Fourth
`Edition
`
`The
`Johns
`
`AgeeSUNNAaN
`of |EUNCulonal
`/\NEKONAY
`
`
`The Johns Hopkins University Press = Baltimore and London
`
`ALVOGEN, Exh. 1049, p. 0001
`
`

`

`
`
`Plates 2, 25, 35, and 46, courtesy of Winthrop Laboratories; plates 3,
`4, and 5, courtesy of the Medical Models Laboratory;plates 11, 12, 13,
`18, 30, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 71, 72, 73, 74, 75,
`76, and 77, all originally published by W. B, Saunders Company;
`plates 14 and 15, courtesy of the Medical Department, U.S. Navy.
`Plate 22 first appeared in Atlas of Aortic Surgery, by G. Melville Wil-
`liams and Leon Schlossberg (Baltimore: Willlams & Wilkins, 1997).
`Plate 41 first appeared in Affas of General Thoracic Surgery, by Mark
`M. Ravitch and Felician M. Steichen (Philadelphia: W. B. Saunders
`Company, 1988). Plates 49, 50, 51, and 52 first appearedin The
`Operative Management of Breast Disease, by R. Robinson Baker and
`John E. Neicerhuber (Philadelphia: W. B. Saunders Company, 1992)
`Plate 56 first appeared In Atlas of Nuclear Medicine, vol. 2, by Frank H.
`Deland and Henry MN. Wagner (Philadelphia: W. B. Saunders Compa-
`ny, 1970). All are reproduced with permission.
`
`© 1977, 1980, 1986, 1997 The Johns Hopkins University Press
`
`All rights reserved. First edition 1977
`Fourth edition 1997
`
`Printed in the United States of America on acid-free paper
`06 05 04 03 0201 00999897 54321
`
`The Johns Hopkins University Press
`2715 North Charles Street
`Baltimore, Maryland 21218-4319
`The Johns Hopkins Press Ltd., London
`
`Library of Congress Cataloging-in-Publication Data will be foundat
`the end of this book.
`
`A catalog record forthis bookis available from the British Library.
`ISBN 0-8018-5651-5
`ISBN 0-8018-5652-3 (pbk.)
`
`ALVOGEN, Exh. 1049, p. 0002
`
`ALVOGEN, Exh. 1049, p. 0002
`
`

`

`Acknowledgments
`
`xi
`
`Introduction Leon Schlossberg xii
`
`Fetal Circulation JohnJ. White, M.D.
`
`2
`
`Skeletal Anatomy JamesL. Hughes, M.D.
`
`4
`
`Skeletal Muscles, Joints, and Fascial Structures Vernon T. Tolo, M.D.
`
`10
`
`The Abdominal Wall, the Inguinal Region, and Hernias
`
`John J. White, M.D.
`
`19
`
`The Hematopoietic System and Development of Blood Cells William R. Bell, M.D.
`
`26
`
`The Autonomic Nervous System George B. Udvarhelyi, M.D.
`
`30
`
`The Anatomical Man Leon Schlossberg
`
`37
`
`The Aorta and Its Branches Leon Schlossberg 42
`
`The Peripheral Nerves George B. Udvarhelyi, M.D.
`
`44
`
`The Central Nervous System Melvin H. Epstein, M.D., and Donlin M. Long, M.D.
`
`49
`
`The Lymphatic System JamesP. lsaacs,M.D.
`
`57
`
`The Eye and the Mechanism of Vision Charles E. Iliff, M.D.
`
`61
`
`The Ear George T. Nager, M.D.
`
`65
`
`The Nose, Paranasal Sinuses, Pharynx, and Larynx Margaret M. Fletcher, M.D.
`
`68
`
`The Head and Neck Melvin H. Epstein, M.D., Donald S. Gann, M.D., David W. Heese, D.D.S.,
`and James J. Ryan, M.D.
`73
`
`The Endocrine Glands Donald S. Gann,M.D.
`
`78
`
`The Mediastinum and the Thymus Gland Gregory B. Bulkley, M.D.
`
`83
`
`Anatomy as Viewed Laparoscopically Mark A. Talamini, M.D.
`
`88
`
`The Circulatory System Robert K. Brawley, M.D.
`
`96
`
`The Breast R. Robinson Baker, M.D.
`
`102
`
`The Heart Vincent L. Gott, M.D.
`
`110
`
`The Lungs) Henry N. Wagner, Jr, M.D.
`
`114
`
`The Gastrointestinal Tract Thomas R. Hendrix, M.D., George D. Zuidema, M.D., and
`John J. White, M.D.
`118
`
`The Liver Michael A. Choti, M.D.
`
`137
`
`The Female Generative Tract and Pregnancy Howard W. Jones, Jr, M.D.
`
`142
`
`The Menstrual Cycle H. LorrinLau,M.D.
`
`147
`
`ocmUCOmUCUCOUCmNLUCODUCTBLUCUD
`
`
`mekaF&FWWNO—
`
`16
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`
`
`ALVOGEN, Exh. 1049, p. 0003
`
`ALVOGEN, Exh. 1049, p. 0003
`
`

