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 ATLAS OF ANATOMY

16th Edition Edited by

Friedrich Paulsen and
Jens Waschke

English Version with

Latin Nomenclature

General
Anatomy and
Musculoskeletal
System

ELSEVIER
F. Paulsen, J. Waschke

Atlas of Anatomy
Friedrich Paulsen, Jens Waschke (Eds.)

Atlas of Anatomy
English Version with Latin Nomenclature

General Anatomy
and Musculoskeletal System

16th Edition

ELSEVIER
ELSEVIER This atlas was founded by Johannes Sobotta t, former Professor of
Hackerbr(icke 6, 80335 Munich, Germany Anatomy and Director of the Anatomical Institute of the University in
All business correspondence should be made with: Bonn, Germany.
books.cs.muc@elsevier.com
German Edlt1ons:
Original Publication 1st Edition: 1904-1907 J. F. L&hmanns Verlag. Munich. Germany
Sobotta Atlas dar Anatomie 2nc1-11'" Edition: 1913-1944 J. F. Lehmanns Verlag, Munich, Germany
@ Elsevier GmbH, 2017. 12111 Edition: 1948 and following editions
All rights reserved. Urban & S<:hwarzenberg. Munich, Germany
ISBN 978-3-437-44021-2 13111 Edition: 1953, ed. H. Becher
14111 Edition: 1956, ed. H. Becher
This translation of SobottB Atlas dar Anatomie. 24111 edition by Friedrich 15111 Edition: 1957, ed. H. Becher
Paulsen and Jens Waschl::e was undertaken by Elsevier GmbH. 16111 Edition: 1967, ed. H. Becher
1Jlh Edition: 1972, eds. H. Ferner and J. Staubesand
ISBN 97~702().5269-9 18111 Edition: 1982, eds. H. Ferner and J. Staubesand
19111 Edition: 1988. ed. J. Staubesand
All rights reserved 20th Edition: 1993, ads. R. Putz and R. Pabst, Urban & S<:hwaJZenberg,
16'h edition 2018 Munich, Germany
~ Elsevier GmbH, Munich, Germany 21" Edition: 2000. ads. R. Putz and R. Pabst, Urban & Fischer. Munich,
Germany
Notic:-e 22nd Edition: 2006, eds. R. Putz and R. Pabst. Urban & Fischer.
The translation has been undertaken by Elsevier GmbH at its sole Munich, Germany
responsibility. 23m Edition: 2010, ads. F. Paulsen and J. Waschke, Urban & Fischer,
Knowledge and best practice in this field are constantly changing. As Elsevier, Munich, Germany
new research and experience broaden our understanding, changes in 24th Edition: 2017, eds. F. Paulsen and J. Waschke, Elsevier. Munich,
research methods, professional practices, or medical treatment may Germany
become necessary.
Practitioners and researchers must always rely on their own Foreign Edlt1ona:
experience and knowledge in evaluating and using any information, Arabic
methods. compounds or experiments described herein. Chinese
Because of rapid advances in the medical sciences. in particular, Croatian
independent verification of diagnoses and drug dosages should be Czech
made. English (nomenclature in English or Latin)
To the fuii&St extent of the law. no r&Sponsibility is assumed by French
Elsevier, authors, editors or contributors in relation to the translation or Greek
for any injury and/or damage to persons or property as a matter of Hungarian
products liability, negligence or otherwise. or from any use or Indonesian
operation of any methods, products, instructions, or ideas contained in Italian
the material herein. Japanese
Korean
Bibliographic information published by the Deutsche Nationalbibliothek Polish
The Deutsche Nationalbibliothek lists this publication in the Deutschen Portuguese
Nationalbibliografie; detailed bibliographic data is available on the Russian
Internet at http://Www.d-nb.de/. Spanish
Turkish
Ukrainian
18 19 20 21 22 5 4 3 2 1

