Fourth
`Edition
`
`The
`Johns
`
`Rfifié‘mtflwimom
`°i Fmotnomsifl
`Amstomy
`
`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 1 1 , 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 Alias of Aortic Surgery. by G. Melville Wil-
`flame and Leon Schlossberg (Baltimore: Williams 3: Wilkins. 1997}.
`Plate 41 first appeared in Arias of Generai Thoracic Surgery, by Mark
`M. Bayitch and FeIICIan M. Steichen (Philadelphia: W B Saunders
`Company, 1989). Plates 49. 50. 51. and 52 iirsl appeared in The
`Operative Management or Breast Disease, by Ft. Robinson Baker and
`John E. Neiderhuber(Philadelphia:w. B. SaundersComp-any. 1992]
`Plate 56 first appeared In Arias ofNuciear-Medr‘aine, vol. 2, by Frank H.
`Defend and Henry N. 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
`06050403020100999897 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 found at
`the end of this book.
`
`A catalog record for this book is 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
`
`—L
`
`Fetal Circulation John J. White, MD,
`
`2
`
`2 Skeletal Anatomy James L. Hughes, MD.
`
`4
`
`3 Skeletal Muscles, Joints, and Fascial Structures Vernon T. Tolo, MD.
`
`10
`
`4 The Abdominal Wall, the lnguinal Region, and Hernias
`
`John J. White, MD.
`
`19
`
`5 The Hematopoietic System and Development of Blood Cells William R. Bell, MD.
`
`26
`
`6 The Autonomic Nervous System George B. Udvarhelyi, MD.
`
`30
`
`7 The Anatomical Man Leon Schlossberg
`
`37
`
`8 The Aorta and Its Branches Leon Schlossberg 42
`
`9 The Peripheral Nerves George B. Udvarhelyi, MD.
`
`44
`
`10 The Central Nervous System Melvin H. Epstein, MD., and Donlin M. Long, MD.
`
`49
`
`11 The Lymphatic System James P. Isaaos, MD.
`
`57
`
`12 The Eye and the Mechanism of Vision Charles E. Iliff, MD.
`
`61
`
`13 The Ear George T. Nager, MD.
`
`65
`
`14 The Nose, Paranasal Sinuses, Pharynx, and Larynx Margaret M. Fletcher, MD.
`
`68
`
`15 The Head and Neck Melvin H Epstein, MD., Donald S. Gann, MD., David W. Heese, D.D.S.,
`and James J. Ryan, MD.
`73
`
`16 The Endocrine Glands Donald S. Gann, MD.
`
`78
`
`17 The Mediastinum and the Thymus Gland Gregory B. Bulkley, MD.
`
`83
`
`18 Anatomy as Viewed Laparoscopically Mark A. Talamini, MD.
`
`88
`
`19 The Circulatory System Robert K. Brawley, MD.
`
`96
`
`20 The Breast R. Robinson Baker, MD.
`
`102
`
`21 The Heart Vincent L. Gott, MD.
`
`110
`
`22 The Lungs Henry N. Wagner, Jr., MD.
`
`114
`
`23 The Gastrointestinal Tract Thomas R. Hendrix, MD., George D. Zuidema, MD., and
`John J. White, MD.
`118
`
`24 The Liver Michael A. Choti, MD.
`
`137
`
`25 The Female Generative Tract and Pregnancy Howard W. Jones, Jr., MD.
`
`142
`
`26 The Menstrual Cycle H. Lorrin Lau, MD.
`
`147
`
`
`
`ALVOGEN, Exh. 1049, p. 0003
`
`ALVOGEN, Exh. 1049, p. 0003
`
`