`

`29
`
`The Skin James J. Ryan, M.D.
`
`157
`
`Index
`
`159
`
`PLATES
`
`ANOoOhWH=
`
`8
`
`24
`
`20
`
`Anatomical Positions, Surface and Topographic Anatomy, and Regions and Planes of Sections_xiii
`Fetal Circulation
`3
`The Skull
`6
`Skeleton—Anterior and Posterior Views
`Skeleton—Lateral View 9
`Muscles, Ligaments and Fasciae, Tendons, and Bursae—Anterior View 12
`Muscles, Ligaments and Fasciae, Tendons, and Bursae—Posterior View 13
`Shoulder and Hip Joints
`15
`Knee Joint
`17
`Abdominal Wall—Inguinal Region
`Inguinal Region
`21
`Hernias
`23
`Sites of Abdominal and Pelvic Hernias
`Hematopoietic System 28
`29
`Developmentof Blood Cells
`32
`Autonomic Nervous System and Effects of Stimulation (Respiratory and Digestive Systems)
`Autonomic Nervous System—Mechanism of Effector Organ Stimulation (Neurohormonal and Genitourinary Systems)
`Visceral Afferent Pathways and Referred Areas of Pain 34
`The Anatomical Man 38
`40
`The Anatomical Man—Organs
`The Anatomical Man—Arteries, Veins, Nerves, and Lymph Systems
`Aorta and Its Branches—Lateral View 43
`46
`Peripheral Nerves (Exclusive of Cranial Nerves)
`Peripheral Nerves, Including Cervical, Brachial, and Lumbosacral Plexuses 47
`The Five Senses of Consciousness
`51
`Vascular Supply of the Brain
`52
`54
`Base of the Brain and of the Skull
`56
`Cerebrospinal Axis and Cervical Cord
`Lymphatics—Head, Neck, and Chest 58
`Lymphatics—Esophagus and Stomach; Colon, Rectum, and Anus 59
`Lymphatics—Genitourinary System; Liver and Bile Ducts
`60
`The Eye and the Orbit
`63
`The Eye—Vision
`64
`The Ear—Apparatus of Hearing and Equilibrium 67
`The Nose and Paranasal Sinuses
`69
`The Pharynx and Larynx
`72
`Innervation of the Teeth and Facial Muscles; Salivary Glands and Muscles of Mastication 75
`Sagittal Section of the Head and Neck; Thyroid and Parathyroid Glands
`77
`Endocrine Glands 80
`Physiology of Endocrine Glands (Schematic Summary)
`Mediastinum 84
`Thymus Gland
`85
`Internal Inguinal Ring
`
`41
`
`:
`
`81
`
`89
`
`ALVOGEN, Exh. 1049, p. 0004
`
`
`
`ALVOGEN, Exh. 1049, p. 0004
`
`

`

`106
`
`125
`
`46
`47
`48
`49
`50
`51
`52
`53
`54
`55
`56
`57
`58
`59
`60
`61
`62
`63
`64
`65
`66
`67
`68
`69
`70
`71
`72
`73
`74
`75
`76
`77
`78
`79
`
`Composite Anatomy of the Vascular System, Based upon Arteriograms and Venograms 99
`The Aorta and Branches—Anterior View 100
`Muscular Venous Pumpof the Leg
`101
`Anatomy of the Breast 103
`104
`Sectional Views of the Breast
`Superficial Muscles of the Thorax
`Lymphatics of the Breast
`109
`The Heart
`111
`112
`Anatomy and Physiology of the Heart
`The Lungs, Bronchi, Pleurae, and Blood Vessels
`Lobes of the Lungs
`116
`119
`Intestinal Rotation (Fetus)
`Small Intestinal Malformations—Embryologic Considerations
`Esophagus—Arteries and Nerves
`123
`The Stomach—Neural Considerations
`Pancreas and Stomach
`126
`Esophagus—Liver Venous Drainage and Collateral Channels
`The Small Intestine
`128
`Colon, Rectum, Anus, and Perineum 129
`131
`Colon, Rectum, and Anus—Blood Vessels
`Colon, Rectum, and Anus—Innervation
`132
`Liver—Vascular and Biliary Systems
`134
`Colon, Rectum, and Anus—Physiology
`136
`Lobesof the Liver and Their Vascular Supply
`Liver—Sectional Views
`140
`144
`Genitourinary Tract, Female
`Genitourinary Innervation of the Uterus, Cervix, Vagina, Bladder, Rectum, and Perineum 145
`Pregnancy
`146
`148
`The Menstrual Cycle
`151
`Genitourinary Tract, Male
`Genitourinary Tract, Male—Vessels and Nerves
`Perineum, Male and Female
`154
`The Prostate and Male Pelvis
`156
`The Skin
`158
`
`121
`
`127
`
`115
`
`138
`
`152
`
`
`
`ALVOGEN, Exh. 1049, p. 0005
`
`ALVOGEN, Exh. 1049, p. 0005
`
`

