ulcers

29

parasympathetic

tubule,

29

251–255 point,

denticulate

seminiferous

173–175

sliding

Straight

anatomy,

157–158

27,

radiology,

29

nerves

transition

seminiferous

217 27,

puncture,

Spinal

4, 5

25–27,

anesthesia,

lumbar

6, 158

Spermatogenesis, meiosis,

meninges,

epidural

nuclei,

279,

285,

291,

292

arteries,

128 rectal

artery,

129,

130

38

ANATOMY

Anatomy

Immunology

Superior

sagittal

sinus,

cerebrospinal dural

fluid

venous

Superior

sinus

cava, 81,

congenital

Medical Genetics

182

187 191

anatomy,

51,

Clara

cells,

cystic

BehavioralScience/Social Sciences

52 50

Testis

fibrosis,

49

corticosteroids hyaline

for

fetal

respiratory

pelvis,

Sympathetic

of

151,

39,

ovary,

52

nervous

ejaculation,

164

basal

230,

221,

231

326

glands,

110

anal

embryology,

micturition,

152

neurons,

sympathetic

dorsal

Thebesian

outflow,

30–32,

232,

4, 5

Syncytiotrophoblast,

7–9

Syringomyelia,

228,

in

valvular

273,

274

defects,

233

Theca

T dorsalis,

272,

“Talk

and

syndrome,

die”

Tanycytes, Tau

protein,

227 regulation,

Temporal

lobe,

anatomy,

association

lesions,

355–356

353

coli,

357,

tympani,

40

cerebelli, muscles, bronchiole,

218,

219

322,

Trabeculae

carneae,

167

carina,

46–49

radiology,

82,

168–169

(descending)

aorta,

spaces,

81–84 section,

Thoracic

diaphragm.

Thoracic

duct,

66,

lymph

Tracheoesophageal

39

39 See

65

Thoracic

outlet,

63,

207

Thoracoepigastric

35 vein

radiology, 64

81–84

anastomoses,

of

Transposition

of

Transpyloric

plane,

spinal See

38

37

354,

132

358 nerves,

Cellular

29 transport

Transverse

colon,

vessels,

62,

329

88,

89,

91

ligament,

152

107

173

Transverse

processes

Transverse

sinuses,

Trapezium,

great 85

herniation,

cervical

Transversus

the

fascia,

Transverse

radiology,

22 nerve,

systems.