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Content Project Management: Dr Andrea Beilmann, Sibylle Hartl
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Prof. Friedrich Paulsen
Dissection course for students
In his teaching. Friedrich Paulsen puts great emphasis on ensuring
that the students in his dissection classes can actually work on body
donation cadavers. 'Carrying out dissection yourself is not only
extremely important for gaining a three-dimensional understanding of
anatomy, forming the fundaments/ basis of virtually any field of
medical science. In dissection cfasses you will also experience for the
first time the touch and feeling of the human body, the organs and
individual tissues, but in most cases it wills/so b8 your first intensive
encounter with issues around death and dying, and the clinical causes
of death. You will not only study anatomy. but also team how to deal
with a quits unique and challenging situation as part of a team. Never
again will you be in such close contact with your fellow students and
teaching staff.'
Friedrich Paulsen was bom in Kiel in 1965 and. after oompleting his
'Abitur· in Brunswick, he initially trained as a nurse. He then studied
medicine at the Christian Albreeht University !CAU} in Kiel. After his
house officer training at the Oromaxillafacial Surgery Clinic and a period
as resident physician at the ENT Clinic of CAU, in 1998 he maved to
the Anatomical Institute of CAU where he graduated as medical doctor
in 1997 and further qualified by performing his State doctorate in
anatomy in 2001. In 2003 he was offered full professorship at the
Anatomy Departments of the Ludwig Maximilians University (LM U) in
Munich and the Martin Luther University (MLU) in Halle,I\Nittenberg. In
Halle. he founded a clinical anatomy training centre. After declining yet
another professorship, this time at the University of Saarland, he acce~
ted a post at the Friedrich Alexander University (FAU) in Nurnberg as
Professor of Anatomy and Head of its Anatomical Institute. a post he
has held since 2010. He has continued to decline professorships
offered by a number of other renowned universities.
Friedrich Paulsen is an honorary member of the Anatomical Society of
Great Britain and Ireland as well as Romania and has been granted
numerous scientific awards including the Dr Gerhard Mann Sicca
research prize, the Sicca research prize of the German Federation of
Ophthalmologists, and the Commemorative Medal of the Comenius
University in Bratislava. Additionally, he received several teaching
awards.
The key focus of his research is on the innate immune response of the
el'(e surface, and on investigating the causes of dry eyes. Visiting
research fallowships have taken him to Spain and the United Kingdom.
He is the editor of the journal Annals of Anatomyand, as vice-presi-
dent of Learning and Teaching {until 3/l018), and now People {since
4/2018) also a member of the FAU university administration since 2016.
Prof. Dr. Friedrich Paulsen
Institute of Anatomy. Department of Functional and Clinical Anatomy
Friedrich Alexander University Er1angen-Niirnberg
UniversitiitsstraBe 19
91054 Erlangen
Germany
Prof. JensWaschke
Making courses more clinically relevant
For Jens Waschke. one of the most important challenges in the
teaching of modem anatomy is how to optimally adapt the courses to
meet the requirements of clinical training and subsequent professional
practice.
The clinical aspects of the Atlas give students in the first semesters
of medical school a grounding in anatomy and at the same time show
them the importance of having a thorough understanding of human
anatomy for their subsequent clinical practice, instead ofju!Jf. learning
anatomical structures by rote. On the other hand, we prefer to avoid
covering highly specialised details that are only needed by a few
specialists for occasions/ diagnostic procedures or surgery, as is the
case in other contemporary anatomy books. Since students at the
beginning of their training are unable to distinguish between the
necessary basics and specialised details, this can cause a mental
overtoad and prevent them from focusing on the essentials:
Jens Waschke {born in 1974 in Bayreuth) studied medicine at the
University of Wi.irzburg, achieving a doctorate in anatomy under Prof.
Detlev Drenckhahn in the year 2000. After his intership training in the
Anatomy and Internal Medicine Departments, he qualified as a
professor of anatomy and cell biology in 2007. JensWaschke spent
nine months as a visiting scholar at the Davis campus of the
University of California under Prof. Fitz-Roy Curry in 2003-2004. From
2008 onward he chaired the newly established Department Ill of the
University ofWUrzburg before being appointed profassor at the
Ludwig Maximilians University in Munich, where he has been the
head of Department I !Vegetative Anatomy) of the Anatomical Institute
since 2011. Jens Wsschke is heavily involved in the German
Anatomical Society as an examiner in specialist anatomy and a
member of its Study Commission. and he heads their worlcing group
on reducing formaldehyde exposure. He is a representative of the
IFAA (International Federation of Associations of Anatomists) and an
honorary member of the Anatomical Society of Ethiopia lASE).
In his research he primarily investigates the biological mechanisms
