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PRECLINICAL
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2023
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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
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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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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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.
.
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.
.
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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
. . . . . . . . . . . . . .
. . .
. . .
. . . .
. . .
. . .
. . .
. . . .
. 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
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form
an
cell
axons
exit
bodies
in
(formed
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the
of
and
sympathetic
neuronal
their
nervous
system
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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
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ganglia celiac,
superior
L1–L2
splanchnic
nerves
(e.g.,
(collateral)
mesenteric
ganglia inferior ganglia)
mesenteric
ganglia)
of
limbs
head
(T1–2)
viscera
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aorticorenal,
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pelvic
3
of
cardiac glands
and
thoracic
Lumbar
one
(Target)
(T1–L2),
nerves
in
pelvis)
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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
=
ri
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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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Development Group, Inc. rights Group, Inc. reserved All T6
Vertebra
Spinal
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Descending
Left
Aorta Esophagus
Figure
II 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
Used
cells secrete
in
transporting
where
base
bacteria.
at Cells
(A) cells
Enteroendocrine stomach,
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functions.
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intestine
cells
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the
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of
fibroblasts
that
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
they
the
move
crypts,
toward
the
tips
replenishing
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of
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population
of
cells. tissue
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Medical Genetics
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where
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Peyer’s
cells
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lymphocytes
macrophages.
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Figure
McGraw
II
Hill
Companies.
Figure Ileum
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with (arrow)
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patches lacteals
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with
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lamina
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and in the
propria
of
the
lamina villi
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The
large
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intestine
wide
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of
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features The
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than
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larger
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longitudinal Because
creating “caterpillar”
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colon between
appearance.
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intestine.
•
the
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teniae
crypts
General
includes colon,
the
short
11
Used
CHAPTER
•
The
mucosa
ing •
has
colonic
lymphoid
more
sparsely
The
villi,
mucous
is
secreted
by
short,
inward
ABDOMEN,
PELVIS,
AND
PERINEUM
project
follicles
are
found
in
the
cecum
and
appendix,
and
elsewhere.
major
lytes
and
|
glands.
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•
no
3
functions
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colon
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the
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urge
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cells.
mucous
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intestine
breakdown of
Copyright
of the
and
intestine,
the
Unlike
the
goblet
is fluid
retrieval.
cellulose
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and
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11
PART
Anatomy
II
|
GROSS
ANATOMY
Immunology GASTROINTESTINAL
Salivary Pharmacology
Biochemistry
The
GLANDS
Glands major
acini
salivary
that
mucous,
or
Medical Genetics
BehavioralScience/Social Sciences
by
Mucous
cells
Table
Pathology
into
both
surrounded Physiology
glands
drain
II 3
Salivary
types a
of
basal
all
branched
which
into
cells, Serous
the
as cells
predominantly
Gastrointestinal
tubuloalveolar
drain
secretory
lamina.
secrete
5.
are
ducts,
glands,
oral
well
as
secrete
cavity.
secretory
contain
myoepithelial
serous,
cells,
various
glycosylated
with
Acini
proteins
both
and
enzymes.
mucins.
Glands
glands
Submandibular
•
Produce
•
Presence
approximately of
smell,
Parotid
end
Microbiology
of
Functions
food or
the
esophagus
of
of
in
sight,
stimulation Sublingual
1.5 the
of
saliva
the
food;
taste,
or
afferents
at
the
the
increase
distal
production
saliva
•
Initial
triglyceride
•
Initial
starch
•
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digestion digestion
(lingual (α
Parasympathetic
Regulation
of
mouth;
thought vagal
L/day
lipase)
amylase)
↑
synthesis
and
secretion
of
saliva
via
receptor
watery
muscarinic stimulation;
(anticholinergics dry
Sympathetic
↑
→
mouth)
synthesis
and
secretion
of
saliva
via
receptor
The
ducts
that
transitions cells.
