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Clinical Anatomy (A Problem Solving Approach), 2nd Edition

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  • 1. Clinical Anatomy (A Problem Solving Approach)
  • 2. Clinical Anatomy (A Problem Solving Approach) Second Edition Professor of Anatomy Dr Somervell Memorial CSI Medical College Karakonam, Thiruvananthapuram Kerala, India Neeta V Kulkarni md Formerly Professor and Head, Department of Anatomy Government Medical College Thiruvananthapuram, Kerala, India Foreword BR Kate JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London
  • 3. Jaypee Brothers Medical Publishers (P) Ltd. Headquarter Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P. Medical Ltd., 83 Victoria Street London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee-Highlights medical publishers Inc. City of Knowledge, Bld. 237, Clayton Panama City, Panama Phone: 507-317-0160 Fax: +50-73-010499 Email: cservice@jphmedical.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2012, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the author(s) contained herein are original, and is intended for educational purposes only. While every effort is made to ensure a accuracy of information, the publisher and the author(s) specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the authors(s). Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. Publisher: Jitendar P Vij Publishing Director: Tarun Duneja Editor: Richa Saxena Cover Design: Seema Dogra, Sumit Kumar Clinical Anatomy (A Problem Solving Approach) First Edition: 2006 (Reprint 2007) Second Edition: 2012 ISBN 978-93-5025-497-4 Printed at: Ajanta Offset & Packagings Ltd., New Delhi
  • 4. Dedicated to The memory of my husband Dr VP Kulkarni who was a pillar of strength during the making of first edition
  • 5. Foreword I am extremely happy to write a foreword for the second edition of the book entitled Clinical Anatomy (A Problem Solving Approach) by Dr Neeta V Kulkarni. Generally, we observe that most books of anatomy and embryology are mainly based on description of structures. Like a born teacher, she has not only described structure but has shown her talent and maturity of thought by stressing the main purpose of knowing gross anatomy and embryology. In the book, the author has given considerable justice to the living anatomy by inclusion of images of plain radiographs, computed tomography (CT), magnetic resonance imaging (MRI), digital subtraction angiography (DSA) and three dimensional reconstruction images using multidetector CT. Added to this, there are intraoperative photographic views of various internal organs in the body. She has shown how technology can be harnessed to convert this so-called static subject into a dynamic entity. She has been an anatomy teacher throughout her career and has assimilated the subject well. Knowledge when it becomes ripe gives wisdom and she has used her experienced wisdom to innovate the presentation according to the need of the day. This edition covers general embryology, genetics, special embryology, gross anatomy and basic knowledge of the tissues of the body with emphasis on application. The reduction in the time of teaching anatomy at preclinical level is a very unfortunate step. This exhaustive subject deserves ample time to learn and understand. Clinical anatomy for students with its problem-solving approach will minimize the hardships of learning to understand anatomy. I often used to wonder, if we should have separate anatomy texts catering to the needs of undergraduate curriculum, clinical postgraduate curriculum (as per the specialty chosen) and separate books for anatomists. But now I feel that books like Clinical Anatomy can build the bridges and provide a refreshing anatomical elixir to all involved in providing health care. Let me wish a wholesome response to the new edition. BR Kate ms, fams, fsams Ex-Director of Medical Education and Research Mumbai, Maharashtra, India
  • 6. Preface to the Second Edition Anatomy is the basis of medical profession as human body is the focus of examination, investigation and intervention for diagnosis and treatment of diseases. There is a re-awakening of the importance of anatomy with the realization that sound knowledge of anatomy is the backbone of safe medical practice. A doctor with sound anatomical knowledge is well-equipped to perform safe procedure or surgery, than the one who makes mistakes by cutting normal anatomical relations of the structure or organ, operated upon (for which the doctor is sued in the court of law for negligence). One must appreciate that application of anatomical knowledge is the ongoing process throughout the medical career. Therefore, clinical anatomy occupies the center stage right from the outset of medical training. There are intentional efforts by health educationists over the world to bridge the gray zone between preclinical anatomy and clinical anatomy. Learning anatomy (which includes gross anatomy, microscopic anatomy, embryology and genetics) in a short span of time is a Herculean task. Therefore, though it is not conceptually difficult, its sheer bulk makes anatomy overwhelming. In this context, a shift towards teaching/learning basic anatomy alongside clinical anatomy is a progressive step. The key to successful and enjoyable learning lies in consciously integrating the basic and the clinical anatomy right from the entry point by initiating the trainees to identify normal anatomical structures in plain radiographs, CT scans, ultrasound scans, MRI, etc. Added to this, they may be exposed to patients presenting with typical deformities due to nerve injury, patients with hemiplegia, paraplegia, etc., patients with obvious congenital defects, patients with thyroid swelling, parotid swelling, etc. This is bound to arouse their interest in learning. Another very interesting approach is to train the trainee in clinical problem solving by using anatomical knowledge. This approach not only convinces the trainees that preclinical anatomy is an integral part of bedside medicine but also expands their thinking capacity (brain power). This approach is indispensable for concept clarity and retention (rather than rote learning). Giving due regard to the constructive suggestions and comments from readers (both students and teachers) and bowing down to the request of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India the work on second edition of Clinical Anatomy (A Problem Solving Approach) was undertaken. The basic theme of the first edition developing skills in anatomical thinking for solving clinical problems has been retained. New chapters have been added on general anatomy (for giving conceptual background about basic tissues), general embryology and genetics besides osteology. All chapters on regional anatomy have been extensively revised and enriched with plenty of new figures including photographs of clinical material (collected from various clinicians) and radiological images (collected from radiologists) to emphasize relevance of anatomy in the practice of medicine. The solved examples on clinicoanatomical problems and multiple choice questions (MCQs) (given at the end of each section) not only aid in revising but also lend credence to the theme of the book. Clinical insight, embryologic insight and know more are displayed in boxes. I am sure that this edition too will spread positive vibes towards this tough subject and will reiterate the fact that the subject is interesting only, if looked through the mirror of its clinical relevance. Moreover, this text can be a good resource material in problem-based learning (PBL) curriculum in graduate medical education. Neeta V Kulkarni
