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Atlas of Medical Anatomy JAN LANGMAN, M.D., Ph.D. Professor and Chairman, Department of Anatomy, University of Virginia
M. W. WOERDEMAN, M.D., Ph.D., D.Sc.h. Professor of Anatomy and Embryology Emeritus; Formerly Director of the Department of Anatomy, The University of Amsterdam
A Saunders Paperback
THE SAUNDERS PRESS W. B. Saunders Company Philadelphia London Toronto
THE SAUNDERS PRESS/SAUNDERS PAPERBACKS W. B. Saunders Company West Washington Square Philadelphia, PA 19105
IN THE UNITED STATES DISTRIBUTED TO THE TRADE BY
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IN CANADA DISTRIBUTED BY
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© 1982, 1978 by W. B. Saunders Company Copyright under the Uniform Copyright Convention. Simultaneously published in Canada. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Made in the United States of America. Library of Congress catalog card number 81-51356 W. B. Saunders Company ISBN: 0-7216-5622-6 Holt, Rinehart and Winston ISBN: 0-03-059656-4 Print number
Portrait painters and sculptors study anatomy to create an accurate surface impression of the underlying structures; sport trainers examine the muscles, bones and joints to analyze and prescribe the most efficient movements. Students of medicine and dentistry study anatomy to better understand and evaluate the symptoms of disease. Every human being interested in body form and function studies anatomy to know where the various organs and structures are located and how they are related to each other. We have composed this atlas with all these groups of interested people in mind. We hope particularly that they will obtain a thorough, three-dimensional knowledge of the normal human body and that the text will help them understand the clinical applications of anatomical knowledge. Certain areas of gross anatomy are difficult to understand even when represented in three-dimensional illustrations. For this reason we have added schematic drawings that either simplify the anatomical relation or explain them by making use of the simple re¬ lations seen in the embryo. The simplicity of the structures found during development helps us understand the complicated topography in the adult. In many chapters we have presented photographs of the surface features in an attempt to bridge the gap between the dissected specimen and the live human being. Similarly, a number of radiographs have been presented. Both the surface photographs and the radio¬ graphs try to correlate anatomical observations with data obtained from normal and diseased human beings. This book was illustrated and written originally with the training of medical students in mind. This is reflected in the selection of illustrations, most of which were prepared from adult specimens, but some from newborn infants. Throughout the writing and illustration of this book, however, we have kept in mind that it is not only medical and dental students who must learn the anatomy of the human body; rather, many if not most human beings are interested in the structure of their bodies. Hence, we expect that while the medical student will benefit from the clinical application of his anatomical knowledge, our other readers will be fascinated by the structure of the human body.
Martin W. Woerdeman, M.D., Ph.D., D.Sc.h.c. Jan Langman, M.D., Ph.D.
The publication of an anatomical atlas is a monumental task involving the dissection of numerous specimens, the preparation of several thousand illustrations and the logical arrangement of the material. The greatest collaborative effort over a prolonged period of time is required to bring such a large work to its final form. We are therefore deeply indebted to our many co-workers, varying from artists to secretaries and from colleagues in anatomy to a host of medical students. This work could not have been accomplished without the dedication of the late Mrs. H. L. Blumenthal-Rothschild, the principal artist, who prepared the majority of the illustrations. She made her artistic and scientific talents available for this work with the greatest enthusiasm
a number of excellent co-workers. These artists, Mmes.
L. M. Binger, W. van Slooten and A. van Hamersveld and Messrs. J. Tinkelenberg and Chr. van Huizen, each contributed a substantial number of illustrations to this book. To them we offer our most sincere thanks. Some of the drawings that were in the collection of the Anatomy Department of the University of Amsterdam were generously made available to us by its Chairman, Dr. J. van Limborgh. We are also greatly indebted to Mr. W. Fairweather, who directed the color work on the illustrations for this atlas and prepared several additional drawings. For this arduous work our thanks go particularly to Mrs. Judy Fairweather, who prepared the thousands of color overlays with endless patience, great enthusiasm and skill. We also wish to express our great appreciation to the W. B. Saunders Company, who undertook the task of publishing this book. In particular, our thanks go to Mr. John Hanley, who encouraged us continuously in the preparation of this work. We are also indebted to Miss Ruth Goddard, who edited the text and checked the labels in the illustrations. Finally, we especially wish to thank Mrs. Hanna Woerdeman and Mrs. Ina Langman for their wonderful encouragement and devotion during the preparation of this book.