The ducts,
basal
infolding
columnar
12
of
into
make the
glands to
ducts,
striated
cells back
the
cuboidal
smallest
larger
saliva
drain
from
have
membranes the blood.
saliva
in to
intercalated ducts,
cell
increase columnar
size
ducts,
have
columnar
cells
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are
lined
pseudostratified
an
transporting
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stratified
myoepithelial with
prominent by
stimulation
by to
striations,
the
next
caused
mitochondria. Na
that
columnar
cells;
basal
viscous
β adrenergic
by
These and
Cl
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out
of
CHAPTER
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McGraw
Hill Companies.
Figure II 3
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Used
The
parotid
glands
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II 3 24. Submandibular 23. Submandibular
acini
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serous
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The
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CLINICAL
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mixed
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sublingual
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saliva.
Pancreas
composed
The
of
glands
contribute
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floor
inside
CORRELATE
are
saliva.
serous/mucous the
the
glands
The
sublingual
into
the
of lie
serous/mucous
PERINEUM
acini mucus
muscles
meatus.
drain
above 25%
AND
acini
masseter
auditory
that
open
PELVIS,
(arrowheads) (arrowheads)
external
glands
submandibular
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•
salivary
ABDOMEN,
permission.
The entirely
|
and at
containing
endocrine exocrine
tubuloacinar cells
that
amylases.
their
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cells
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of
the
of
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The
enzymes
functionally
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zymogen
cells
gland
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eosinophilic
producing
exocrine
produce
polarized, membrane their
are
acini
are
including with bound, apex.
embedded
within
pancreas.
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.
Used
II Pancreas 3 25. Pancreas
surrounded(arrows)
(arrows)
with
withwith light light
surrounded by exocrine by
and adjacent (arrowheads)
Unlike
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liver
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body. endocrine
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The
liver
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The
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portal
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visceral
Hepatocytes,
and
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largest
bile
ducts,
into
the
the flow
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system
hepatocytes
lined
by
duodenum, is dual is via
(75% hepatic
CHAPTER
3
|
ABDOMEN,
PELVIS,
AND
PERINEUM
Hepatocyte Central
vein Bile
canaliculi
Sinusoid
ethmoidal
cell
Sinusoid
Bile
flow
Space
of
Disse Inlet
Kupffer
venule
cell
Sinusoid Bile
duct Hepatocyte
Portal
vein Bile canaliculi
Hepatic
Figure
Hepatocytes than
are
being
functionally
polarized
“apical”
Where
like
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axis,
•
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Where
a
Organization II 3 26. Organization
many
each
other
of
epithelial
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3 25. Figure
surfaces.
•
The
II
artery
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a portal hexagon. from
tract
at
Blood the
central
each flow
corner is from vein
to
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.
Figure II 3 26. Liver
3
each connective
Used
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12
the
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In
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and drug,
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detoxification.
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cells
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1
CHAPTER
Ito
cells
(stellate
contain
fat
cells)
and
are
are
mesenchymal
involved
in
storage
of
cells
that
fat
soluble
live
in
the
space
vitamins,
of
Disse.
mainly
They
3
|
CLINICAL
vitamin
formation
Bile
salts
well
as
by
hepatocytes
secreted
into
excretion
cannot
be
of
serves
the
by
the
an
aid
endogenous
excreted
both
duodenum
in
exocrine
fat
metabolites
and
excretory
emulsification
(bilirubin)
and
absorption,
drug
as
metabolites
that
release
diseases
gallbladder
is lined
secretory
gallbladder
lacks
externa
is not
gallbladder the
which
duct
to
the
simple
muscularis into
covered
by
fundus,
and
spiral
valves
has form
before
a
with
organized
is end,
by
function,
the
a
and
submucosa,
layers
like
serosa
narrowing of
The
duct,
and the
gut.
which
empties duct
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absorptive the
the
The
I collagen
and
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tube,
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development
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ethanol). of
portacaval
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other
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bleeding.
the
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and
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surface
The
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with
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mucosae
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peritoneal
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columnar
underlying
PERINEUM
injury,
into
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
pudendal •
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 •
Bulbospongiosus of
•
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
•
Bulbourethral
perineal
muscle
(Cowper)
gland
(in
the
male
only)—duct
enters
bulbar
urethra
The
greater
vestibular
are
located
in
pouch
of
the
the
(Bartholin) superficial
glands perineal
female.