  • 7. Preface to the First Edition It is a well-known fact that is documented right from the Greek era that anatomy provides a firm foundation to the edifice of medical education. However, in the new paradigm, the clinical anatomy provides the keystone to this foundation. It must be appreciated that no part of the human body can be learnt in isolation and that relations of the same structure change from region-to-region. These anatomical relations may be the basis of the symptoms of a particular disease or of the signs of the disease or of a clinical test (used for diagnosis of a disease) or of a surgical procedure (used to diagnose and/or treat the disease). Traditionally, we are conditioned to equate anatomy to the science of muscles and bones, which gives the beginner an incorrect impression about the potential of the subject. The key to successful and enjoyable learning lies in consciously correlating the basic and clinical anatomy (like for example, understanding anatomical basis of the symptoms and signs of diseases, surgical procedures, contraceptive measures, understanding embryological basis of congenital anomalies, identifying normal structures in radiographs and comparing them with changes in the disease state, etc.). Medical Council of India (MCI) in its stipulations of 1997 has reduced the duration of the first MBBS course and has recommended problem-based learning in preclinical subjects. This situation demands a fresh approach in which the students are trained to solve clinical problems using the anatomical knowledge gained during the first professional course. To choose essentials of anatomy for first MBBS students from a vast body of anatomical facts posed a challenging task. Reading through the paraclinical and clinical texts besides special interactive sessions with clinical teachers gave an insight (to a certain extent) into how much of anatomy learnt at preclinical level is actually applied to gain sound clinical training. Accordingly, in a few instances, clinically-oriented concepts or interpretations are mentioned along with the conventional. The clinical testing of skeletal muscles is included to make the learning of muscles more meaningful. Thus, the problem-solving approach creates an imprint on the minds of the students that preclinical anatomy is an integral part of bedside medicine. The presentation of the subject matter throughout the text is logical and reader-friendly. Essentials of anatomy covering all regions of the body are encapsulated in a single volume in order to gain a holistic perception of the anatomical structures. The central theme of this text is, developing skills in anatomical thinking for solving clinical problems. It was indeed a Herculean task to give concrete shape to such a complex theme. Let us hope that students will enjoy learning anatomy when they are able to solve clinical problems given at the end of the sections. Neeta V Kulkarni
  • 8. Acknowledgments What was uppermost in my mind while planning the second edition of Clinical Anatomy (A Problem Solving Approach) was the fear that without the backing of the living anatomy (portrayed through radiological images, intraoperative photographs of internal organs, photos of clinical examination of patients and of procedures done on the patients) it would be a futile effort. How to procure the images of clinical material was a big question mark. But soon lady luck smiled on me when Dr MA Elezy, Head of Department (Anatomy), Karuna Medical College, Palaghat, Palakkad, Kerala, India, began sending me almost on regular basis anatomically relevant images collected from her numerous contacts in clinical fraternity, with missionary zeal. I am immensely grateful to Dr Elezy, her family and friends for being so gracious. I would like to place on record the names of the clinicians who responded to Dr Elezy’s call, Dr Sreekumar VK, Professor of Surgery, Medical College, Trichur, Kerala, India; Dr Raghushankar, Associate Professor of Surgery, Karuna Medical College, Palaghat, Palakkad; Dr Kesavan, Anesthesiologist, Medical College, Trichur; Dr NK Sanil Kumar, Kochi, Dr R Vijayakumar, Orthopedic Surgeon, Medical College, Trichur; Dr Bejohn JK, Pediatric Surgeon, Medical College, Trichur; Dr Shameer VK, Medical College, Trichur; Dr Santhosh Nambiar, Medical College, Trichur, and Dr Jamal Medical College, Calicut, Kerala, India . It was a generous gesture of Dr Girijamony, Head of Department (Anatomy), Medical College, Trichur, Kerala, India to send the CD on laparoscopic anatomy of abdomen and pelvis. I thank Dr Bertha for the Meckel’s scan. I am ever indebted to the clinical fraternity of Dr Somervell Memorial CSI Medical College, Karakonam, Kerala, India, for their cooperation. Special thanks are due to Dr R Varma, Head of Department (Pediatric Surgery); Dr Vimala, Head of Department (Nephrology); Dr Punithen, Associate Professor of Surgery; Dr Jacob Thomas, Professor of Surgery, Dr Mariam Philip (Dermatology); Dr Regi Ebenezer (ENT); Dr Sara Ammu Chacko, Head of Department, Dr Nita H and Dr Sebastian (Radiodiagosis); Dr Aneesh Elias and Dr Sara Varghese (Plastic Surgery) and Dr Adeline Thankam (Obstetrics and Gynecology). Special thanks are extended to Dr Paul Augustine, Surgeon from RCC Thiruvananthapuram for providing the image of peau d’ orange. I am thankful to Dr Chandrakumari and Dr Vilasini Anatomy Department, Gokulam Medical College, Thiruvananthapuram, Kerala, India, for providing the image of sirenomelia—a rare congenital anomaly. My joy knew no bounds when I received a CD from Dr Avijit Basu, Cardiothoracic Surgeon, Chennai, Tamil Nadu, India, who is my son’s friend, containing images of heart and blood vessels. I found a multimedia expert, Dr Jeyachandran G (Associate Professor of Biochemistry), who willingly shared the major burden of designing the figures on the newly added topics like general anatomy, general embryology (including genetics) and osteology. He deserves many thanks. I would like to appreciate the support and encouragement extended by all staff members of anatomy, physiology and biochemistry departments. The availability of reference books in the college library was a great boon. My heartfelt thanks are due to Dr Bennet Abraham (Director) and Dr Samson Nissiah (Principal) of Dr Somervell Memorial CSI Medical College, Karakonam, Thiruvananthapuram, Kerala, India for providing institutional and infrastructural support.