Transversalis

64

207

vertebrae,

point

Transport

Transtentorial

67

38,

Transition

44

37,

septum, apraxia,

38

nodes,

systems

Diaphragm

43–45

mediastinum, inlet,

67 37,

fistula,

Tracheoesophageal

43–45

mediastinum,

Thoracic

50

46

fistula,

Transcortical

transverse

Thymoma,

38,

system,

radiology,

Thorax

pathway, mediastinum,

Tracheobronchial

39

39–41

Thoracic

83

tracheoesophageal

intercostal

73

36–38

respiratory

superior

84

38,

191

as

64

cavity

posterior

72,

67

histology,

boundaries,

217 323

Trachea

167

Thoracodorsal

290

syndrome,

167

syndrome,

118

pneumothorax,

minor

360

foramen syndrome,

166,

superior

353–354,

Tentorium

386

cortex,

area,

lesions,

Terminal

360

356

Wernicke

Teres

341

344

visual

Tensor

357,

338,

213

215

166,

pleura,

13 160

211, cyst,

interna,

83,

16

13

folliculi,

lymphatic

238

Temperature

Tension

350

242

Telencephalon,

Teniae

274

types,

Theca

Thoracic

Tabes

157,

Theca

radiology,

13,

pathway, cells,

Tourette

lemniscal

77 166,

cells,

249

15

embryology,

Thoracic

247,

polarity,

lingual

262,

262–264

externa,

lutein

74–76

barrier, plexus,

jugular

veins,

249

201 16–18

embryology,

system,

63

242,

206

Tongue

336

column–medial

30

trunks,

thoracolumbar Synapsis,

30

196

205

junctions,

Tissue

346

nucleus,

system,

195,

203–205

fractures,

Sertoli

336

265–267 neurons,

joints, joints,

paracellular

363

projections,

anterolateral

138

postganglionic preganglionic

361,

lateral

335, 107,

plexus,

microfilaments,

syndrome,

203

199

epithelial 336

pain

67

198

choroid

315

227

system,

213 lesion,

ligaments,

blood–brain

324 314,

335,

ventropostero

sphincter,

nerves

Tight

336

317–319, efferents,

339

internal

Tibial

shaft

344

335,

thalamocortical

79

hypothalamus,

collateral

knee

63

320,

nuclei,

thalamic

120

innervation,

277,

ganglia,

limbic

system,

Tibial

radiology, 276,

functions,

innervation,

salivary

30,

212, nerve

ankle

61,

211

Tibias

3, 160

3

Fallot,

213

embryology,

lumbosacral

3, 4

212,

215

injuries,

148

(TDF),

synthesizing,

of

anatomy,

30–32,

system,

gastrointestinal

Systole

cells

embryology,

cerebellar

autonomic

syndrome, factor

thalamic

system,

gland

Thalamus

152

152

nervous

cartilage

Thyroid

sensory,

Leydig

232–233

heart

feminization

testis

Thyroid

laryngeal

90

determining

duct,

embryology, 8

66

215

ectopic,

156

5

artery,

Tetralogy syndrome,

ligament

female

52

39

37

distress

Suspensory

synthesis,

disease,

embryology,

160

Testosterone

membrane

lung Microbiology

154,

158,

90–91 4, 6,

4,

Testicular

157,

150, cord,

212

64

cyst,

136

64

mediastinum,

Thyroglossal

148 134,

barrier,

meiosis,

215

tumors,

156–165

Testicular

Pathologyalveolar,

147

tubules,

spermatogenesis,

199

mediastinum,

ectopic,

superior

abnormalities,

spermatic

Surfactant

eye

male

148

4, 91,

mesonephric

muscles,

nerve,

3,

histology,

gland

anterior

embryology, 91,

blood–testis

184,

Supraspinatus Sural

338–340

338–340

Thymus

91–92

cryptorchidism,

341

nerves,

33

91

descent, Biochemistry

340

183,

32,

embryology,

nuclei, 338,

ganglia,

Testes cancer,

292

nucleus,

lesions, Physiology Suprascapular

247

66

rhythms,

Supraoptic

249

83

Suprachiasmatic circadian

Terminal 246,

drainage, gyrus,

vena

injury,

219

circulation,

temporal

Superior Pharmacology radiology,

217,

abdominis 19

of 219,

vertebrae,

23

247 muscle,

88,

89

63

INDEX

Trapezius

muscles,

Trapezoid,

193

Treacher

Collins

Tremors,

315

208

carpal

syndrome,

215

gait,”

198

auscultation,

74,

flow,

murmurs,

73

brain

stem,

(CN

V)

275–280,

cavernous corticobulbar

219,

288,

247 289

280,

medulla,

303–305

of

138

Triquetrum,

193

Trisomy

13

Trochlear

holoprosencephaly, nerves

brain

stem,

cavernous

228

(CN

IV)

275–278, 219,

220,

247

functions,

287

orbital

muscles,

Trophoblast,

177

Tuber

cinereum,

Tumors. Tunica

septation, pregnancy,

See

Tympanic

by

60–63

156

of,

embryology,

290,

291

(radiology), arteries,

Ulnar

nerves,

brachial

189

182,

183

plexus,

lesions,

186,

radiology,

system

arteries,

Umbilical

region,

midgut

55,

referred

Umbilical Umbilicus patent

urachus,

portacaval Uncinate

process,

ventral

101,

102

herniation,

Undescended Upper

testes,

91,

collateral

supply,

pelvis,

151,

155

135–136

4,

91

Urogenital

triangle,

connective

tissue,

135,

155

189,

190

histology,

245,

147 8

also

242 228,

of

heart,

flow,

248

70

72–73

69, 70

70

circulation, tube,

54–56 53,

54

septal

defects,

63

ventricular

septation, 81,

59

84

Vermis

170

anatomy,

278,

279,

309

function,

309,

310,

314

lesions,

171

(See

227

radiology,

165,

246

fluid)

