Anatomy for anaesthetists - 8th edition

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Anatomy for Anaesthetists

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ANATOMY FOR

ANAESTHETISTS

HAROLD ELLIS

CBE, MA, DM, FRCS, FACS(Hon)

Clinical Anatomist,

Guy’s King’s and St Thomas’s School of Biomedical Sciences, London

Emeritus Professor of Surgery,

University of London

STANLEY FELDMAN

BSc, MB, FRCA

Emeritus Professor of Anaesthetics,

Charing Cross and Westminster Medical School

WILLIAM HARROP-GRIFFITHS

MA, MB, BS, FRCA

Consultant Anaesthetist,

St Mary’s Hospital, Paddington, London

with a chapter on the

Anatomy of Pain

contributed by

ANDREW LAWSON

FFARCSI, FANZCA, FRCA, MSc

Consultant in Anaesthesia and Pain Management,

Royal Berkshire Hospital, Reading

Eighth edition

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© 1963, 1969, 1977, 1983, 1988, 1993, 1997, 2004

by Blackwell Science Ltd

a Blackwell Publishing company

Blackwell Science, Inc., 350 Main Street, Malden,

Massachusetts 02148-5020, USA

Blackwell Publishing Ltd, 9600 Garsington Road,

Oxford OX4 2DQ, UK

Blackwell Science Asia Pty Ltd, 550 Swanston Street,

Carlton, Victoria 3053, Australia

The right of the Author to be identified

as the Author of this Work has been

asserted in accordance with the

Copyright, Designs and Patents Act 1988.

All rights reserved. No part of

this publication may be reproduced,

stored in a retrieval system, or

transmitted, in any form or by any

means, electronic, mechanical,

photocopying, recording or otherwise,

except as permitted by the UK

Copyright, Designs and Patents Act

1988, without the prior permission

of the publisher.

First published 1963

Second edition 1969

Third edition 1977

Reprinted 1979

Fourth edition 1983

Fifth edition 1988

Reprinted 1990

Sixth edition 1993

Reprinted 1995

Seventh edition 1997

Reprinted 1998

Italian first edition 1972

Japanese fourth edition 1989

German fifth edition 1992

Library of Congress Cataloging-in-Publication Data

Ellis, Harold, 1926–

Anatomy for anaesthetists / Harold Ellis, Stanley

Feldman, William Harrop-Griffiths; with a chapter

on the Anatomy of pain contributed by Andrew

Lawson.—8th ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 1-4051-0663-8

1. Human anatomy. 2. Anesthesiology.

[DNLM: 1. Anatomy. 2. Anesthesia.

QS 4 E47a 2003] I. Feldman, Stanley A.

II. Harrop-Griffiths, William. III. Title.

QM23.2.E42 2003

611′.0024617—dc22

2003020753

ISBN 1405 1066 38

A catalogue record for this title is available from the

British Library

Set in 10/13.5pt Sabon by Graphicraft Limited,

Hong Kong

Printed and bound in Denmark, by Narayana Press,

Odder

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For further information on Blackwell Publishing,

visit our website:

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Contents

Part 1: The Respiratory Pathway 1

The Mouth 3

The Nose 7

The Pharynx 16

The Larynx 26

The Trachea 42

The Main Bronchi 48

The Pleura 50

The Lungs 53

Part 2: The Heart 71

The Pericardium 73

The Heart 75

Developmental Anatomy 86

Part 3: The Vertebral Canal and its Contents 95

The Vertebrae and Sacrum 97

The Spinal Meninges 119

The Spinal Cord 125

Part 4: The Peripheral Nerves 137

The Spinal Nerves 139

The Cervical Plexus 146

The Brachial Plexus 153

The Thoracic Nerves 180

The Lumbar Plexus 183

The Sacral and Coccygeal Plexuses 192

Part 5: The Autonomic Nervous System 213

Introduction 215

The Sympathetic System 218

The Parasympathetic System 228

Part 6: The Cranial Nerves 233

Introduction 235

The Olfactory Nerve (I) 238

The Optic Nerve (II) 239 v

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vi Contents

The Oculomotor Nerve (III) 242

The Trochlear Nerve (IV) 244

The Trigeminal Nerve (V) 245

The Abducent Nerve (VI) 266

The Facial Nerve (VII) 267

The Auditory (Vestibulocochlear) Nerve (VIII) 272

The Glossopharyngeal Nerve (IX) 273

The Vagus Nerve (X) 276

The Accessory Nerve (XI) 282

The Hypoglossal Nerve (XII) 283

Part 7: The Anatomy of Pain 285

Introduction 287

Classification of Pain 288

Peripheral Receptors and Afferent fibres 288

The Spinal Cord and Central Projections 290

Modulation of Pain 294

The Gate Control Theory of Pain 295

The Sympathetic Nervous System and Pain 296

Part 8: Zones of Anaesthetic Interest 297

The Thoracic inlet 299

The Diaphragm 305

The Intercostal Spaces 311

The Abdominal Wall 318

The Antecubital Fossa 324

The Great Veins of the Neck 330

The Orbit and its Contents 336

Index 349

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Acknowledgements

The first two editions of this textbook were prepared in collaboration with that

skilled medical artist Miss Margaret McLarty. The illustrations for the sixth

edition were almost all drawn or redrafted by Rachel Chesterton; we thank her

for the excellent way in which they have been executed. Further illustrations for

the seventh and this edition were prepared by Jane Fallows with great skill.

vii

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Introduction

The anaesthetist requires a particularly specialized knowledge of anatomy. Some

regions of the body, for example the respiratory passages, the major veins and

the peripheral nerves, the anaesthetist must know with an intimacy of detail that

rivals or even exceeds that of the surgeon; other areas can be all but ignored.

Although formal anatomy teaching is no longer part of the syllabus of the FRCA

in the UK, its importance for the safe practice of anaesthesia is recognized by

the examiners, who always include questions on anatomy related to anaesthesia

in this examination. The role of anatomy in anaesthetic teaching is often con￾sidered merely as a prerequisite for the safe practice of local anaesthetic blocks.

However, it is also important in understanding the anatomy of the airway, the

function of the lungs, the circulation, venous access, monitoring neuromuscular

block and many other aspects of practical anaesthesia. For this reason, this book

is not intended to be a textbook for regional anaesthetic techniques; there are

many excellent books in this field. It is an anatomy book written for anaesthetists,

keeping in mind the special requirements of their daily practice.

In this eighth edition, we have revised much of the text, we have taken the

opportunity to expand and update the sections of special interest to anaesthetists

and we have included new and improved illustrations. William Harrop-Griffiths

of St Mary’s Hospital, London, joins us as our new co-author. He brings with

him special expertise in modern anaesthetic technology and has greatly assisted

us in updating the text and illustrations. Dr Andrew Lawson has fully updated

his important section on the Anatomy of Pain and has given valuable advice on

procedures relevant to the practice of pain medicine.

viii

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Part 1

The Respiratory Pathway

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3

The Mouth

The mouth is made up of the vestibule and the mouth cavity, the former commun￾icating with the latter through the aperture of the mouth.

The vestibule is formed by the lips and cheeks without and by the gums and

teeth within. An important feature is the opening of the parotid duct on a small

papilla opposite the 2nd upper molar tooth. Normally the walls of the vestibule

are kept together by the tone of the facial muscles; a characteristic feature of a

facial (VII) nerve paralysis is that the cheek falls away from the teeth and gums,

enabling food and drink to collect in, and dribble out of, the now patulous

vestibule.

The mouth cavity (Fig. 1) is bounded by the alveolar arch of the maxilla and

the mandible, and teeth in front, the hard and soft palate above, the anterior

two-thirds of the tongue and the reflection of its mucosa forward onto the

mandible below, and the oropharyngeal isthmus behind.

The mucosa of the floor of the mouth between the tongue and mandible

bears the median frenulum linguae, on either side of which are the orifices of the

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Uvula

Palatopharyngeal

arch

Palatine tonsil

Palatoglossal

arch

Fig. 1 View of the open mouth with the tongue depressed.