  • 9. It is a great luck to be able to pay respects to one’s teachers of yesteryear from Medical College, Nagpur, Maharashtra, India. Dr BR Kate is a renowned anatomist. He has to his credit a number of research papers, a few of which have been cited in 38th edition of Gray’s Anatomy. He retired as Director of Medical Education, Maharashtra, India. I thank him profusely for the thoughtful foreword. I also thank Dr Kadasne who is a unique blend of a popular anatomy teacher, a practicing surgeon and an author. His recent book on embryology is deftly illustrated with line diagrams. I will ever remain indebted to Shri Jitendar P Vij, (Chairman and Managing Director), Mr Tarun Duneja (DirectorPublishing), Mr KK Raman (Production Manager) and the entire team of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India. Mr SS Shine of DK Press, Neyyattinkara, Thiruvananthapuram, Kerala, India has been an efficient graphic artist and designer without whose help this edition would not have seen the light of the day. Mr Sivaraman was available to draw new diagrams on osteology. He provided the precious photograph of Vesalius, the Father of Modern Anatomy. My son and daughter (and their respective spouses) are my inspirational strength. I place on record the technical help rendered by Technosys India, Pune, Maharashtra, India, headed by Mr Ujjwal Deshpande. With all humility in my heart, I place this edition at the feet of Almighty and seek his blessings.
  • 10. Contents Section 1 ♦ Introduction 1. Anatomy—Past, Present and Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2. Basic Tissues of the Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Anatomy in Brief  3  •  Greek Era  3  •  Roman Era  3  •  Dark Ages  3  •  Fourteenth Century  3  •  Renaissance (15th and 16th Centuries)  3  •  Seventeenth Century  4  •  Eighteenth Century  4  •  Nineteenth Century  4  •  Twentieth Century  5  •  Twenty First Century  5 Structural Organization of Human Body  6  •  Types of Basic Tissues  6  •  Epithelial Tissue  6  •  Characteristic Features of Epithelium  6  •  Basement Membrane  7  •  Cell Turn Over  8  •  Classification of Epithelium  8  •  Classification of Exocrine Glands  9  •  Connective Tissue  10  •  Basic Components  10  •  Connective Tissue Fibers  10  •  Classification of Connective Tissue Proper  12  •  Muscular Tissue  13  •  Types of Muscle Tissue  13  •  Additional Features of Skeletal Muscles  15  •  Neural Tissue  15  •  Subdivisions of Nervous System  15  •  Classification of Neurons  16  •  Microscopic Structure of Multipolar Neuron  16  •  Neuroglia  17  •  Myelination in CNS and PNS  17 Cartilage, Bones and Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Cartilage  18  •  General Features  18  •  Histological Types of Cartilage  18  •  Bone or Osseous Tissue  19  •  Components of Osseous Tissue  19  •  Microscopic Structure of Bone  20  •  Development and Ossification of Bone  20  •  Types of Bones  21  •  Parts of Developing Long Bone  22  •  Types of Epiphyses  22  •  Blood Supply of Long Bone  22  •  Joints  23  •  Types of Synarthroses  23  •  Types of Synovial Joints  23 4. Vascular Tissue and Lymphatic Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 5. Skin, Hypodermis and Deep Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 6. Descriptive Anatomical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 7. General Embryology and Genetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 8. Clinicoanatomical Problems and Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Vascular Tissue  26  •  General Layout of Arteries  26  •  Brief Review of Histology of Arteries and Veins  •  26  •  Lymphatic Tissue  27  •  Functions of Lymphatic Tissue  28  •  Types of Lymphocytes  28  •  Primary Lymphoid Organs  28  •  Secondary Lymphoid Organs  28  •  Lymphatic Tissue within Other Organs  28  •  Thymus  28  •  Lymph Node  28  •  Spleen  28  •  Palatine Tonsil  29 Skin  30  •  Functions of Skin  30  •  Layers of Skin  30  •  Glands of Skin  32  •  Hypodermis or Superficial Fascia  33  •  Deep Fascia  33  •  Modifications of Deep Fascia  33 Various Anatomical Terms  34  •  Additional Descriptive Terms for Position of Body  35  •  Directional Planes of Human Body  35 Gametogenesis  36  •  Oogenesis  36  •  Spermatogenesis  37  •  Fertilization  38  •  Cleavage of Zygote and Formation of Morula  38  •  Blastocyst Formation  39  •  Decidua  39  •  Normal Site of Implantation  40  •  Formation of Bilaminar Embryonic Disc  40  •  Amniotic Cavity  40  •  Primary and Secondary Yolk Sac  40  •  Chorion  41  •  Prochordal Plate  41  •  Primitive Streak and