(heart)

heart

152

152

152,

7,

246 fluid,

cells,

59,

ligament,

170,

245,

ventricular

152

255

embryology

136

bridge,” 151,

151,

26 254,

(brain)

surfaces,

152

fertilization,

187–190

89

270 252

nerve

252,

borders,

fetal

152–153,

septum,

under

spinal

28,

blood

sinus,

embryology,

circulation,

motor,

anatomy

154

Urogenital

artery,

233,

ligaments,

Ventricles

152

150,

3,

tube,

of

269,

32,

hydrocephalus,

153

innervation,

anatomy,

148

limbs

arterial

149

Uterus

329

root

28,

ependymal

ridge,

Uterine

Ventral

sections,

embryology,

pouch,

pelvis,

Uterosacral

276

uncal

diaphragm,

“water bud,

cord rami,

cerebrospinal

Micturition

perineal

255–257

252–254

anatomy,

137

Urogenital

Uterine

133

105

pancreatic

Uncus,

calculi,

Urorectal

137

anastomoses,

254–255

motoneurons,

Cerebrospinal

extraperitoneal

95

54–56

136–137

136

77 mesentery,

97

motor,

139–146

Urogenital

pain,

vein,

38,

deferens

minimae,

horn,

Ventricles

abnormalities,

agenesis,

119

74 Ductus

embryonic

Ventral

as

134–136

pudendal

56

86

cordis

spinal

Bladder

67

defecation, 74

See

denticulate

See

male

193

150

137–139

female

187

Umbilical

See

Urination.

deep

179–181

192,

149, 138

66, in

162

lower as

138,

bladder.

renal

192

regurgitation,

deferens.

95,

138

congenital

188,

Valvular

Ventral

162

histology,

Ulnar

insufficiency,

Ventral

bladder,

renal

Valvular

164

Urinary

mediastinum, maneuver

Venae 154

164

Urinary

283

Vasectomy,

150,

79

Valsalva

Vas

165

embryology,

U

155

spongiosus,

sphincters,

212

150

138–139

anatomy,

membrane,

Ulna

151,

innervation,

344

prostate,

283

303

nuclei,

136 139,

of

nucleus,

innervation,

superior

embryology,

8

Cancers

albuginea,

152

288

211

lesions,

bridge,”

spermatozoa,

arteriosus ectopic

152

279

fibers,

motor

heart

151,

under

neck

7, 8

Tubal

135

prostate, 294

X)