Bladder Prostate Levator
Deep
perineal
(urogenital
internus
Sphincter
urethrae
of
penis
membrane
perineal
(Cowper)
fascia
Ischiocavernosus
space
Bulb
Bulbourethral
muscle
space diaphragm)
Buck
Superficial
muscle
Obturator
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
the
shaft
the
penis
of
penis.
(contains
the
penis.
Medical Genetics
In
the
male,
BehavioralScience/Social Sciences to the bulb of the
injury
Ductus penis
(blue
arrow)
extravasation urethra Microbiology
urethra).
of into
space.
the
From
may
result
urine
from
superficial
this
space,
the
Prostate
perineal urine
into
penis,
the
and
abdominal Scarpa
scrotum,
onto wall
fascia
the in (green
into
plane
lobe
(M)
Anterior
lobe
(A)
Posterior
lobe
the A
P
anterior the
gland
Median
may M
pass
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.
Pubic
Pudendal
of
symphysis
canal
• Pudendal
Urethra nerve
• Internal
Ischiopubic
ramus
Urogenital
triangle
pudendal
vessels
Vagina Ischial
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
the
into
by
each
is
a dense
continuous
approximately
lobule
fibrous with
250
are
1–4
capsule
tubes,
Fig. the # of
many
pyramidal
Author, called
the
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compartments I 10 1
where
Title, Ed
albuginea. Step USMLE septa
(testicular10 Anat_I
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seminiferous
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Each
diameter testes. well
lobules).
2nd Pass
spermatozoa
are
and The defined
tubule 30–70
is cm
a coiled, in
seminiferous basal
non
length.
tubules
branching
Both
ends
contain
closed of
each
loop
is
μm
that
150–200
electronic publishing services inc. tubule converge on the 845 Third Ave 6th FloorNY, NY10022
spermatogenic
cells,
Sertoli
cells,
rete and
lamina.
BehavioralScience/Social Sciences
Microbiology Ductus Seminal
deferens
vesicle
Ejaculatory Corpus
duct
cavernosum Prostate
Cowper
gland
Corpus spongiosum
Penis Epididymis Urethra Testicle
Figure
II
3
53. Figure
15
1 Anatomy
Date divide 1st Pass
that
Medical Genetics produced.
Pathology
surrounded albuginea
testis
Within Physiology
is
Male II 3 54.
reproductive Male
Reproductive
system System
09
02
10
3rd
12
07
10
4th
Author’s review (if needed)
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
Connective
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
between
the
stem cells
the cells develop,
epithelium) basement
are
(spermatogonia) they
stacked
membrane
and are
move
from
adjacent the
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
first
B)
a single
through
(and
form
(1n,
haploid).
are
stem
that long
the in
enter
well
second
days
to
2
(2n, meiotic
sections)
connected
differentiation
as Type
meiosis. (10
histologic
remain their
meiosis.
spermatocytes
undergo seen
spermatogonium throughout
as
to
prophase
2 secondary
rarely
cells
committed
a
rapidly
minutes
bridges
are
spermatocytes
pass
division
maturing
cytoplasmic
more
that
primary
spermatocytes of
spermatids
of by
producing and
diploid)
meiotic
secondary
a matter
progeny
A
into (4n,
the
mitosis, (type
differentiate
division
The
resume
spermatocytes
haploid).
Physiology
cells
spermatogonia
to
to into
one
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
a basement
on
the
(C), the have
Hill
blood
Companies.
membrane
basement
and testis
elongated,
Used
(A) and
membrane,
spermatozoa
(D)
are
barrier. pale
staining
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
This
condensation, loss
of
much
process
and of
the
of
elongation
of
cytoplasm.