Gastrulation  41  •  Fate of Primitive Streak  41  •  Formation of Notochord  42  •  Formation of Neural Tube (Neurulation)  43  •  Neural Crest  43  •  Subdivisions of Intraembryonic Mesoderm  43  •  Folding of Embryonic Disc  44  •  Fetal Membranes  44  •  Gross Appearance of Placenta  47  •  Genetic Factors and Congenital Anomalies  47  •  Genetic Diseases due to Gene Mutation  48  •  Modes of Inheritance of Monogenic Diseases  48  •  Polygenic Diseases  48  •  Mitochondrial Inheritance  49  •  Chromosomes  49  •  Parts of a Chromosome  49  •  Morphological Types of Chromosomes  49  •  Karyotyping  49  •  Common Techniques for Studying Chromosomes  50  •  Karyotyping Using Giemsa Banding  50  •  Denver Classification of Chromosomes  50  •  Sex Chromosomes  50  •  Role of Y chromosome in Sex Differentiation  50  •  Structural Anomalies of Chromosomes  51  •  Philadelphia Chromosome (Ph1 Chromosome)  53  •  Numerical Anomalies of Chromosomes  53  •  Cell Cycle in Somatic Cells   53 Section 2 ♦ Upper Extremity 9. Bones of Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 10. Pectoral Region and Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Clavicle  71  •  Parts  71  •  Shaft  71  •  Articulations  71  •  Unique Features of Clavicle  71  •  Posterior Relations of Medial Two-Third  72  •  Ligaments Attached to Clavicle  72  •  Growing End  72  •  Blood Supply  72  •  Special Features  72  •  Scapula  72  •  General Features  73  •  Palpable Parts  73  •  Vertebral Levels  73  •  Triangle of Auscultation  73  •  Neurovascular Relations  73  •  Humerus  75  •  General Features  75  •  Growing End  76  •  Radius  77  •  Articulations of Radius  77  •  General Features  77  •  Growing End  78  •  Ulna  78  •  Articulations of Ulna  78  •  General Features  79  •  Growing End  80  •  Bones of Hand  80  •  Carpal Bones  80  •  Features  80  •  Carpal Tunnel  80  •  Ossification  80  •  Time of Appearance of Ossification Centers  80  •  Metacarpal Bones  82  •  Unique Features of First Metacarpal  82  •  Bennett’s Fracture  82 Pectoral Region  83  •  Surface Landmarks  83  •  Superficial Fascia  83  •  Cutaneous Nerves  84  •  Line of Discontinuous Dermatomes  84  •  Deep Fascia  84  •  Deltopectoral Triangle  85  •  Pectoralis Major  85  •  Pectoralis Minor  85 
  • 11. xiv   Clinical Anatomy (A Problem Solving Approach) •  Subclavius  86  •  Clavipectoral Fascia  86  •  Breast or Mammary Glands  87  •  Female Breast  87  •  Parts of Breast  88  •  Base of Breast  88  •  Nipple and Areola  88  •  Structure  88  •  Modes of Secretion  89  •  Arterial Supply  89  •  Venous Drainage  89  •  Lymphatic Drainage  89 11. Axilla and Axillary Lymph Nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 12. Brachial Plexus and Axillary Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 13. Superficial Muscles of Back and Scapular Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 14. Pectoral Girdle and Shoulder Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 15. Upper Limb (Cutaneous Nerves, Dermatomes, Venous Drainage and Lymph Vessels) . . . . . . . . . . . . . 120 16. Compartments of Arm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 17. Cubital Fossa and Elbow Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 18. Compartments of Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 19. Radioulnar Joints and Wrist Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 20. Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 21. Long Nerves of Upper Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 22. Axilla  94  •  Contents of Axilla  94  •  Walls of Axilla  94  •  Serratus Anterior Muscle  95  •  Long Thoracic Nerve  96  •  Axillary Lymph Nodes  96 Brachial Plexus  98  •  Location and Parts  98  •  Formation  98  •  Root Stage  98  •  Trunk Stage  99  •  Branches of Upper Trunk  99  •  Division Stage  99  •  Cord Stage  99  •  Connections with Sympathetic Chain  100  •  Axillary Artery and Vein  102  •  Surface Marking  102  •  Course  102  •  Parts of Axillary Artery  102  •  Branches  104  •  Scapular Anastomosis  104  •  Axillary Vein  105 Superficial Muscles  106  •  Trapezius  106  •  Latissimus Dorsi  107  •  Muscles Taking Origin from Medial Border of Scapula  108  •  Dorsal Scapular Nerve (Nerve to rhomboid)  108  •  Deltoid Muscle  108  •  Teres Minor  109  •  Teres Major  109  •  Supraspinatus  109  •  Infraspinatus  109  •  Subscapularis  110  •  Intermuscular Spaces  110  •  Boundaries of Quadrangular Space (from anterior side)  110  •  Boundaries of Quadrangular Space (from posterior side)  110  •  Boundaries of Upper Triangular Space  110  •  