`

`29 The Skin James J. Ryan. MD.
`
`157
`
`Index
`
`159
`
`PLATES
`
`meU’t-bOJM—A
`
`8
`
`24
`
`20
`
`xiii
`
`Anatomical Positions, Surface and Topographic Anatomy. and Regions and Planes of Sections
`Fetal Circulation
`3
`The Skull
`6
`Skeleton~Anterior and Posterior Views
`Skeleton—Lateral View 9
`Muscles. Ligaments and Fasciae. Tendons. and BursaeiAnterior View 12
`Muscles. Ligaments and Fasciae. Tendons. and Bursae—Posterior View 13
`Shoulder and Hip Joints
`15
`9 Knee Joint
`17
`10 Abdominal Wall—Inguinal Region
`11
`Inguinal Region
`21
`12 Hernias
`23
`13 Sites of Abdominal and Pelvic Hernias
`14 Hematopoietic System 28
`29
`15 Development of Blood Cells
`32
`16 Autonomic Nervous System and Effects of Stimulation (Respiratory and Digestive Systems)
`17 Autonomic Nervous System——Mechanism of Effector Organ Stimulation (Neurohormonal and Genitourinary Systems)
`18 Visceral Afferent Pathways and Referred Areas of Pain 34
`19 The Anatomical Man 38
`40
`20 The Anatomical Man—Organs
`21 The Anatomical Man—Arteries. Veins. Nerves. and Lymph Systems
`22 Aorta and Its Branches—Lateral View 43
`46
`23 Peripheral Nerves (Exclusive of Cranial Nerves)
`24 Peripheral Nerves. Including Cervical. Brachial. and Lumbosacral Plexuses 47
`25 The Five Senses of Consciousness
`51
`26 Vascular Supply of the Brain
`52
`54
`27 Base of the Brain and of the Skull
`56
`28 Cerebrospinal Axis and Cervical Cord
`29 Lymphatics—Head. Neck. and Chest 58
`3O Lymphatics—Esophagus and Stomach; Colon. Rectum. and Anus 59
`31 Lymphatics—Genitourinary System; Liver and Bile Ducts
`60
`32 The Eye and the Orbit
`63
`33 The Eye—Vision
`64
`34 The Ear—Apparatus of Hearing and Equilibrium 67
`35 The Nose and Paranasal Sinuses
`69
`36 The Pharynx and Larynx
`72
`37
`Innervation of the Teeth and Facial Muscles; Salivary Glands and Muscles of Mastication 75
`38 Sagittal Section of the Head and Neck; Thyroid and Parathyroid Glands
`77
`39 Endocrine Glands 80
`4O Physiology of Endocrine Glands (Schematic Summary)
`41 Mediastinum 84
`42 Thymus Gland
`85
`43
`Internal Inguinal Ring
`
`41
`
`.
`
`81
`
`89
`
`ALVOGEN, Exh. 1049. p. 0004
`
`
`
`ALVOGEN, Exh. 1049, p. 0004
`
`

`

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

`

`System
`and
`Development
`of
`
`Blood
`
`Cells
`
`William R. Bell, MD.
`
`The hematopoietic system is composed of red blood
`cells, white blood cells, 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-
`pended inside blood vessels (Plate 14). In the embryo,
`the source of these formed elements is the connective
`tissue called mesenchyme.
`In the human embryo,
`blood cells are first formed in the blood islands of the
`yolk sac At a later time, when the embryo reaches 5 to 8
`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, production sites in the liver, thymus,
`and spleen gradually decrease and the bone marrow
`takes over hematopoietic production. The fixed mes-
`enchymal cells are reduced to scant reticular stroma,
`
`26
`
`Erythropoiesis (production ol red blood cells) in the
`infant and adult takes place continuously in 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 major sites of hematopoietic activ—
`ity. Within the bone marrow, the red cell is derived irorrr :1
`primitive nucleated cell called the orythrobiasr. Pretri—
`eration results from successrve mitotic cell divisions
`(Plate 15) As maturation progresses, hemoglobin ap—
`pears and the nucleus becomes smaller and is eventu-
`ally extruded trom 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. The intrinsic factor, by complexing with an
`extrinsic factor (vitamin B12), is responsible for its ab—
`sorption from the intestinal tract into the blood. The ma—
`ture red cell is then introduced into the circulating blood
`via the vascular channels of the bone marrow.
`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 red cell
`production and removal of senescent red cells (more
`than 120 days old} lrom the circulation by the spleen is
`accurately maintained The rate of red cell production is
`normally controlled by a hormone called erythropoief/‘n,
`which is mainly produced in the kidneys
`White blood cells (leukocytes) are independently
`motile cells, composed of 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,
`eosir'rophils, 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
`eosinophiis
`(red cytoplasrrric granules]
`basophils (dark blue cytoplasmic granules) total about
`3 percent. I'deutrophils function in defense and repair
`by cartooning 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, which total 7 percent of all leukocytes. Their ori—
`gin is probably rn the bone marrow. Monocytcs are m0—
`tile and are capable of phagocytosis. They are
`
`ALVOGEN, Exh. 1049, p. 0006
`
`ALVOGEN, Exh. 1049, p. 0006
`
`

`

`Lymphocytes originate in the iympl‘i-nodes, spleen,
`thymus. and the tnnsillar and lymphord 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 lhe cell and is surrounded by a rim of cytoplasn'i
`that contains very few granules. Lympi‘iocyles function
`in the body as the system responsible for acquired
`immunity to foreign cells and antigens. One type of lym—
`pmcyte is capable of producing imrni.rnog_lobulir'is
`(antibodies), and the other type is concerned with cell—
`meciiated 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 capable of cell division. Platelets orig-
`inate as segmental structures 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 of the 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—
`tein is albumin, but other proteins, including antibodies,
`hormones,
`lipids, and carbohydrate—protein com—
`plexes, and the various factors and components of 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 I), prothrombin (Factor II). and
`other coagulation factors that enable the blood to clot,
`including Factors V, Vll, 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
`
`