regulating cell adhesion and the external and internal barrier functions
of the human body. His research predominantly focuses on the
regulation of the endothelial barrier during inflammation. and also the
mechanisms behind the impaired cell adhesion seen in diseases such
as the blistering skin disorder pemphigus, Crohn's disease and
arrhythmogenic cardiomyopathy. The aim is to better understand cell
adhesion and to disoover new treatment approaches.
Prof. Dr. Jans Wsschke
Institute of Anatomy
Department I -Vegetative Anatomy
Ludwig Maximilians University (LMU)
PattenkoferstraBe 11
80336 Munich
Germany
Preface of the 24th German Edition
In the preface of the first edition of his atlas in May 1904, Johannes
Sobotta writes: 'Long-standing experience in cadaver dissection clas-
ses has prompted the author to ensure that the illustrations of the peri-
pheral nervous system and the blood vessels depict the relevant struc-
tures in the same way that the student is accustomed to seeing them
on the cadaver, i.e. that they depict the vessels and nerves from the
same region together. Furthermore, the atlas alternates between pages
of text and full-page diagrams. The latter contain the key illustrations in
the atlas, while the former - in addition to sketches and schematic
drawings and legends- contain a brief, concise text to help the student
find information quickly when using the book in the dissection hall~
Just as fashions change on a regular basis, so do students' reading and
studying habits. The ubiquitousness of multi-media and the ready avail-
ability of information and stimuli are surely the main reasons why these
habits are changing at a much faster rate than ever before. Publishers
and publishing houses must stay abreast of these developments and of
students' changing expectations regarding atlases and textbooks they
wish to use, as well as ensuring the digital availability of the contents.
In addition to interviews with students and systematic surveys, a pub-
lisher can sometimes gauge students' expectations from the textbook
market itself. Detailed textbooks claiming to be completely comprehen-
sive are increasingly being abandoned in favour of textbooks that di-
dactically meet students' educational needs and cover the contents of
their courses and exams -whether they are studying medicine, den-
tistry or biomedical science. Likewise, although the images in atlases
such as Sobotta have fascinated many generations of doctors and me-
dical professionals around the world with their precise naturalistic re-
presentations of real dissections, they are sometimes perceived by
students as being too complicated and too detailed. This realisation re-
quires us to consider how we can build upon the obvious strengths of
an atlas -which in the course of over 100 years of tradition and 23
German editions, has become a benchmark of accuracy and quality- to
meet modern didactic concepts without the overall work losing its
unique, exclusive characteristic and its originality.
For educational reasons, we have maintained the Sobotta's original con-
cept and chosen to publish the atlas, as it has been since the first edi-
tion, in three volumes: General Anatomy and Musculoskeletal System
(1 ); Internal Organs (2); and Head, Neck and Neuroanatomy (3). And while
the concept mentioned in the preface of the first edition, i.e. linking the
pictures in the Atlas with an explanatory text, may be old-fashioned, it
has now come back into fashion- we have simply modernised the con-
cept. Each picture is thus completed with a short explanatory text to in-
troduce the students to the structure depicted and to explain why those
particular dissection and depiction methods have been chosen for that
particular region. The individual chapters have been systematically struc-
tured to follow today's methods of studying, while various illustrations
have been updated or replaced. The majority of these new illustrations
have been designed from the point of view of the Ieamer, to make it
easier to study the key pathways of blood supply and innervation. We
have furthermore revised numerous existing illustrations and reduced
the number of labels, using bold type to facilitate access to the anatomi-
cal content. The numerous clinical practice examples ('Clinical Remarks')
show the somewhat 'dry' subject of anatomy at its most vibrant best,
demonstrating to beginners how relevant anatomy is for their subse-
quent professional life and giving them a tantalising taste of their clinical
training to come. Another revised feature is the introductory preface to
the individual chapters, which sum up the content and the key issues,
and include a real-life clinical case. In addition, each chapter ends with a
summary of questions which would typically be asked in oral anatomy
exams and exam tests. As in the 23ra edition, each chapter contains a
brief introduction to the embryology of each body region.
Readers should please note two things:
1. The 24th edition of the Sobotta Atlas cannot replace an explanatory
textbook.
2. No matter how good an educational concept is, students still have to
put in many hours of intensive studying themselves - a good con-
cept can but make that knowledge more accessible. Learning anato-
my is not difficult, but it does take a lot of time; time that is well