Boundaries of Lower Triangular Space  110  •  Axillary Nerve  111  •  Suprascapular Nerve  111 Pectoral Girdle  113  •  Special Features  113  •  Girdle Joints  113  •  Sternoclavicular Joint  113  •  Acromioclavicular Joint  114  •  Movements of Scapula  114  •  Shoulder Joint  115  •  Articular Surfaces  115  •  Fibrous Capsule  115  •  Glenohumeral Ligaments  116  •  Other Small Ligaments  116  •  Synovial Membrane  116  •  Bursae   116  •  Relations  116  •  Stability  117  •  Blood Supply  117  •  Nerve Supply  117  •  Movements  117 Upper Limb  120  •  Cutaneous Nerves   120  •  Dermatomes  121  •  Veins of Upper Limb  122  •  Lymphatic Drainage of Upper Limb  124 Compartments of Arm  126  •  Contents of Anterior Compartment  126  •  Contents of Posterior Compartment  130 Cubital Fossa  133  •  Boundaries  133  •  Contents  133  •  Anastomosis Around Elbow  134  •  Functional Importance   134  •  Elbow Joint  134  •  Articulating Bones  135  •  Fibrous Capsule  135  •  Synovial Membrane  136  •  Collateral Ligaments  136  •  Relations of Joint  136  •  Movements  137 Forearm  139  •  Anterior Compartment of Forearm  139  •  Posterior Compartment of Forearm  147 Radioulnar Joints  151  •  Superior Radioulnar Joint  151  •  Inferior Radioulnar Joint  152  •  Middle Radioulnar Joint  152  •  Relations of Anterior Surface  152  •  Relations of Posterior Surface  152  •  Functions  153  •  Supination and Pronation  153  •  Muscles of Pronation  153  •  Muscles of Supination  154  •  Wrist Joint  155  •  Ligaments  156  •  Fibrous Capsule  156  •  Relations  156  •  Nerve Supply  156  •  Arterial Supply  156  •  Movements at Wrist Joint  156  •  Muscles Responsible for Movements  156  •  Anatomical Snuffbox  157  •  Retinacula at the Wrist  157  •  Special Note  158 Features of Hand  159  •  Dorsum of Hand  159  •  The Palm  160  •  Arteries of Hand  164  •  Nerves of Palm  165  •  Intrinsic Muscles of Hand  166 Median Nerve  174  •  Union of Roots  174  •  Course and Relations  174  •  Branches  174  •  Ulnar Nerve  176  •  Course and Relations  176  •  Branches in Forearm  177  •  Distribution in Palm  177  •  Radial Nerve  179 Course and Relations  179  •  Branches of Radial Nerve in Axilla  179  •  Branches of Radial Nerve in Spiral Groove  179  •  Terminal Branches of Radial Nerve  179  •  Superficial Branch of Radial Nerve  179 Clinicoanatomical Problems and Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Section 3 ♦ Thorax 23. Bones of Thoracic Cage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 24. Thoracic Inlet and Thoracic Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 25. Mediastinum and Respiratory Organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Thoracic cage  193  •  Sternum  193  •  Posterior Relations  194  •  Ribs or Costae  195  •  Thoracic Vertebrae  197 Thoracic Inlet  199  •  Boundaries of Thoracic Inlet  199  •  Scalene Triangle  200  •  Thoracic Wall  200  •  Surface Landmarks  200  •  Orientation Lines  201  •  Intercostal Spaces  201 Mediastinum  208  •  Boundaries of Mediastinum  208  •  Extent  208  •  Subdivisions  209  •  Boundaries of Superior Mediastinum  209  •  Boundaries of Anterior Mediastinum  209  •  Boundaries of Middle Mediastinum  210  •  Boundaries of Posterior Mediastinum  210  •  Trachea  211  •  Length  211  •  Location  211  •  Extent  211  •  Mobility  212 
  • 12. Contents  xv •  Tracheal Patency  212  •  Comparative Features of Adult and Infant Trachea  212  •  Anterior Relations of Cervical Part of Trachea   213  •  Posterior Relations  213  •  Lateral Relations  213  •  Anterior Relations of Thoracic Part of Trachea   213  •  Posterior Relation  213  •  Left Lateral Relations  214  •  Right Lateral Relations  214  •  Surface Marking  214  •  Blood Supply  214  •  Lymph Drainage  215  •  Nerve Supply  215  •  The Pleura and Pleural Cavities  216  •  Visceral Pleura   216  •  Parietal Pleura   216  •  Lines of Pleural Reflections  217  •  Cervical Pleura  218  •  Pleural Recesses   218  Nerve Supply of Pleura  218  •  Arterial Supply of Pleura  218  •  Functional Importance of Pleural Cavity  218  •  Lungs  219  •  Gross Features  219  •  Surfaces  219  •  Borders (Margins)  219  •  Fissures  220  •  External Features of Right and Left Lungs  220  •  Surface Markings of Fissures  220  •  Surface Marking of Lung  220  •  Relations of Apex  221  •  Medial Surface  221  •  Impressions on Mediastinal Surface of Right Lung  222  •  Vertebral Surface of Right Lung  223  •  Impressions on Mediastinal Surface of Left Lung  223  •  Vertebral Surface of Left Lung  224  •  Root of Lung  224  •  Vertebral Level  