Acrosome
Head Nucleus
Mitochondria Mid piece Microtubules
Flagellum
Tail
Principal piece
End piece
Figure
The
acrosome,
from
the
such
as
which Golgi
of
hyaluronidase, cells
produced
secondary
result
basic of
56. Spermatozoan II 3 57. Spermatozoan
over
the
the
of
interaction
the
corona
anterior
spermatid
and
neuraminidase,
structure the
located
complex
dissociate
The
is
II 3 Figure
and
radiata
and
half
of
contains acid
digest
the
nucleus,
several
phosphatase; the
zona
is
these pellucida
derived
hydrolytic
enzymes enzymes
of
the
recently
oocyte.
of
a flagellum among
is similar microtubules,
to
that ATP,
of and
a
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
the
These
tubule
cells
during
multifunctional
prior times
to of
cells
puberty
and
maximal
in
are
the
elderly
men
spermatogenesis.
Biochemistry Irregular
in
extends
to
oriented Medical Genetics
•
shape; the
•
Do
•
Support,
divide protect,
that
cells •
a
the
and
that
Secrete
are fail
cell
by
with
the
the
long
neighboring barrier
an
apical
end
axis
Sertoli by
adluminal
nutrition
cells
separating
the
compartment.
to
the
developing
spermatid
by
Sertoli
protein
concentrations
maturation.
stimulated
and
with
period.
excess
binding
High
germ
lamina oval
spermatozoa.
cytoplasm cells.
They
is also
shed
as
residual
phagocytize
germ
mature.
androgen
tosterone.
contact
reproductive
phagocytized
be
membrane.
and
provide
basal to
blood–testis
basal
the
to
the
basement
the
into
during
to tends
make
spermiogenesis,
bodies
the
forming tubule
not
adheres nucleus
extensions
junctions,
During
Microbiology
base The to
cytoplasmic tight
seminiferous
BehavioralScience/Social Sciences
the
lumen.
perpendicular
The via
Pathology
Barrier
columnar
predominant
•
Physiology
the
The
follicle
that of
binds
these
production
of
stimulating
testosterone
hormones androgen
hormone
and
are
for
binding
(FSH
dihydrotes
essential
normal
protein
receptors
are
is on
Sertoli
cells). •
Secrete
inhibin,
•
Produce
anti
which Müllerian
development
The
blood–testis
ous
tubule
earliest
primary
material
between
Interstitial
Tissues
interstitial
and one.
Leydig
cells.
cells
an
the
The
cells
adluminal basal
advanced the
suppresses
the
divides
the
spermatogonia
barrier
spermatocytes
the
(containing
compartment stages
seminifer and
compartment
The
by
primary
which the
more
products
that
has of
formed
access
spermatogenesis
by
traverse
the free
the
this
tight barrier
are junctions by
a
understood.
of tissue
tissue
Sertoli
spermatids).
while
borne
yet
of
and
blood,
Sertoli not
connective
in
life structures.
(containing
and
blood
mechanism
The
16
from the
network
spermatocytes)
found
protected
fetal
reproductive
compartment
spermatocytes
synthesis.
during
internal
is a
a basal
FSH
hormone
female
barrier
remaining to
of
into
suppresses
the lying
composed (also
called
Testis between of
the fibroblasts,
interstitial
seminiferous
tubules
collagen, cells).
The
blood Leydig
is
a
loose
network
and
lymphatic
vessels,
cells
synthesize
testoster
of
CHAPTER
Copyright
McGraw
Hill Companies.
Figure Figure II II3
The
withCopyright permission. McGraw
Interstitium cells cells
Hill
Companies.
between tubules between seminiferousseminiferous
(arrow) (arrow) and
fibroblasts (arrowhead) and fibroblasts
Used
with
|
ABDOMEN,
PELVIS,
AND
PERINEUM
permission.
contains tubules (arrowhead)
Ducts seminiferous
efferentes. are
357.58.
