AFAA01 11/11/03 13:38 Page i Anatomy for Anaesthetists .. This page intentionally left blank AFAA01 11/11/03 13:38 Page iii 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 .. .. AFAA01 11/17/03 10:26 Page iv © 1963, 1969, 1977, 1983, 1988, 1993, 1997, 2004 Library of Congress Cataloging-in-Publication Data by Blackwell Science Ltd Ellis, Harold, 1926– a Blackwell Publishing company Anatomy for anaesthetists / Harold Ellis, Stanley Blackwell Science, Inc., 350 Main Street, Malden, Feldman, William Harrop-Griffiths; with a chapter Massachusetts 02148-5020, USA on the Anatomy of pain contributed by Andrew Blackwell Publishing Ltd, 9600 Garsington Road, Lawson.—8th ed. Oxford OX4 2DQ, UK p. ; cm. Blackwell Science Asia Pty Ltd, 550 Swanston Street, Includes bibliographical references and index. Carlton, Victoria 3053, Australia ISBN 1-4051-0663-8 1. Human anatomy. 2. Anesthesiology. The right of the Author to be identified [DNLM: 1. Anatomy. 2. Anesthesia. as the Author of this Work has been QS 4 E47a 2003] I. Feldman, Stanley A. asserted in accordance with the II. Harrop-Griffiths, William. III. Title. Copyright, Designs and Patents Act 1988. QM23.2.E42 2003 All rights reserved. No part of 611′.0024617—dc22 this publication may be reproduced, 2003020753 stored in a retrieval system, or ISBN 1405 1066 38 transmitted, in any form or by any means, electronic, mechanical, A catalogue record for this title is available from the photocopying, recording or otherwise, British Library except as permitted by the UK Copyright, Designs and Patents Act Set in 10/13.5pt Sabon by Graphicraft Limited, 1988, without the prior permission Hong Kong of the publisher. Printed and bound in Denmark, by Narayana Press, Odder First published 1963 Second edition 1969 Commissioning Editor: Stuart Tayler Third edition 1977 Editorial Assistant: Katrina Chandler Reprinted 1979 Production Editor: Rebecca Huxley Fourth edition 1983 Production Controller: Kate Charman Fifth edition 1988 Reprinted 1990 For further information on Blackwell Publishing, Sixth edition 1993 visit our website: Reprinted 1995 http://www.blackwellpublishing.com Seventh edition 1997 Reprinted 1998 Italian first edition 1972 Japanese fourth edition 1989 German fifth edition 1992 .. .. AFAA01 11/11/03 13:38 Page v 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 .. .. AFAA01 11/11/03 13:38 Page vi 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 .. .. AFAA01 11/11/03 13:38 Page vii 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 .. .. AFAA01 11/11/03 13:38 Page viii 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 .. AFAC01 11/11/03 13:39 Page 1 Part 1 The Respiratory Pathway .. This page intentionally left blank AFAC01 11/11/03 13:39 Page 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 Uvula Palatopharyngeal arch Palatine tonsil Palatoglossal arch Fig. 1 View of the open mouth with the tongue depressed. 3 .. .. AFAC01 11/11/03 13:39 Page 4 4 The Respiratory Pathway Frenulum linguae Sublingual fold Orifice of submandibular duct Fig. 2 View of the open mouth with the tongue elevated. 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 .. .. AFAC01 11/11/03 13:39 Page 5 The Mouth 5 Submandibular duct and gland Tongue Hyoglossus Genioglossus Geniohyoid Mylohyoid Sublingual gland Lingual N. Anterior belly of digastric Lingual A.