224  •  Contents  224  •  Pulmonary Ligament  224  •  Bronchial Tree  224  •  Right Main Bronchus  224  •  Left Main Bronchus  225  •  Intrapulmonary Airways  226  •  Bronchopulmonary Segments  226  •  Blood Supply of Lungs  226  •  Lymphatic Drainage  227  •  Nerve Supply  228  •  Radiological Anatomy  228 26. Diaphragm and Phrenic Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 Diaphragm  230  •  Parts and Relations  230  •  Surface Marking  230  •  Attachments  230  •  Apertures in Diaphragm   231  •  Motor Nerve Supply  232  •  Sensory Nerve Supply  232  •  Arterial Supply  232  •  Lymphatic Drainage  232  •  Actions  232  •  Phrenic Nerves  235  •  Origin  235  •  Course and Relations  236 27. Development of Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 28. Pharyngeal Arch Arteries and Fetal Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 29. Pericardium and Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 30. Blood Supply of Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 31. Fibrous Skeleton, Conducting Tissue and Nerve Supply of Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 32. Major Blood Vessels of Thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 33. Lymphatic Organs and Autonomic Nerves of Thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Events in Development of Heart  238  •  Fate of Components of Cardiac Tube and Pericardial Coelom  238  •  Subdivisions of Cardiac Tube  238  •  Further Development of Cardiac Tube  239  •  Fate of Sinus Venosus  239  •  Septation of Embryonic Heart  240  •  Development of Pulmonary Veins  241  •  Developmental Sources of Atria  241  •  Atrioventricular Valves  242  •  Septation in Truncus Arteriosus, Bulbus Cordis and Common Ventricle  242  •  Development of Ascending Aorta and Pulmonary Trunk  242  •  Development of Semilunar Valves  242  •  Development of Outflow Tracts of Ventricles  242  •  Developmental Sources of Ventricles  243  •  Development of Conducting Tissue  243 Pharyngeal Arch Arteries  244  •  Transformation of Arch Arteries  244  •  Derivatives of Arch Arteries  244  •  Relation to Recurrent Laryngeal Nerves  245  •  Fetal Circulation  246  •  Unique Features of Fetal Circulation  247  •  Blood Circulation  247  •  First Shunt in Liver  247  •  Second Shunt in Heart  247  •  Third Shunt to Bypass Lung  247  •  Postnatal Changes in Fetal Circulation  248  •  Time of Anatomical Closure  248  •  Fate of Fetal Shunts and Umbilical Blood Vessels  248 Pericardium  249  •  Subdivisions  249  •  Pericardial Cavity  249  •  Heart  251  •  Orientation of Heart in Thorax  251  •  External Features  252  •  Atrioventricular Sulcus  252  •  Interventricular Sulci  252  •  Interatrial Sulcus  253  •  Crux of Heart  253  •  Borders (Margins) and Surfaces  253  •  Apex of Heart  253  •  Margins of Heart  253  •  Surfaces of Heart  253  •  Chambers of Heart  255  •  Interventricular Septum  259  •  Surface Markings of Cardiac Valves   260  •  Surface Markings of Cardiac Auscultation Areas  260  •  Radiological Anatomy of Heart  260 Blood Supply  262  •  Unique Features of Coronary Arteries  262  •  Origin of Right Coronary Artery  262  •  Origin of Left Coronary Artery  264  •  Coronary Dominance  264  •  Coronary Anastomosis  264  •  Veins of Heart  265  •  Coronary Sinus  266 Fibrous Skeleton of Heart  268  •  Component Parts  268  •  Conducting Tissue of Heart  268  •  Components  268  •  Nerve Supply of Heart  269  •  Efferent Nerve Supply  269  •  Afferent Nerve Supply  270 Major Blood Vessels  271  •  Pulmonary Vessels  271  •  Ascending Aorta  273  •  Arch of Aorta  274  •  Descending Thoracic Aorta  276  •  Major Veins of Thorax  277  •  Hemiazygos Vein (Inferior Hemiazygos Vein)  278 Lymphatic Organs  280  •  Thymus  280  •  Lymph Nodes of Thorax  281  •  Thoracic Duct  282  •  Right Lymphovenous Portal  283  •  Autonomic Nerves of Thorax  283  •  Vagus Nerve (Parasympathetic Supply)  284  •  Sympathetic Chains   284  •  Visceral Afferent Fibers  285  •  Autonomic Plexuses in Thorax  285  •  Superficial Cardiac Plexus  285  •  Deep Cardiac Plexus  285  •  Coronary Plexuses  285  •  Pulmonary Plexuses  285  •  Esophageal Plexus  285 34. Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Esophagus  286  •  Course  286  •  Constrictions  286  •  Relations of Cervical Esophagus  287  •  Relations of Thoracic Esophagus  287  •  Relations to Vagus Nerves  288  •  Relations at Esophageal Aperture in Diaphragm  288  •  Abdominal Part of Esophagus  288  •  Lower Esophageal Sphincter  288  •  Arterial Supply  288  •  Venous Drainage  288  •  Lymphatic Drainage  288  •  Nerve Supply  288 35. Clinicoanatomical Problems and Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 Section 4 ♦ Head and Neck 36. Bones of Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 Skull  303  •  Bones of Calvaria  303  •  Bones of Facial Skeleton  303  •  External Features of Skull  303  •  Jugular Foramen  309  •  Interior of Cranium  309  •  Internal Acoustic Meatus  311  •  Fetal Skull  311  •  Individual Cranial Bones  312  •  Temporal Bone in Newborn  315  •  Zygomatic Bone  316  •  Nasal Bones  317  •  Hyoid Bone  317  •  Cervical Vertebrae  317