`

`LYMPH NODES
`
`Produce:
`
`Humerus
`
`Sternum
`
`-
`.
`Lymphocytes
`
`
`
`Monocytes
`
`
`
`
`
`THYMUS
`
`Produces and modifies:
`
`Lymphocytes
`LIVER
`Produces:
`
`Prothrombin, fibrinogen, and
`other coagulation factors
`
`Excretes:
`Bilirubin
`
`S ores:
`
`Erythrocyte-maturing
`factor
`
`as extramedullary
`hematopoietic center
`on demand
`
`STOMACH
`
`Fl eos:
`
`Iron, protein, and extrinsic
`erythrocytic-maturing
`factor from food
`
`Secreies:
`
`Intrinsic
`
`erythrocytic-maturing
`factor
`
`RED BONE MARROW
`
`Produces:
`
`
`
`.. .
`Neutrophils
`
`Basophils
`
`,
`
`. Q
`
`:50 Liver
`4;
`.
`Platelets
`
`Vertebra
`
`
`
`”‘77,.
`" “.
`.-‘"
`g)
`l
`Erythrocytes
`
`Lymph nodes
`
`SPLEEN
`
`Produces:
`
`
`
`Monocytes
`
`.
`
`'
`
`‘
`
`.
`
`.
`
`Lymphocytes
`
`
`
`Destroys:
`
`Worn-out blood cells
`
`Acts as extramedul lary
`hematopoietic center on demand
`
`
`
`YELLOW BONE MARROW
`
`Acts as extramedullary hematopoietic
`center on demand
`
`ALVOGEN, Exh. 1049, p. 0008
`
`ALVOGEN, Exh. 1049, p. 0008
`
`

`

`o-<:umgm
`
`BLOOD ISLANDS—YOLK SAC
`
`l
`
`Liver—Spleen
`l
`Reticulo-Endothelial Cell
`
`(PARENT CELL OF ALL BLOOD CELLS)
`
`
`
`Lymph Glands, /\
`
`Spleen, etc.
`
`Red Bone Marrow
`
`MONOBLAST
`
`LYMPHOBLAST
`
`MYELOBLAST
`
`II!
`
`.r’
`
`(0
`
`PROERYTHROCYTE
`
`
`
`MEGAKARYOBLAST
`
`\
`
`
`mm:—I>§§— a
`
`
`
`(DI—'l-I'I'IO
`
`
`
` MONOCYTE
`
`#0."
`NEUTR PHILIC
`MYELOCYTE
`
`NEUTROPHlLIC
`JUVENILE
`
`BASOPHILIC
`MYELOCYTE
`
`EOSINOPHILIC
`MYELOCY‘I’E
`
`l
`
`-
`
`J
`
`MEGAKARYOCYTE
`
`// '
`. O
`NORMO-
`BLAST
`
`.,.
`
`.I' ';
`
`FE“;
`
`RETICULOCYTE
`
`LARGE
`LYMF'HOCYTE
`
`
`SEGM ENTED
`NEUTROPHIL
`
`
`
`
`ERYTHHOCYTE
` LYMPH OCYTE
`
`EOSINOPHIL
`BASOPHIL
`PLATELET§
`HYPERSEGMENTED
`
`
`NEUTROPHIL
`
`ALVOGEN, Exh. 1049, p. 0009
`
`
`ALVOGEN, Exh. 1049, p. 0009
`
`

`

`Nervous
`System
`
`George B. Udvarhelyi, MD.
`
`The autonomic nervous system consists of a central
`and a peripheral component: information on oentral au-
`tonomic connections is still incomplete. A mechanism
`for interaction exists between the frontal cortex and the
`hypothalamus. The frontal cortex represents an afferent
`projection area that. receives visceral impulses mainly
`from the hypothalamus, either directly or by way of the
`way stations in the thalamus. In response to stimulation
`the frontal cortex activates other cortical areas, and
`issues efferent messages either 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 important roles in
`cardiovascular function, respiratory movements, gas—
`tric motility, pupillary changes, and other autonomic
`responses such as piloerection, salivation, bladder
`
`30
`
`with the second important structure 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 regiorr produces bladder contraction,
`crease of gastrointestinal mobility, cardiac depression,
`and vasodilatation Drowsiness, unconsciousness, and
`slowrng 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 dilata—
`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 temperature is 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
`promote it. Stimulation of the dorsal hypothalamus in-
`creases the urge for drinking, whereas lesions of the
`hypothalamus result in hypodipsia. Observation in Elk”-
`perimental animals and humans confirms that the ante—
`rior region of the hypothalamus is primarily concerned
`withthe regulation ofparasympathetic activities,wherr.—:—
`as the posterior and lateral hypothalamic areas govern
`sympathetic responses. The pituitary gland is partly
`under the influence of the hypothalamus and partly cot I-
`trolled by a feedback mechanism of other endocrine
`glands. Through the anterior lobe of the pituitary Qlcrl till.
`the hypothalar'nus participates in the control of the son.
`cycle, the activity of the adrenal cortex. and the funcl ion
`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 component of the autonomic nervous
`system consists of an efferent motor and an afferent
`sensory division. The peripheral motor autonomic divi—
`sion consists of
`two neurons:
`at preganglionic one.
`which has its cell of origin in the 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-sheel and are white when viewed
`in the 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 r'nc-r—
`iority produce an adrenalinelike or noradrenalinelil-:.e
`
`ALVOGEN, Exh. 1049, p. 0010
`
`ALVOGEN, Exh. 1049, p. 0010
`
`