275–277,

embryology,

ejaculation,

293,

(CN

stem,

dorsal

pelvis,

male,

fibers,

Truncus

137

“water

221

152 155

nerves

brain

137

corpus

nuclei,

vestibular

Vagus

radiology,

280

171 151,

perineum,

134–136

laceration

280

lesions,

137

147 152

corticobulbar

female,

211

136, into,

histology,

sinuses,

compression

220

embryology,

herniation

Urethra

287

sinus,

thrombosis,

embryology,

137

female

294

Vagina

192–193

embryology,

136

293,

V

183–187

Ureters

bladder,

291 system,

182–183

bud,

double,

the

152 290,

pelvis,

anatomy,

embryology,

injuries,

191

or

8

152

179–182

136

patent,

285–286

Trigone

prolapse, Utricle,

182

cuff,

Ureteric

283

nuclei,

plexus

fistulas

280

lesions,

brachial

Urachus,

211

functions,

plexus,

rotator

220,

fibers,

embryology,

brachial

radiology,

287

sinus,

193

7,

151,

vestibular

sensory,

nerves

190,

pelvis,

187

210

segmental,

74–76

Trigeminal

183,

186,

innervation

75

72,

implantation, lesions,

syndrome,

valve

blood

190

nerve

embryology,

“Trendelenburg Tricuspid

tunnel,

median

313,

315

congenital radiology,

malformations,

228

365

38

ANATOMY

Anatomy

Immunology

Vertebral

arteries,

cerebral

300–301

cortex,

occlusion,

346,

22

Biochemistry

inferior

embryology,

limit,

21,

disks, foramina,

limit,

canal,

Pathology vertebral

Visual

notches,

BehavioralScience/Social Sciences

23

295

Vesicouterine

pouch,

Vestibular

fibers,

Vestibular

nuclei,

cerebellar Microbiology

151

293,

efferents,

lesions,

294,

Vestibular

314,

315

303–305

system,

caloric

294

test,

dysfunction,

ocular

brain

stem

Vestibule,

295,

stem,

division,

functions,

281 281,

292,

287

reflex,

integrity,

304

282,

293,

294

column–medial

cord

Visceral

layer,

lemniscal

system,

269

peritoneum, embryology, intraperitoneal secondary 99

38

113

nerve

gonad

degeneration,

hypoblast

in

liver,

Zona

diverticulum, gut fistula,

Vitelline

fistula,

Vitelline

veins,

Vitreous

humor,

Volvulus,

103

103 tube,

See

96

Zona

103

retroperitonealization,

97,

Wallerian

12,

3

229

embryology,

4

origins, gut

8–9

tube,

occludens, also

94,

16,

Tight

96

103

enzymes,

cortical

54

development,

graafian nucleus),

286

follicle,

Zonula

syndrome,

303

Zygotes,

243,

244

Zymogen

168

adherens,

Zygapophyseal

168

8

body,

183–184

166–168

166,

implantation,

syndrome,

degeneration,

8 7, 8

follicular

(ventroposteromedial

159

reaction,

fertilization, 326

18

junctions

pellucida

acrosome

W

Wallenberg

gene,

Z

125

98 99

Sry

sac

polar

98,

187

323

derivatives,

68–69

organs,

186

185,

cramp,

primitive

stored

tip

186

lesion,

drop,”

113

274

vitelline

Waiter’s

lesion,

193

Y

Yolk

39

98

147

110

primitive

VPM pericardium,

110

296

264 lesion,

339

duct

ileal

nerve

Writer’s

325

degeneration,

tract,

anemia,

K,

Vitelline

295,

GI

combined

Vitamins

294

neural

factor,

subacute

blindness,

136

Gartner,

Y chromosome

of

273,

303,

ulnar

night

4, 136

125 and

pernicious

sense

263,

B12

bacteria

306 293,

ocular

dorsal

Vitamin

VIII)

of

“wrist

storage,

3, 134,

radiology,

326–329

and

3

ducts,

median 331–333

A

291

294, 244,

stem

reflexes,

Vitamin

system,

Vibratory

279, 290,

schwannomas,

Vestibulo

294

296

(CN

275–277,

cochlear

visual

intrinsic nerves

vestibular

293,

gene,

187

260

Wrist

340

336

defects,

B1

155

Vestibulocochlear

lesions,

282,

integrity,

151,

335,

339,

323 35,

embryology,

nucleus,

field

233 322,

reflex,

duct

Vitamin

32,

scapula,”

Wolffian

360

121

disease,

WNT4

341

330

visual

liver

reflex,

“Winged

326

deficiency

296

295

vestibulo

330

Vitamin

293–296

295,

327

reflex,

rhythms,

thalamus,

285,

Wilson

353

357,

ducts, rami,

355

351,

16–18 joints,

21,

7, 8 granules,

121

336, area

292

353–354,

Withdrawal

325,

retina,

cortex, system,

Wharton’s White

346,

syndrome,

comprehension

320

lesions, 332

pathways

chiasm,

oral

auditory

355

light

optic

Korsakoff

cerebral

body,

307

293

anatomy,

355–356

360

suprachiasmatic

293

351,

296–298

Gennari,

eyeball,

test,

355

352,

circadian

23

syndrome,

Weber Wernicke

cortex,

333, of

Weber

Wernicke’s

field,

pupillary

23

108

geniculate

line

27

tract,

351,

eye

lateral

21–23 arch,

spinal

26

41

356

lesions, 22–24,

Medical Genetics

inferior

vertebral

brain

cortex,

lesions,

vertebral

brain

association

Visual

24

vertebrae,

Vertigo,

Visual

22–24

82–84 cord

GI

agnosia,

frontal

intervertebral ligaments, Physiology radiology,

27

of

Visual

210

intervertebral

40 reflections,

serosa

column

curvatures, Pharmacology dural sac

39,

pleural

359

Vertebral

spinal

pleura,

348

24

364