spent. since everybody- doctor and patient- will benefit from it in
the long run. The aim of the 24th edition of the Sobotta Atlas is not
only to facilitate your study, but also to make the time you spend
studying engaging and interesting, so that the atlas is something you
will repeatedly want to pick up and consult, both during your medical
training and your subsequent professional career.
Erlangen and Munich, summer of 2017,
exactly 113 years after the first edition was published
Friedrich Paulsen and Jens Waschke
Acknowledgements of the 24th German Edition
The work on the 24th edition of the Sobotta Atlas has once again been a
lot of fun, and this intensive involvement has continued to strengthen
our sense of pride in the Sobotta.
Today, more than ever, an extensive anatomy atlas of the calibre of the
Sobotta requires a lot of teamwork with the coordination of the publi-
shing house. The cornerstone of the 241h edition has been laid by Dr
Katja Weimann, who extensively coordinated the project. We are very
grateful for her hard work. Also, without the long-standing experience
of Dr Andrea Beilmann, who has worked on several previous editions of
the Sobotta and has been a true pillar of strength for the Sobotta team,
many things would not have been possible. We would like to thank her
again most profusely for all her help and support. Benjamin Rempe,
another member of the four-person team behind the 24th edition of the
Sobotta, has contributed to Sobotta for the first time, approaching the
task with real passion and enthusiasm. His unique way of motivating
the team served as a continual source of encouragement and motiva-
tion for the editors. Benjamin: thank you very much. We fondly recall the
monthly conference calls in which Benjamin Rempe and Dr Andrea Bail-
mann helped us carefully craft the Sobotta Atlas and, despite their dif-
ferent approaches, showing a remarkable gift for intuitively adopting a
uniform working style. Sibylle Hartl coordinated the project in collabora-
tion with Dr Andrea Beilmann and was responsible for the entire print
production. We are truly grateful to her. Without the tenacity and the
protective hand of Dr Dorothea Hennessen and Rainer Simader, who
were both in charge of the overall management of the 'Sobotta 24th
edition' project and who never lost faith in their Sobotta team or the
tight schedule, this edition in its present form would not have been
possible. Others whom we are similarly grateful to for their involve-
ment in the project and their share of its success are: Dr Antje Kronen-
berg (editing), the abavo GmbH team (technical image processing and
typesetting) and Nicola Kerber (layout design). We would very much like
to thank Dr Ursula Osterkamp-Baust for exhaustively compiling the in-
dex.
Special thanks to our team of illustrators Dr Katja Dalkowski, Marie Da-
vidis, Johannes Habla, Anne-Kathrin Hermanns, Martin Hoffmann, Son-
ja Klebe, Jorg Mair and Stephan Winkler. who in addition to updating the
existing images also helped us develop a large number of new illustra-
tions.
For their help in producing the clinical images, we would also like to
thank Dr Frank Berger, Institute of Clinical Radiology of Ludwig Maximi-
lians University, Munich; Prof. Christopher Bohr, Phoniatrics and
Paediatric Audiology, ENT Clinic at Friedrich Alexander University,
Erlangen/Nurnberg; Dr Eva Louise Bramann, Ophthalmology Clinic at
Heinrich Heine University, Dusseldorf; Prof. Andreas Dietz, Director of
the ENT Clinic and Outpatients' Clinic at the University of Leipzig; Prof.
Gerd Geerling, Ophthalmology Clinic at Heinrich Heine University, Dussel-
dorf; Dr Berit Jordan, University Clinic and Outpatients' Clinic for Neu-
rology, Martin Luther University, Halle/Wittenberg; Dr Axel Kleespies,
Surgical Clinic, Ludwig Maximilians University, Munich; Prof. Norbert
Kleinsasser, University Clinic for Illnesses of the Ear, Nose and Throat,
Julius Maximilians University, Wurzburg; Dr Hannes Kutta, ENT prac-
tice, Hamburg-Aitona/Ottensen; Dr Christian Markus, Anaesthesiology
Clinic, Julius Maximilians University, Wurzburg; Jorg Pakarsky, Institute
for Anatomy II, Friedrich Alexander University, Erlangen/Nurnberg; Dr
Dietrich St6vesandt, Clinic for Diagnostic Radiology, Martin Luther Uni-
versity, Halle/Wittenberg; Prof. Jens Werner, Surgical Clinic, Ludwig
Maximilians University, Munich; Dr TobiasWicklein, Erlangen, and Prof.
Stephan Zierz, Director of the University Clinic and Outpatients' Clinic
for Neurology, Martin Luther University Halle/Wittenberg.
Last but not least, we would like to thank our families, who not only
were very gracious and understanding of all the time we devoted to the
24th edition of the Sobotta, but who also gave us very helpful sugges-
tions whenever we needed feedback. You have been a true support.
Erlangen and Munich. summer of 2017
Friedrich Paulsen and Jsns Waschks
1. List of Abbreviations
Singular:
Arteria
Plural:
Aa. Arteriae
<? = female
male Percentages:
A. ~
Lig. Ugamentum Ligg. Ligamenta In the light of the large variation in
individual body measurements, the
M.
N.
= Musculus
Nervus
Mm.
Nn.
= Musculi
Nervi percentages indicating size should
Proc. Processus Prooc. = Processus only be taken as approximate
values.
R.
v.
= Ramus
Vena
Rr.
Vv.
= Rami
Venae
Var. Variation