Amsterdam, Holland Charlottesville, Virginia
Martin W. Woerdeman Jan Langman
Surface view of the thorax
The superficial fascia of the thorax
The breast and its lymph drainage
Bones and joints of the thorax
The large thoracic muscles
Intercostal musculature, nerves and vessels
Contents of the thorax in the newborn
The anterior thoracic wall
Lungs and pleura in sections through the thorax
Auscultation of the heart
Contents of the thorax in the adult
Right lung —surface aspects and bronchial tree
Left lung —surface aspects and bronchial tree
Trachea and tracheobronchial lymph nodes
Surface views of the heart
The pericardium and its sinuses
The coronary vessels
Interior aspect of the heart
Conducting system of the heart
The pericardial cavity
The great vessels in relation to the trachea and esophagus
Structures in the posterior mediastinum
The diaphragm and diaphragmatic hernia
Surface views of the abdomen
The bony pelvis
The superficial fascia, nerves and vessels VI
CONTENTS A7- 412
Muscles of the abdominal wall
The inguinal region and spermatic cord
The peritoneum and its development
The abdominal contents
The lesser omentum
The stomach—position, vascularization and lymph drainage
Small and large intestines —position, vascularization and lymph drainage
Attachment of the mesenteries
The pancreas, duodenum and spleen
The kidneys and suprarenal glands
The autonomic nervous system
The diaphragm and posterior abdominal wall
The bones and joints of the pelvis
External genital organs in the male
The testis and epididymis
The penis —position, vascularization and lymph drainage
Anal and urogenital triangles in the male
The urogenital diaphragm in the male
Vascularization and lymph drainage of the male pelvis
The bladder, prostate and seminal vesicles
The rectum and ischiorectal fossa
The internal iliac artery and its branches
External genital organs in the female —vascularization and lymph drainage
Sections through the female pelvis
Vascularization of the female pelvis
Uterus, ovary and vagina
Ligaments of the uterus
Lymph drainage of the female pelvis
The pelvic diaphragm
The lumbosacral plexus
The autonomic nervous system in the pelvis
Brachial plexus and segmental innervation
The bones of the shoulder girdle
The pectoral muscles
Vessels and nerves
The scapular muscles
Humerus, radius and ulna
Muscles, vessels and nerves of the arm
The shoulder joint
Muscles, vessels and nerves of the anterior side of the forearm
The bones of the hand
Arteries and nerves of the palm of the hand
The thenar and hypothenar musculature
The lumbrical and interosseous muscles
The median and ulnar nerves
Muscles, vessels and nerves of the posterior side of the forearm
Nerves and arteries of the dorsum of the hand
The radial nerve
The elbow joint
The carpal bones
Joints and ligaments of the wrist and hand
LOWER LIMB LL1-LL3
Lumbosacral plexus and segmental innervation
Major nerves and vessels
Lymph drainage and cutaneous innervation of the anterior aspect of the thigh
The saphenous opening, femoral sheath and femoral hernia
Muscles, vessels and nerves on the anterior and medial sides of the thigh
The femoral nerve
Muscles, vessels and nerves in the gluteal region
Muscles, vessels and nerves in the posterior region of the thigh
The common peroneal and superior gluteal nerves
The femur, hip bone and hip joint
Muscles, vessels and nerves on the interior side of the leg and dorsal aspect of the foot
Muscles, vessels and nerves on the posterior side of the leg
Tendon sheaths on the medial side of the foot
The tibiofibular joints
The knee joint
Muscles, vessels and nerves of the sole of the foot
The sciatic nerve
Joints and ligaments of the ankle and foot
HEAD AND NECK HN1-HN4
The newborn and adult skull
Major vessels of the head and neck
The trigeminal nerve
The facial nerve and musculature
The parotid gland and its relations
Bones and cartilages of the ear and nose
The eye and lacrimal apparatus
The scalp and its relation to the brain IX
CONTENTS HN23, HN24
Extracranial and intracranial veins and sinuses
The cranial cavity and the dura
The cranial nerves and the base of the skull
The middle cranial fossa and hypophysis
The bony orbit
The muscles of the eye and their nerves
Median sections through the head
The nose and paranasal sinuses
The temporal bone
The external, middle and internal ear
The posterior triangle of the neck with its nerves and vessels
The infrahyoid musculature and vessels of the neck
The sympathetic trunk and vessels in the neck
Fascial layers in the neck
The salivary gland and muscles of mastication
The mandible and temporomandibular joint
The parasympathetic ganglia
The oral cavity and tongue and their innervation
The teeth and their innervation
The base of the skull and foramina
The pharyngeal musculature and nerves
The prevertebral musculature
The oropharynx, nasopharynx and palate
The larynx and its cartilages and muscles
The thyroid gland
The vertebrae and vertebral column
The spinal nerve
Nerves and vessels in the occipital region
Superficial and deep muscles of the back
Suboccipital muscles, vessels and nerves
Atlanto-occipital and atlantoaxial joints and ligaments
Ligaments of the vertebral column
The spinal cord and the meninges
THORAX -T1 clavicle
The following landmarks are important in
Anterior surface of the thorax in a male.