  • 13. xvi   Clinical Anatomy (A Problem Solving Approach) 37. Scalp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Anatomy of Scalp  320  •  Extent  320  •  Subdivisions  320  •  Layers of Scalp  320  •  Nerves of Anterior Quadrant  321  •  Nerves of Posterior Quadrant  321  •  Arterial Supply  321  •  Venous Drainage  322  •  Lymphatic Drainage  322 38. Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323 Development of Face  323  •  Facial Processes  323  •  Nerve Supply  325  •  Blood Supply  326  •  Venous Drainage  328  •  Muscles of Facial Expression  329  •  Compound Sphincter of the Mouth  331  •  Testing Function of Facial Muscles  332  •  Extracranial Course of Facial Nerve  332  •  Eyelids  334  •  Lacrimal Apparatus  336 39. Parotid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338 Anatomy of Parotid Gland  338  •  General Features  338  •  Location  338  •  Parts, Surfaces and Borders  338  •  Processes  338  •  Surface Marking  339  •  Fascial Capsule  339  •  Relations  339  •  Contents  339  •  Exit of Structures from the Gland  340  •  Parotid Duct or Stensen’s Duct  340  •  Parotid Sialography  341  •  Secretomotor Innervation of Parotid Gland  341  •  Lymphatic Drainage  341 40. Cervical Fascia and Triangles of Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 41. Submandibular Region and Submandibular Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357 42. Pharyngeal (Branchial) Apparatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 43. Thyroid Gland and Parathyroid Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 44. Blood Vessels, Nerves and Lymph Nodes of Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 45. Infratemporal Fossa and Pterygopalatine Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388 Cervical Fascia  343  •  Superficial Fascia  343  •  Deep Fascia of Neck  343  •  Triangles of Neck  348  •  Posterior Triangle of Neck  348  •  Median Region of Front of Neck  352  •  Carotid Triangle  354 Digastric Triangle  357  •  Boundaries  357  •  Subdivisions  357  •  Contents of Anterior Part  358  •  Contents of Posterior Part  358  •  Digastric Muscle  358  •  Stylohyoid Muscle  358  •  Hyoglossus Muscle  359  •  Mylohyoid Muscle  359  •  Geniohyoid Muscle  360  •  Submandibular Salivary Gland  360  •  Parts  361  •  Fascial Capsule  361  •  Bidigital Palpation  361  •  Surface Marking  361  •  Surfaces of Superficial Part of Gland  361  •  Relations  361  •  Relation to Facial Artery  362  •  Relations of Deep Part of the Gland  362  •  Submandibular or Wharton’s Duct  362  •  Secretomotor Nerve Supply  363  •  Sublingual Salivary Gland  363  •  Relations  364  •  Secretomotor Supply  364 Pharyngeal (Branchial) Arches  365  •  Components of Each Arch  365  •  Nerves of Arches  365  •  Derivatives of First Arch  366  •  Derivatives of Second Arch  366  •  Derivatives of Third Arch  366  •  Derivatives of Fourth and Sixth Arches  366  •  Derivatives of Endodermal Pouches  367 Thyroid Gland  368  •  General Features  368  •  Capsules of Thyroid Gland  369  •  Relations of Lobes  370  •  Relations of Surfaces  370  •  Relations of Isthmus  370  •  Arterial Supply  370  •  Venous Drainage  371  •  Lymphatic Drainage   372  •  Nuclear Scan of Thyroid Gland  372  •  Parathyroid Glands  373  •  Location  373  •  Blood Supply  373 Blood Vessels  375  •  Common Carotid Arteries  375  •  Internal Carotid Artery  376  •  External Carotid Artery  377  •  Subclavian Artery  378  •  Veins of Neck  380  •  Internal Jugular Vein  380  •  Subclavian Vein  380  •  Cervical Plexus  381  •  Formation  381  •  Deep or Muscular Branches  381  •  Superficial Branches  381  •  Communicating Branches  382  •  Ansa Cervicalis  382  •  Phrenic Nerve  382  •  Cervical Sympathetic Chain  382  •  Cervical Lymph Nodes  383  •  Superficial Lymph Nodes  384  •  Deep Lymph Nodes  384  •  Paravertebral Muscles of Neck  385  •  Prevertebral Muscles of Neck  387 Infratemporal Fossa  388  •  Bony Boundaries  388  •  Contents  388  •  Pterygopalatine Fossa  390  •  Communications   390  •  Temporomandibular Joint  393  •  Testing the Function of Muscles of Mastication  398 46. Orbit and Eyeball . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 47. Oral Cavity, Tongue and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 48. Nasal Cavity and Paranasal Air Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 Orbit  399  •  Bony Boundaries  399  •  Periorbita  399  •  Communications  399  •  Contents  400  •  Extraocular Muscles  401  •  Ophthalmic Nerve  404  •  Ciliary Ganglion  404  •  Ophthalmic Artery  405  •  Ophthalmic Veins  406  •  Fascia Bulbi (Tenon’s Capsule)  406  •  Eyeball  406  •  Coats of Eyeball  408  •  Retina  411  •  Refractive Media  413 Oral Cavity  414  •  Teeth or Dentition  414  •  Floor of the Mouth  415  •  Tongue  415  •  Parts of the Tongue  415  •  Gross Appearance of Dorsum  415  •  Muscles of Tongue  416  •  Nerve Supply  417  •  Arterial Supply   417  •  Venous Drainage  418  •  Lymphatic Drainage  418  •  Gustatory or Taste Pathways  419  •  Palate  420  •  Components of Hard Palate  420  •  Soft Palate  420 Nasal Cavity  423  •  Subdivisions  423  •  Functions of Nasal Cavity  423  •  Communications of Nasal Cavity  424  •  Boundaries of Nasal Cavity Proper  424  •  Arterial Supply of Nasal Cavity  426  •  Venous Drainage of Nasal Cavity  426  •  Nerve Supply of Nasal Cavity  426  •  Paranasal Air Sinuses  427  •  General Characteristics  427  •  Frontal Sinus  427  •  Ethmoidal Sinuses  428  •  Sphenoidal Sinus  428  •  Maxillary Sinus  428  •  Radiology of PNS  429 49. Pharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430 Anatomy of Pharynx  430  •  Shape  430  •  Length  430  •  Width  430  •  Extent  430  •  Deficiencies in Anterior Wall  430  •  Subdivisions  430  •  Layers of Pharyngeal Wall  430  •  Pharyngeal Aponeurosis (Pharyngobasilar Fascia)  431  •  Nasopharynx  433  •  Oropharynx  435  •  Laryngopharynx  437 50. Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439 Anatomy of Larynx  439  •  Location  439  •  Differences in Male and Female  439  •  Differences in Adult and Infant  439  •  Laryngeal Cartilages  439  •  Membranes and Ligaments of Larynx  441  •  Subdivisions of Laryngeal Cavity  441 
  • 14. Contents  xvii •  Mucosa of Laryngeal Cavity  443  •  Sensory Nerve Supply and Blood Supply  443  •  Lymphatic Drainage  443  •  Laryngoscopic Examination  443  •  Laryngeal Muscles  443 51. Ear (External and Middle), Eustachian Tube, Mastoid Antrum and Internal Ear . . . . . . . . . . . . . . . . . . 446 52. Clinicoanatomical Problems and Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459 Ear  446  •  External Ear  446  •  Middle Ear or Tympanic Cavity  448  •  Auditory Tube or Eustachian Tube  452  •  Length  452  •  Direction  453  •  Parts  453  •  Diameter  453  •  Location of Pharyngeal Opening  453  •  Muscles Attachment  453  •  Actions  453  •  Nerve Supply  453  •  Blood Supply  453  •  Lymphatic Drainage  453  •  Mastoid or Tympanic Antrum  454  •  Boundaries of Mastoid Antrum  454  •  Boundaries of Suprameatal Triangle  454  •  Surface Marking of Suprameatal Triangle  454  •  Mastoid Air Cells  454  •  Extra-Mastoidal Sites of Air Cells  454  •  Internal Ear  455 Section 5 ♦ Vertebral Column and Spinal Cord, Cranial Cavity and Brain 53. Deep Muscles of Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473 54. Vertebral Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478 55. Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486 56. Cranial Meninges, Middle Meningeal Artery and Pituitary Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500 Deep Muscles or Intrinsic Muscles  473  •  Nerve Supply  473  •  Classification of Postvertebral Muscles  473  •  Semispinalis Capitis  474  •  Suboccipital Triangle  474 Anatomy of Vertebral Column  478  •  Length of Vertebral Column  478  •  Number of Vertebrae  478  •  Parts of Vertebra  478  •  Intervertebral Joints  480  •  Boundaries of Intervertebral Foramina  480  •  Contents of Intervertebral Foramen  480  •  Vertebral Canal  480  •  Curvatures of Vertebral Column  480  •  Ligaments of Vertebral Column  481  •  Intervertebral Discs  482  •  Craniovertebral Joints  482  •  Lumbosacral Joint  483  •  Sacrococcygeal Joint  483  •  Movements of Vertebral Column  483  •  Arterial Supply  484  •  Venous Drainage  484 Anatomy of Spinal Cord  486  •  Development of Spinal Cord  486  •  Extent  486  •  Length  486  •  Spinal Meninges   487  •  Enlargements of Spinal Cord  488  •  Surface Features of Spinal Cord  488  •  Spinal Nerves  488  •  Cauda Equina  489  •  Internal Structure  489  •  Central Canal of Spinal Cord  490