Leydig Leydig
contains
Genital
Used
3
tubules The
ciliated.
The
ciliated
cells
smooth
muscle
Copyright
ductuli ciliary
reabsorb
McGraw
Figure Figure
empty are
into
lined
action some
surrounds
Hill Companies.
by
the a
propels of
the
each
Used
rete
testis
single
layer
the
nonmotile
fluid
produced
and of
then
into
epithelial
10–20
cells,
some
spermatozoa. by
the
The
testis.
ductuli
A
thin
of
which
non band
of
ductus.
with permission. McGraw Copyright
IIII 3 359. 58. Efferent Efferent ductules
ductules with
columnar
Hill
Companies.
ciliated with cuboidal ciliated
and
Used
cuboidal columnar
with
permission.
cellsand
cells
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
It
epididymis
is
is
the
m
The long)
accumula that
the
a pseudostratified
microvilli)
on
phagocytizes
substances
major
is the
epididymis
with
(tall fluid,
secretes
in
lined
stereocilia
and
the
(approximately
testicular
spermatozoa, of
efferentes
spermatozoa.
motile.
epithelium
formed
ducti duct
maturation
epithelium
surface.
the
convoluted
become
columnar
poorly
from
highly
the
luminal
residual
thought
to
bodies
play
and
a role
in
the
spermatozoa.
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
ligation
of to
the
and
the urethra.
and vas
conducts
then
muscular
smooth
mis
deferens
into tube
an deferens
the consisting
intermediate prevents
lined lined
McGraw
by
from urethra.
circular movement
an
Used
with
permission.
columnar columnar
(arrow) (arrow)
spermatozoa
of
Companies.
pseudostratified pseudostratified
stereocilia with with stereocilia
prostatic
Hill
the The
inner
and
layer.
ductus outer
Vasectomy of
epididymis
spermatozoa
to (vas)
layer or
of the from
the
deferens longitudinal bilateral the
epididy
is
a
CHAPTER
Copyright
McGraw
Figure
II 3 Figure
Accessory The
seminal
vesicles of
secretory
the
are
bladder.
seminal
that
vesicles
ejaculate
citrate,
deferens
prostate
to
Hill
with with
Companies.
Used
with
thick layers of smooth thick layers of smooth muscle
Figure
a
McGraw
II
an the
nuclei
to
ejaculatory
the
posterior
that
have
columnar
the
ABDOMEN,
PELVIS,
AND
PERINEUM
permission. muscle
cell
motility.
which
duct
The
inferior mucosa is
approximately substances
Fructose,
duct.
folded
lined
rich
in
70%
of
base.
constitutes
The
and
a
epithelium
activating
proteins. for
prostatic
Hill Companies.
The
secretion
several
on glands
spermatozoa
energy
form into
situated
convoluted
the
in
and
to
glands
epithelium.
is rich
the
empty
Copyright
of highly
produce and
provides
ductus
pair
displace
prostaglandins, sperm,
a These
columnar
granules
human
for
60. Ductus deferens II 3 61. Ductus deferens
pseudostratified
The
Used with permission. Copyright McGraw
|
Glands
surfaces with
Hill Companies.
3
of
each
ejaculatory
such is
a
major
seminal duct
as
fructose,
nutrient vesicle
traverses
joins
a
the
urethra.
Used with permission. Copyright McGraw
Hill
Companies.
3 61. Seminal vesicle showing mucosal Figure II 3 62. Seminal vesicle showing mucosal pseudostratified columnar epithelium with pseudostratified columnar epithelium
Used
with
folds lined folds lined (arrow) (arrow)
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
There and
the
is
are
2 types
main
The acid,
tubuloalveolar
surrounded of
prostatic
glands
with
products
of
fibrinolysin,
by
the
and
in
pale,
whose
fibroelastic
the the
that
prostate,
periurethral Glandular
cytoplasm
granules
ducts
capsule
periphery.
foamy
secretory other
glands a
in
glands
columnar
granules. citric
branched
prostate
pseudostratified
secretory
phosphatase,
of The
muscle.
submucosal Pharmacology
collection
urethra.
and
include
numer acid
proteins.