`

`System
`and
`Development
`of
`Blood
`Cells
`
`William R. Bell, M.D.
`
`The hematopoietic system is composedof red blood
`cells, white bloodcells, and platelets, and their produc-
`tion sites and controlling sites responsible for cellular
`maturation and growth (e.g., stomach, liver), plus the
`fluid (plasma) in which these formed elements are sus-
`pendedinside blood vessels (Plate 14). In the embryo,
`the source of these formed elernents is the conneclive
`tissue called mesenchyme.
`In the human embryo,
`bloodcells are first formed in the blood islands of the
`yolk sac. Ata latertime, when the embryo reaches 5to8
`mm in length, the major source of blood cells is the
`liver, and a few weeks later production is supple-
`mented by sites in the thymus and spleen. By the fifth
`month of gestation, productionsitesin theliver, thymus,
`and spleen gradually decrease and the bone marrow
`takes over hematopoietic production. The fixed mes-
`enchymalcells are reduced to scant reticular stroma,
`
`26
`
`ALVOGEN, Exh. 1049, p. 0006
`
`Erythropolesis (production of red blood cells) in the
`infant and adult takes place continuouslyin the marrow
`of certain bones. The principal marrow sites are located
`in the skull, vertebrae, ribs, sternum, pelvis, femurs,
`and the humeri. As age progresses, the vertebrae, ribs,
`and sternum are the majorsites of hematopoietic activ-
`ity. Within the bone marrow, the red cellis derived frama
`primitive nucleatedcell called the erythroblast. Prolii-
`eration results from successive rnitotic cell divisions
`(Plate 15). As maturation progresses, hemoglobin ap-
`pears and the nucleus becomes smaller and is eventu-
`ally extruded from the cell.
`The maturation process is a complex biochemical
`process
`regulated by numerous agents. Notable
`among these agents is an intrinsic factor produced by
`the stomach. Theintrinsic factor, by complexing with an
`extrinsic factor (vitamin B,.), is responsible for its ab-
`sorption from theintestinaltract into the blood. The ma-
`ture red cellis then introducedinto the circulating blood
`via the vascular channels of the bone marrow. In the
`adult there is 0.56 gm of marrow per gram of blood, and
`the bone marrow approximates 3 to 6 percent of the
`total body weight. A steady balance between redcell
`production and removal of senescentred cells (more
`than 120 days old) fromthe circulation by the spleen is
`accurately maintained. The rate of red cell production is
`normally controlled by a hormone called erythropoietin,
`which is mainly produced in the kidneys
`White blood cells (leukocytes) are independently
`motile cells, composedof three classes, each unique
`and different in morphologic structure and function:
`granulocytes, monocytes, and lymphocytes. In gener-
`al, the leukocytes survive in the circulation for two to
`eight days. The most numerous of the leukocytes are
`the granulocytes, which originate in the bone marrow
`and can be divided into three subtypes: neutrophils,
`eosinophils, and basophils. Their orderly maturation
`and development from precursor blasts is shown in
`Plate 15. They are identified by a multilobed nucleus
`surrounded by numerous granules in the cytoplasm.
`Approximately 60 to 65 percent of the leukocytes in the
`body are neutrophils (pink cytoplasmic granules); and
`the
`eosinophils
`(red cytoplasmic granules)
`basophils (dark blue cytoplasmic granules)total about
`3 percent, Neutrophils function in defense and repail
`by performing phagocytosis of foreign cells, bacteria,
`
`and other infectious organisms. Eosinophils are pha-
`gocytic and participate mainly in antigen-antibody tis-
`sue interactions. Precise information on the function of
`the basophil is as yet lacking.
`The largest cells in the circulating blood are mono-
`cytes, whichtotal 7 percentof all leukocytes. Their ori-
`gin is probably in the bone marrow. Monocytes are mo-
`tile and are capable of phagocytosis. They are
`
`ALVOGEN, Exh. 1049, p. 0006
`
`