2. General Terms of Direction and Position

The following tenns indicate the position of organs and parts of the longitudinalis= parallel to the longitudinal axis (e.g. Musculus
body in relation to each other, irrespective of the position of the body longitudinalis superior of the tongue)
(e.g. supine or upright} or direction and position of the limbs. These ssgittalis =located in a sagittal plane
tenns are relevant not only for human anatomy but also for clinical me- tfansversalis =located in a transversa plana
dicine and comparative anatomy. =
transversus transverse direction (e.g. Processus transversus of a
thoracic vertebra)
General tenns
anterior- posterior= in front- behind (e.g. Arteriae tibiales anterior et '&rme of direction and poeltlon for the limbe
posterior) proxima/is - distalis = located towards or away from the attached end
ventfalis -dorsalis = towards the belly- towards the back of 8 limb or the origin of a structure (e.g. Articulationes radioulnares
superior- inferior= above - below {e.g. Conchae nasales superior et proximalis et distalis)
inferior)
crsni81is - csud8fis =towards the head -towards the tail for the upper limb:
dexter- sinister= right- left (e.g. Arteriae iliacae communes dextra et radialis- ulnaris = on the radial side - on the ulnar side (e.g. Artariae
sinistral radialis et ulnaris}
intemus - extemus = internal -external
=
superficialis -profundus superficial - deep (e.g. Musculi flexoras for the hand:
digitorum superficialis et profundus) palmaris - dorsalis =towards the palm of the hand - towards the back
medius, intermedius= located between two other structures (e.g. the of the hand (e.g. Aponeurosis palmaris, Musculus interosseus
Concha nasalis media is located between the Conchae nasales dorsalis}
superior and inferior)
medianus = located in the midline (fissura medians anterior of the for the lower limb:
spinal cord). The median plane is a sagittal plane which divides the tibialis - fibularis =on the tibial side - on the fibular side (e.g. Arteria
body into right and left halves. tibialis anterior)
medialis - laterslis = located near to the midline - located away from
the midline of the body (e.g. Fossae inguinales medialis et lateralis) for the foot:
frontJJiis = located in a frontal plane, but also towards the front (e.g. plantaris - dorsalis =towards the sole of the foot- towards the back
Processus frontalis of the maxilla) of the foot (e.g. Arteriae plantares lateralis et medialis, Arteria
dorsalis pedis)

3. Use of Brackets
II: Latin terms in square brackets refer to alternative terms as given in
the Tanninologia Anatomica {1998), e.g. Ran INephros). To keep the
legends short. only those alternative terms have been added that
differ in the root of the word and are necessary to understand clinical
tanns, e.g. nephrology. They are primarily used in figures in which the
particular organ or structure plays a central role.
II: Round brackets are used in different ways:
- for terms also listed in round brackets in the Terminologia Anatomi-
es, e.g. (M. psoas minor)
- for terms not included in the official nomenclature but which the
editors consider important and clinically relevant, e.g. !Crista
zygomaticoalveolaris)
- to indicate the origin of 8 given structure, e.g. R. spinalis (A.
vertebral is).

Colour Chart
Concha nasalis inferior Os oocipitala In the newborn the following cranial bones are
indicated by only one colour:

-
Mandibul8 Os palatinum

Maxilla Os parietale Os nasale, Os temporale, Mandibula

Os ethmoidale Os sphenoidale Maxilla, Os incisivum

- ..-
Osfrontale Os temporala Os occipitale, Os palatinum

Os lacrimala Os zygomaticum

Os nasale Vomer
Table of Content
General Anatomy
Anatomical Planes and Positions • • . . • • • • • . . . . • • • • • . . . . • • • • • 4
Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Development • • • . . . • • • • • • . . . . • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 18
Musculoskeletal System • . . . . • • • • • • . . • • • • • . . . . • • • • • . . . . • • • • • 20
Neurovascular Pathways . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 36
Imaging Methods . • • • • • . . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • . 47
Skin and its Appendages . . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • . 51

Trunk
Surface Anatomy . • • • • • • . . . . • • • • • • . . • • • • • • . . . • • • • • . . . . • • • • • . 58
Development • • • . . . • • • • • • . . . . • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 61
Skeleton . . • • • • . . . • • • • • • . . . . • • • • • • . . • • • • • • . . . . • • • • • . . . • • • • • . 63
Imaging Methods . • • • • • • . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 88
Muscles.................................................... 94
Neurovascular Pathways . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 118
Topography, Posterior Abdominal Wall • • • • . . . . • • • • • . . . • • • • • . 127
Female Breast • • . . . • • • • • • . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 138
Topography, Anterior Abdominal Wall • • • • • . . . . • • • • • . . . . • • • • . 142