the physical examination of the thorax. They can all be easily palpated and are helpful as reference points in determining the position of the heart and lungs.
*f Suprasternal notch: the midline depression bordered by the superior margin of the sternum and the medial ends of the clavi¬ cles. Deep to the depression the tracheal cartilages can be felt. By moving the finger xiphisternal joint
slightly upwards the cricoid cartilage of the larynx can be palpated.
Sternal angle: the angle between the manu¬ brium and the body of the sternum. At this level the second costal cartilage joins the lateral border of the sternum. The sternal angle
important landmark when
counting the ribs and intercostal spaces.
Xiphisternal joint: the joint between the body of the sternum and the xiphoid proc¬ ess. The cartilage of the seventh rib attaches
Anterior view of the thorax. The bony skeleton is superimposed.
to the sternum just above the joint; occa¬ sionally it is attached to the xiphoid proc¬ ess. Palpation of the inferior tip of the xiphoid process may be painful. ♦f Costal margin: the lower boundary of the thorax, formed by the cartilages of the seventh, eighth, ninth and tenth ribs. «f Clavicle: one of the few bones whose entire length lies immediately under the skin.
Ribs: The ribs can best be palpated and counted by first determining the position of the second rib, which is easily identifiable because it attaches to the sternum at the sternal angle. Counting of the ribs is easiest in the midclavicular line. The first rib cannot be felt since it lies deep to the clavicle. Similarly, the eleventh and twelfth ribs are difficult to palpate. The number of each intercostal space corresponds to the number of the rib forming its upper boundary. (For bony components of the thorax see T9 and T10.) 2
Anterior view of the thorax in a female. Orientation lines are indicated.
Subcutaneous fat tissue and the mam¬ mary glands make palpation of the bony landmarks and auscultation and per¬ cussion of the heart and lungs more dif¬ ficult in the female than in the male. The following orientation lines may be helpful in physical diagnosis:
1. Midsternal line: lies in the median plane of the sternum. 2. Parasternal line: is drawn about half an inch from the lateral border of the sternum. 3. Midclavicular
down from the midpoint of the clavi¬ cle. 4. Anterior axillary line: runs vertically down from the anterior axillary fold. 5. Mammillary or nipple line: is not of much value considering individual
Schematic drawing of the anterior aspect of the thorax. The outline of the heart and lungs is superimposed.
variations and the changes in the position of the nipple that occur with age.
Note also the following important points: The top or apex of the lung extends above the first rib and clavicle into the neck, where it forms a dome. Deep wounds above the clavicle may penetrate into the apex of the lung. «J
On the right side of the sternum the heart is covered anteriorly by the right lung; on the left side, it is covered anteriorly by the lung except in parts of the fourth and fifth inteicostal spaces and behind the fourth and fifth ribs (see B).
The apex of the heart, formed by the left ventricle, lies behind the fifth intercostal space. The beat of the heart (apex beat) can be felt in this space 3% inches from the midsternal line. When the heart is enlarged, the apex beat may be felt in the midclavicular or even in the anterior axillary line.
spine of scapula
root of spine
Posterior view of the thorax in a male.
examining the posterior aspect of the
thorax only a few bony landmarks and orien¬ tation lines are used as reference points.
The vertebra prominens. This is the seventh cervical
contrary to that of the other cervical verte¬ brae, can be palpated easily by moving the fingers downward along the midline of the posterior aspect of the neck. The first spinous process that is easily distin¬ guishable is that of the seventh cervical vertebra (C7).
The spinous processes of the thoracic verte¬ brae. Once the spinous process of C7 has been determined, it is easy to palpate the The bony points, lungs and pleura are superimposed.
spines of the thoracic vertebrae by moving the fingers downward along the vertebral column.