`

`Lymphocytes originate in the lymph nodes, spleen,
`thymus, and the tonsillar and lymphoid tissue of the
`alimentary tract and total about 25 to 30 percent of
`circulating leukocytes. Lymphocytes are identified by a
`single circular homogeneous nucleus that occupies
`most of the cell and is surrounded by a rim of cytoplasm
`that contains very few granules. Lymphocytes function
`in the body as the system responsible for acquired
`immunity to foreign cells andantigens. One type ot lym-
`phacyte Is eapable of producing Immunoglobulins
`(antibodies), and the othertype is concerned with cell-
`mediated immunity. The latter type is responsible for
`rejection of transplanted organs and certain allergic
`reactions.
`Platelets (thrombocytes) are the smallest cells in the
`circulating blood. Like mature red cells they lack a nu-
`cleus and are not capableof cell division. Platelets orig-
`inate as segmentalstructures that are released into the
`circulation from the cytoplasm of megakaryocytes, the
`largest cells in the bone marrow (Plate 15). The main
`function of the blood platelets is participation in hemo-
`stasis, the prevention and control of bleeding. In addi-
`tion, platelets function in the maintenance ofthe integri-
`ty of the endothelial lining of vessels. Their circulation
`time in the blood is about ten days.
`
`PLASMA
`
`Plasma is a complex solution of electrolytes, proteins
`(7-8 percent), and water (90 percent). The major pro-
`teinis albumin, but other proteins, including antibodies,
`hormones,
`lipids, and carbohydrate-protein com-
`plexes, and the various factors and componentsof the
`coagulation system, are present. The liver is the major
`site for the production of most of the proteins in the
`circulating blood. The liver is known to produce albu-
`min, fibrinogen (Factor |), prothrombin (FactorIl), and
`other coagulation factors that enable the blood toclot,
`including Factors V, VII, IX, and X. The liver also acts as
`a storage site for other agents that influence the pro-
`duction of elements in the blood. The blood produced
`by the hematopoietic system, the “milieu intérieur,” is
`essential for normal function and life.
`
`
`
`ALVOGEN, Exh. 1049, p. 0007
`
`ALVOGEN, Exh. 1049, p. 0007
`
`

`

`
`
`
`
`
`Humerus Monocytes
` % Liver
`
`LYMPH NODES
`Produce:
`
`Lymphocytes
`
`RED BONE MARROW
`
`Produces:
`
`Neutrophils
`
`Basophils
`
`®
`
`aePlatelets
`
`Vertebra
`
`TS
`fi? ™,
`i
`Erythrocytes
`
`Lymph nodes
`
`SPLEEN
`
`Produces:
`
`
`
`Monocytes
`
`one
`
`@
`
`Lymphocytes
`
`Destroys:
`
`Worn-out blood cells
`
`Acts as extramedullary
`hematopoietic center on demand
`
`
`
`ALVOGEN, Exh. 1049, p. 0008
`
`THYMUS
`
`Produces and modifies:
`
`Lymphocytes
`LIVER
`Produces:
`
`Prothrombin, fibrinogen, and
`other coagulation factors
`
`Excretes:
`Bilirubin
`
`Shores:
`
`Erythrocyte-maturing
`factor
`
`as extramedullary
`hematopoietic center
`on demand
`
`STOMACH
`
`Retelves:
`
`Iron, protein, and extrinsic
`erythrocytic-maturing
`factor from food
`
`Secretes:
`
`Intrinsic
`
`erythrocytic-maturing
`factor
`
`YELLOW BONE MARROW
`
`Acts as extramedullary hematopoietic
`center on demand
`
`ALVOGEN, Exh. 1049, p. 0008
`
`