Upper Limb
Surface Anatomy . • • • • • • . . . . • • • • • • . . • • • • • • . . . • • • • • . . . . • • • • • . 156
Development •••...••••••....•••••..••••••....•••••....••••• 158
Skeleton. . . • • • • • . . . • • • • • • . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 160
Imaging Methods . • • • • • . . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • . 182
Muscles . . . • • • • • . . . • • • • • • . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 188
Neurovascular Pathways . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 224
Topography................................................. 256
Cross-Sectional Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Lower Limb
Surface Anatomy . . • • • • • • . . . . • • • • • • . . • • • • • . . . . • • • • • . . . . • • • • • 294
Skeleton . . • • • • . . . • • • • • • . . . . • • • • • • . . • • • • • • . . . . • • • • • . . . • • • • • . 296
Imaging Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Muscles . . . • • • • . . . • • • • • • . . . . • • • • • • . . • • • • • • . . . . • • • • • . . . • • • • • . 350
Neurovascular Pathways . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 380
Topography • • • . . . • • • • • • . . . . • • • • • • . . • • • • • • . . . . • • • • • . . . • • • • • . 404
Cross-Sectional lmagea • • . . . • • • • • • . . • • • • • • . . . . • • • • • . . . . • • • • • 428
General Anatomy
Anatomical Planes and Positions . . . 4