Microbiology
Copyright
McGraw
Hill Companies.
Figure
II Figure 3 62.
Used Copyright with permission. McGraw
II Prostate 3 63.
II
3
9.
Male
Reproductive
columnar columnar
occurs
splanchnic
in
response
nerves).
corpus accumulate
to
Nitric
cavernosum the
glandsglandslined
with
lined
permission.
by
epithelium epithelium
Erection
parasympathetic
oxide
and
in
Used
Physiology
Penile
Erection
Companies.
Prostate with with tubuloalveolar tubuloalveolar
pseudostratified by pseudostratified
Table
Hill
is
corpus
stimulation
released,
causing
spongiosum,
trabeculae
of
which
erectile
(pelvic
relaxation allows
of blood
the
to
tissue.
Ejaculation
•
Sympathetic
nervous
mediates vas •
•
deferens
and
and
fertility.
16
of
the
bulbourethral
rapid
semen
in through
that
nerve) muscles
ejection
waves
the
nerves)
epididymis
(Cowper)
fluids
(pudendal
ischiocavernosus
Peristaltic
splanchnic
from
and
duct.
secrete
efferents
and the
as
(lumbar
spermatozoa
ejaculatory
vesicles
motor
stimulate
stimulation
mature
such
seminal
pongiosus
ejection
the
glands
tate,
Somatic
of
into
Accessory
tion.
system
movement
of the
vas the
semen deferens urethra.
that at
out
glands,
aid
in
survival
innervate the
base
the
urethra
aid
in
a
pros
sperm
the of
the
during more
complete
bulbos penis ejacula
is
CHAPTER
Clinical
•
Injury
to
the
urethra
may
pass
the
bulb
into
abdominal •
penis
may
result
perineal
scrotum,
ABDOMEN,
PELVIS,
AND
PERINEUM
Correlate
superficial
the
of
wall
penile to
the
the
|
into
the
in
extravasation
space.
From
this
onto
the
penis,
and
of
urine
space,
from urine
anterior
wall.
Accumulation nal
of
into
3
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FEMALE
REPRODUCTIVE
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Ovary The
paired
produce maintain wide,
have
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Female Female
Reproductive Reproductive
System
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16
PART
II
|
GROSS
ANATOMY
Anatomy
Immunology Folliculogenesis
and
Ovulation
14 Pharmacology
days
Biochemistry
Developing Primary Physiology
Medical Genetics
Secondary
follicles
oocyte Mature
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(graafian) follicle
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oocyte
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and
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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
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the
has
the
in
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radiata
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granulosa
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plasma,
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follicles.
ovulation.
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meiotic
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cells.
antrum.
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it
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of granulosa radiata
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layer
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CHAPTER
and
form
lutein
lutein
cells
cells
now
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In
and thereby
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corpus
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pregnancy
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in
lutein The
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site
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tissue,
produced
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macrophages.
gonadotropin
for
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lutein and
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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
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endometrium
growth
and
internal
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connective
glands,
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17
PART
II
|
GROSS
Anatomy
ANATOMY
Immunology Mammary CLINICAL
Breast Pharmacology born
cancer in
the
of
the
cancers cells
CORRELATE
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affects United
(carcinomas) lactiferous
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RADIOLOGY
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Immunology Inferior Liver
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PART
Anatomy
II
|
GROSS
ANATOMY
Immunology
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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
Microtubules organelles
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,
The
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,
is usually
that
segment
segment
contains
segment
is
an
action
If the
lacks
marked
Nissl
axon
is of
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
an
axon
The
sodium
where
membrane ion
of
channels.
conduction
of
the
The
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.
In
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