The spine of the scapula. This is an easily palpable subcutaneous part of the scapula. The root of the spine lies at the level of the spinous process of the third thoracic vertebra (T3). This landmark is of little value since the scapula can move considerable distances along the posterior body wall. Its relationship to the spine is valid only if the arms are hanging at the sides.
The scapular line, which runs vertically downward from the inferior angle of the scapula when the arms are hanging at the sides.
The posterior axillary line, which runs vertically downward from the posterior axillary fold (see T12 A).
Note also: The lower border of the pleural cavity extends at least the width of two fingers below the border of the lungs, a fact of great clinical importance. During respiration the lungs move up and down in the pleural cavity (see T26 and T27). 4
areolar venous plexusaxillary vein
- thoracoepigastric vein (channel)
umbilical venous plexus
anastomoses with paraumbilical veins
superficial epigastric vein
- superficial circumflex iliac vein femoral vein __ - superficial external pudendal vein superficial dorsal vein of penis great saphenous vein
The veins in the superficial fascia.
The superficial fascia connects the corium of the skin to the underlying deep fascia, which invests the musculature (see T12 A). The superficial fascia consists of loose are¬ olar tissue with collagenous and elastic fibers and usually contains considerable fat. «J
The subcutaneous nerves and the superficial veins are located in the super ficial fascia. Under normal conditions few anastomoses exist between the thoracic veins and the epigastric veins of the abdominal wall. Occasionally, however, if the inferior vtna cava is obstructed, large anastomoses may develop; the most important channel to bypass the vena cava is the thoracoepigastric venous channel.
THORAX-T5 nipple /tV'i'ktTC
fatty tissue .lactiferous ducts suspensory ligaments (Cooper)
lobes of mammary gland pectoralis major fascia of pectoralis major
Section through the mammary gland.
The mammary gland is the most important organ in the superficial fascia of the thorax. Note the following clinical¬ ly important points:
Position and attachment. The breast lies in the superfi¬ cial fascia and rests on the deep fascia covering the pectoralis major and serratus anterior muscles. Fibrous bands, called Cooper's suspensory ligaments, fix the breast to the skin and the underlying fascia. These ligaments
Schematic drawing of the milkline and accessory nipples. (From Langman, J.: Medical Embryology, 3rd ed. Baltimore, The Williams & Wilkins Co., 1975.)
are clinically important because the invasion of cancer cells may cause them to retract: on the skin this causes dimpling, and in the nipple area it causes retraction of the nipple. When the tumor invades the fibers inserting into the deep fascia, the breast tissue cannot be moved over the muscles, as in normal women.
Axillary tail (Spence).
This is a tail-like prolongation of the upper-outer quadrant
in an axillary direction. It passes through an opening in the axillary fascia and is thus located deep to the fascia. When the gland is palpated the tail tissue is sometimes con¬ fused with enlarged axillary lymph nodes (see T6 B). ^
Inversion of the nipple is either a congenital condition or the result of
the ingrowth of cancer tissue in the suspensory ligaments in the nipple region.
Ectopic nipple. length
Additional nipples (polythelia) may be found anywhere along the the so-called tnilkHw#, which extends the axillary region to the inguinal
region. Extra nipples are usually not accompanied by breast tissue. Occasionally, how¬ ever, an extra nipple and functional breast tissue are found in the axillary region (poly¬ mastia). 6
interpectoral lymph nodes
apical or infraclavicular lymph nodes I
; lymph channels to parasternal nodes
central axillary lymph nodes pectoralis major
subareolar lymph plexus
(cut and reflected)
lymph channels to epigastric region rectus abdominis
lateral axillary lymph nodes subscapular lymph nodes pectoral (ant. axillary) lymph nodes
latissimus dorsi serratus anterior
Lymph drainage of the female breast. central axillary lymph nodes
infraclavicular (apical) lymph nodes
to parasternal and mediastinal lymph nodes
pectoral (ant. axillary)
Schematic drawing of the lymph drainage of the breast.
to opposite breast
areolar lymphatics to epigastric and peritoneal lymph nodes
The lymph drainage of the breast is extremely important because of the frequent occurrence of cancer in this region and the spread of malignant cells along the lymph vessels.
Most lymphatics of the glandular tissue course in a superolateral direction and drain into the pec¬ toral (anterior axillary) nodes. Subsequently they drain into the central axillary nodes located in the fat of the axilla under the axillary tuft of hair and along the inner border of the axillary vein. From here they pass toward the apical or infraclavicular group. Finally, they reach the deep cervical or supra¬ clavicular lymph nodes.