Surface Anatomy . .. .. .. .. .. .. .. .. .. 14

Development . . . . . . . . . . . . . . . . . . . . . . 18

Musculoskeletal System............ 20

Neurovascular Pathways . . . . . . . . . . . 36

Imaging Methods . . . . . . . . . . . . . . . . . . 47

Skin and its Appendages . . . . . . . . . . . 51

 r-----
~-;~~~~------- l~m ------~--~~~---
Appendix vermlfolmls -
Overview
The Greek word 'a;v«t!f.~VeLv• (anatemneln) means 'cut open'. It
describes the oldest method in anatomy, which was already prac-
tised in ancient times. Anatomy is the study of the structure of the
healthy body. Without the knowledge of anatomy, no functions can
be derived and without the knowledge of structure and function,
no pathological changes can be understood. In order to learn a
new language, there needs to be a foundation of vocabulary and
grammatical knowledge. The same is true of anatomy. In order to
be able to learn the subject, you need principles and functional
knowledge which will be of central Importance throughout your
Main Topics
After studying this chapter, you should be able to:
• orientate yourself on the human body, divide the body into dif-
ferent sections and describe its blueprint know the main axes
and levels, describe movement directions and know directional
teJms, the position of the parts of the body and general terms
of anatomy;
• divide the body surface into regions and describe the projection
of inner organs onto the body surface;
• explain principles of embryonic development, starting wi1h
fertilisation;
• know principles of the musculoskeletal system, such as the
classification of bones, construction of a tubular bone, names
of bones of the skeleton, structure of a joint joint types,
terminology of joint motion and auxiliary structures of joints
(intervertebral joints, labra, bursae, ligaments);
• explain basic concepts of general muscle theory, such as the
structure of a skeletal muscle, muscle types, tendon attach-
ment sites, auxiliary muscles and tendons, and describe princi-
ples of muscle mechanics;
2
Colon
medical studies. Not only do levels, axes and orientation lines on
the body. descriptions and possibilities of movement play a role in
clinical practice, but also knowledge of the musculoskeletal sys-
tem, including biomechanical processes, the location of internal
organs and their projection onto the body surface, the circulatory
systems of the body and the structure of the nervous system. They
fo1m the buls for any diagnostic (especially imaging techniques
such as X-ray, ultrasound, scintigraphy, computed tomography, mag-
netic resonance imaging) and therapeutic measures.
• describe the various circulatory systems, such as systemic
circulation, including the heart and major arteries and veins,
pulmonary circulation, organisation of the prenatal cardiovascu-
lar system, portal vein circulation and lymphatic vessel system
(lymph circulation) with lymph nodes;
• understand the nervous system (structure, somatic and auton~
mous nervous system) and know the dermatomes on the body
surface;
• describe principles of diagnostic imaging techniques such as
oonventional X-ray, sonography (ultrasound), computed tom~
graphy, magnetic resonance imaging, scintigraphy;
• describe the structure of the skin and its appendages.
Clinical Relevance
In order not to lose reference to futura everyday clinics/life with so many anatomical details, the following describes a typical case that
shows why the content of this chapter is so important.
An Open Ductus Arteriosus (BOTALLI) (PDA)
Case Study
A premature infant, bom in the 34111 week of pregnancy plus two
days (34+2 NNW) develops shortly after birth W" day of life) incre-
ased shortness of breath and poor feeding. The girl is very pale and
her hands and feet are relatively cold.
Result of Examination
The on-duty pediatrician at the neonatal station notices on palpation of
the abdomen an enlargement of 1he li11'9r and spleen (hepatosplenome-
galy) and auscultation of the heart reveals a loud machine-like murmur
(systolic crescendo and diastolic decrescendo murmul) in the 2nd in-
tercostal space on 1he left. which is accompanied by a tactile whirring
across the chest. Palpation of the pulse shows a fast pulse with high
blood pressure {Pulsus celer et altus). He immediately takes further
diagnostic steps.
Diagnostic Procedure
The electrocardiogram (ECG) shows left-ventricular stress. The chest
X-ray indicates an enlarged pulmonary vessel and a left-sided wide-
ning of 1he heart. The completed echocardiography (colour Doppler
examination, _. Fig. a) shows blood flow between the aorta and pul-
monary vessels, enabling the direct imaging of a shunt.
A shunt is s short circulation connection betwHn
Q normally S41psrate vessels or csvities.
The diagnosis of a patent Ductus arteriosus (BOTALLI) {PDA) 1- Fig.
b} is thus confirmed.
Diagnosis
An open Ductus arteriosus (BOTALLI).
Treatment
A drug treatment with the prostaglandin synthesis inhibitor ibuprofen
is initiated to close the haemodynamically effective open PDA.
Further Developments
Although the symptoms improve slightly under treatment. a pro-
nounced systolic heart murmur can still be heard and the PDA is
detectable in the colour Doppler examination. For this reason, an
interventions! closure by means of cardiac catheterisation is intro-
duced the following day by inserting an umbrella system. Shortly
after the procedure, the pulse of the girl is already within the normal
range, breathing is calm and no heart murmur is detectable. The girl
remains for some time on the neonatal ward and progresses well,
and can therefore be discharged.
Dissection Lab
Consider the pressure and flow conditions in the large and small
circulation with the heart as the central organ and reflect on how the
blood flows in the baby girl with PDA t- Fig. 1.39}.
Q Consider which other shunts are obliterated after
birth.
Back in the Clinic
After birth, the increasing oxygen concentration arising from the
lungs unfolding and the first breaths normally cause the ductus aF-
teriosus to contract and close. In premature babies many organs
are not yet fully developed. The cause of the persistence of a PDA is
therefore attributed to the fact that the vessel muscles here contract
less well, as they are lass developed, and a relatively high pro~
glandin concentration leaves Ductus arteriosus open.
From pregnancy week 28 women should not take
Q prostaglandin synthesis inhibitors (e.g. ibu-
profen) for pain medication, so that the Ductus
arteriosus does not close too esrly.
After birth, 1he prostaglandin levels normally drop quicldy and the duo-
tus arteriosus closes up sponmneously. Therefore, therapeutic mea-
sures with prostaglandin synthesis inhibitors are often successful.
Right after birth, initial examination of the new-
Q born is carried out in order to determine whether
all vital functions, such as the respiratory and
csrdiovsscular systems, are in order.
In the case of a haemodynamically effective PDA, a left-to-right
shunt occurs due to high pressure in the systemic circulation and
low pressure in the pulmonary circulation with volume overload on
the left side of the heart so that blood from the aorta flows into
the lungs, which causes increased pulmonary blood flow and i~
creased pressure in the pulmonary circulation. Thus a certain part
of the blood from the lungs reaching the left ventricle and from there
the aorta, circulates through the Patent ductus arteriosus again
with the lungs (machine-like murmur). There is a lack of circulating
blood in the systemic circulation (cold hands and feat); as a reaction,
the heart rate increases (Pulsus celer et altus) in order to transport
enough oxygen to the periphery of the body. If the PDA is not trea-
ted, the continual increased pressure leads to damage of the ves-
sels in the lungs. These thus react to a remodelling (modification
of the vessel structure), whereby the increased pressure is further
'fixed' and may increase so much that it exceeds the pressure of
the systemic circulation with the result of a shunt reverse {right-to-
left shunt), whereby blood reaches the systemic circulation directly
from the pulmonary circulation, without being pre-saturated with
oxygen. The result is cyanosis (bluish discolouration of the skin, lips
and mucous membranes) and a rapid decrease in capacity. At some
point the heart undergoes decompensation.
• b
Flg.a A colour Doppler examlnat1on. [0548)
Flg.b Patent Ductus artedosus (BOTAW). IL126)
3
 Anatomical Planes and Positions

0 Parts of the Body

>
E
....,
0
co
c
<(
....coQ)
c
Q)
(.!)