`

`o<~70SM™M
`
`BLOOD ISLANDS—YOLK SAC
`
`Liver—Spleen
`'
`Reticulo-Endothelial Cell
`(PARENT CELL OF ALL BLOOD CELLS)
`
`Spleen, etc.
`
`MONOBLAST
`
`|
`
`“Bieras”
`MYELOCYTE
`
`NELTROALIC
`
`JUVENILE
`
` BASOPHILIC
`MYELOCYTE
`
` -
`
`EOSINOPHILIC
`MYELOCYTE
`
`
`
`BASOPHILIC
`
`"
`
`Pe
`
`ag
`
`si me
`*
`JUVENILE
`MEGAKAAYOCYTE
`
`a a (2 ('&
`
`Lymph Glands,a Red Bone Marrow
`
`aX 4© ®LYMPHOBLAST
`
`
`
`MEGAKARYOBLAST macH4apszsts—
`
`
`Orrma NEUTROPHILIC
`
` fa RETICULOCYTE
`
`7
`
`
`
`ne”
`
`ar
`
`
`
`LARGE
`SEGMENTED
`LYMPHOCYTE
`
`
`NEUTROPHIL
`
`MONOCYTE
`
` ERYTHROCYTE
`LYMPHOCYTE
`
`EOSINOPHIL
`BASOPHIL
`PLATELETS
`HYPERSEGMENTED
`
`NEUTROPHIL
` ALVOGEN, Exh. 1049, p. 0009
`
`
`ALVOGEN, Exh. 1049, p. 0009
`
`

`

`Nervous
`System
`
`George B. Udvarhelyi, M.D.
`
`The autonomic nervous system consists of a central
`and a peripheral component: information on central au-
`tonomic connectionsis still incomplete. A mechanism
`for interaction exists between the frontal cortex and the
`hypothalamus. Thefrontal cortex represents an afferent
`projection area that receives visceral impulses mainly
`fromm the hypothalarnus, either directly or by way of the
`waystations in the thalamus, In responseto stimulation,
`the frontal cortex activates other cortical areas, and
`issues efferent messageseither directly to peripheral
`effectors or through the hypothalamus. Other cortical
`areas, like the cingulum and the posterior orbital, ante-
`rior insular, and temporal cortex, play importantroles in
`cardiovascular function, respiratory movements, gas-
`tric motility, pupillary changes, and other autonomic
`responses such as piloerection, salivation, bladder
`
`30
`
`ALVOGEN, Exh. 1049, p. 0010
`
`with the secand importantstructure of the central part of
`the autonomic system, namely, the hypothalamus, Stim-
`ulation of various areas of the hypothalamus evokes
`special responses. Excitation of the anterior hypo-
`thalamic region produces bladder contraction,
`crease of gastrointestinal mobility, cardiac depression,
`and vasodilatation. Drowsiness, unconsciousness, and
`slowing of the heart occur in man after stimulation of the
`preoptic area. Excitation of the posterior and lateral re-
`gions of the hypothalamus results in the elevation of
`blood pressure, cardiac acceleration, pupillary cilata-
`tion, sweating, piloerection, hypoglycemia, and arrest
`of gastrointestinal movements. In animals, these effects
`are usually accompanied by expression of fear and
`rage. Control of body temperatureis achieved in warm-
`blooded animals by release of excess heat through pe-
`ripheral vasodilatation, sweating, and panting. Hunger
`and thirst are regulated by the hypothalamus, the appe-
`tite being inhibited by the ventromedial part, whereas
`the lateral and posterior hypothalamic regions seem to
`promoteit. Stimulation of the dorsal hypothalamusin-
`creases the urge for drinking, whereas lesions of the
`hypothalamus result in hypodipsia. Observation in ex-
`perimenial animals and humans confirms thal the ante-
`rior region of the hypothalamusis primarily concerned
`with the regulation of parasympathetic activities, where-
`ag the posterior and lateral hypothalamic areas govern
`sympathetic responses. The pituitary gland is partly
`underthe influenceof the hypothalamus and partly can-
`trolled by a feedback mechanism of other andocrine
`glands. Throughthe anteriorlobeof the pituitary gland,
`the hypothalarnus participates in the control of the sex
`cycle, the activity of the adrenal cortex, and the function
`of the thyroid gland. Through the neuroendocrine con-
`nections to the posterior pituitary lobe, the hypotha-
`lamus controls the production of antidiuretic hormone
`and also the release of oxytocin.
`The peripheral componentof the autonomic nervous
`system consists of an efferent motor and an afferen!
`sensory division. The peripheral motor autanomic divi-
`sion consists of
`two neurons: a preganglionic one,
`which hasits cell of origin inthe central nervous system,
`which synapses with several cell bodies of the second,
`the postganglionic neurons. The postganglionic nerve
`fibers terminate at the effectors, i.e., smooth muscle,
`glands, and heart. Preganglionic nerve fibers are COv-
`ered with a thin myelin sheetand are white when viewed
`inthe fresh state. Preganglionic neurons manufacture a
`chemical substance, acetylcholine, and are therefore
`called cholinergic. Postganglionic nerve fibers are un-
`myelinated and therefore are gray in appearance.
`Some postganglionic fibers are cholinergic, but the ma-
`jority produce an adrenalinelike or noradrenalinelike
`
`ALVOGEN, Exh. 1049, p. 0010
`
`