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4 The Respiratory Pathway

submandibular salivary glands (Fig. 2). Backwards and outwards from these

ducts extend the sublingual folds that cover the sublingual glands on each side

(Fig. 3); the majority of the ducts of these glands open as a series of tiny orifices

along the overlying fold, but some drain into the duct of the submandibular gland

(Wharton’s duct).

The palate

The hard palate is made up of the palatine processes of the maxillae and the

horizontal plates of the palatine bones. The mucous membrane covering the

hard palate is peculiar in that the stratified squamous mucosa is closely con￾nected to the underlying periosteum, so that the two dissect away at operation

as a single sheet termed the mucoperiosteum. This is thin in the midline, but

thicker more laterally due to the presence of numerous small palatine salivary

glands, an uncommon but well-recognized site for the development of mixed

salivary tumours.

The soft palate hangs like a curtain suspended from the posterior edge of the

hard palate. Its free border bears the uvula centrally and blends on either side with

the pharyngeal wall. The anterior aspect of this curtain faces the mouth cavity

and is covered by a stratified squamous epithelium. The posterior aspect is part

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Frenulum linguae

Sublingual fold

Orifice of

submandibular

duct

Fig. 2 View of the open mouth with the tongue elevated.

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The Mouth 5

of the nasopharynx and is lined by a ciliated columnar epithelium under which

is a thick stratum of mucous and serous glands embedded in lymphoid tissue.

The ‘skeleton’ of the soft palate is a tough fibrous sheet termed the palatine

aponeurosis, which is attached to the posterior edge of the hard palate. The

aponeurosis is continuous on each side with the tendon of tensor palati and may,

in fact, represent an expansion of this tendon.

The muscles of the soft palate are five in number: the tensor palati, the levator

palati, the palatoglossus, the palatopharyngeus and the musculus uvulae (see

Fig. 13).

The tensor palati (tensor veli palatini) arises from the scaphoid fossa at the root

of the medial pterygoid plate, from the lateral side of the Eustachian cartilage

and the medial side of the spine of the sphenoid. Its fibres descend laterally to the

superior constrictor and the medial pterygoid plate to end in a tendon that pierces

the pharynx, loops medially around the hook of the hamulus to be inserted into

the palatine aponeurosis. Its action is to tighten and flatten the soft palate.

The levator palati (levator veli palatini) arises from the undersurface of the

petrous temporal bone and from the medial side of the Eustachian tube, enters

the upper surface of the soft palate and meets its fellow of the opposite side.

It elevates the soft palate.

The palatoglossus arises in the soft palate, descends in the palatoglossal fold

and blends with the side of the tongue. It approximates the palatoglossal folds.

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Tongue

Hyoglossus

Submandibular

duct and gland

Geniohyoid

Mylohyoid

Anterior belly

of digastric

Lingual A.

Genioglossus

Lingual N.

Sublingual gland

Fig. 3 Coronal section through the floor of the mouth.

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6 The Respiratory Pathway

The palatopharyngeus descends from the soft palate in the palatopharyngeal

fold to merge into the side wall of the pharynx: some fibres become inserted along

the posterior border of the thyroid cartilage. It approximates the palatopharyngeal

folds.

The musculus uvulae takes origin from the palatine aponeurosis at the posterior

nasal spine of the palatine bone and is inserted into the uvula. Injury to the cranial

root of the accessory nerve, which supplies this muscle via the vagus nerve, results

in the uvula becoming drawn across and upwards towards the opposite side.

The tensor palati is innervated by the mandibular branch of the trigeminal

nerve via the otic ganglion (see p. 265). The other palatine muscles are supplied

by the pharyngeal plexus, which transmits cranial fibres of the accessory nerve

via the vagus.

The palatine muscles help to close off the nasopharynx from the mouth in

deglutition and phonation. In this, they are aided by contraction of the upper

part of the superior constrictor, which produces a transverse ridge on the back

and side walls of the pharynx at the level of the 2nd cervical vertebra termed

the ridge of Passavant.

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Partial clefts of palate

Premaxilla

Vomer

Unilateral complete

cleft palate

Bilateral complete

cleft palate

Fig. 4 Types of cleft palate deformity.

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