llembn.tm
suplrfus TruiiCWI

llembn.tm
lnflrfus
Crus --------------~

a b

Fig. 1.1a and b Surface anatomy of the man (a) and the woman (b);
ventral view. [J8031
Usually anatomical descriptions relate to an upright position; the
face is facing the front. the arms are suspended sideways, palms are
turned to the body or to the front, the legs are parallel and the feet
face forward.
The body is divided up into the head (caput), neck: (collum), trunk (trun-
cus) including the chest (thorax), tummy (abdomen). hips (pelvis) and
back: (dorsum) and the upper limbs (membrum superius) and lower
limbs (membrum inferius). The limbs are sub-divided into the upper
arm (brachium), forearm (antebrachium) and hand (manus), and the
thigh {femur), lower leg (crus) and foot (pes).
Secondary HXU.al chan~cterlsdce: the external appearance of a
human being is identified in the different stages of life by physical
attributes. These occur in men and women as gender dimorphism
(gender differences) (especially after sexual maturity). The develop-
ment of sexual organs is genetically determined. Responsible for their
development are the primary sex organs (ovaries and testes), which
are referred to as the primary sexual characteristics. Responsible for
the outer appearance are mainly the secondary sexual characteristics
(table), which develop in puberty.

Outer Appurance

Man Woman
Beard growth Mammary gland (Mamma)

Hair growth on the front thorax and abdomen (great individual Distribution of subcutaneous fat (more consistent, smoother outlines)
variation) and also on the back and extremities

Pubic hair growth up to the navel Pubic hair growth up to the height of the mons pubis

Reduced hairline (receding hairline, pattern baldness) Even hairline

Larger body size Smaller body size and muscle mass

Narrower pelvis Horizontally oval pelvis

4
 Parts of the Body 0
- - - - - - C.put

----lft--i-- - - Truncus,
Dorsum

• b

Fig. 1.28 and b Surface anatomy of the man Ia) and tlta woman lb);
dorsal view. [JB03[

r- Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . .
~ part of the anamnatlis (from old Greek a.vaiMJau;, anamnesis = cal history is normally collected prior to medical examination, but in
reminder), the medical history of a patient in relation to his or her cur the case of an emergency requiring immediate treatment.. it must be
rent complaints is taken. A detailed medical history includes biological. postponed until later.The aim of the medical history is to restrict to the
psychological and social aspects. The information gathered often ena- greatest possible extent all possible diagnoses preferably by means of
bles conclusions regarding risk factors and causal relationships. The the main symptoms and exclusion criteria. In order to be able to make
anamnesis does not have a direct link to treatment although talking a definitive diagnosis, further examinations are usually necessary fol-
about the issues may have a beneficial and clarifying effect. The medi- lowing the medical history.

5
 Anatomical Planes and Positions
0 Body Proportions

> ... 0 a 3 4

E
....,
0
co
c
1211

110
-.....,
I

~
I I~
0-6,.... ~ -·~--
....-
''~ .LUL.ti1 ~
llolglrlolil1e-. ... ...

'
-'-1:
z
10111

110

Top edge of .Jl!'

<( the thorax
100 1111

....coQ)
c
Q)
(.!)
Botlomedge
of the thorax
''•
•1. of the total
body size
10

70
:1.
• •. i
A
;:...-· _),V~
~1
..
t::::rr 1 l ..
••
.q·; .. ""....
A"' ...

17
Pubic aymphyais ~r" /~
··r't-- 1 ..·· t~
11

• 13••
..'~ ...-:- ..
14
.-f .· ] ....... ·····
I
~~~ 2 t:r:Jl:±'.- I J .· ..
!-'1 '" t1 "11
liz I

+!~·) .. 1{P.s-~ +•· -- -~~ •

10

f ------------- Knee joint gap

,.'
~f. t :r H
+
'" r ~~l
·fH· II til· H-
't I r1 H
0 4

1
/z

• ...
-
2

.,. ... ~"

·~
Ho,.oi!M- ::
120 0-6- Ho,.oi!M- an - 1210
/.
~g ~.
l.,glh
L: ll
110
-
•• 1'-' •• j • 1111
100 ..

~.
.
~;1 ;r. -;7
.-
f.-

Ill

10
.,..,. .I
t ·- i
-~
II
t t
a
7

WOIJjl1l
~

- ••
.HJH • •
Newborn Infant School child AdoiBSCBnt Adun 0
·ft.·
a
I 1
fl
4 5
Ago In,_
b c

Fig. 1.3a to c is divided into stages of development. In the different stages of

a Nonnal body proportions; frontal view. [L1271
If an adult is divided horizontally into two equal halves, the middle is
approximately at the level of the upper edge of the pubic bone. The
bottom half can be divided into another two equal halves at the level of
the knee. The top half can be divided into five equal sections, of which
the head and neck. down to the top of the shoulders form %. the thorax
another% and the abdominal area 1;5. The spine occupies % of the total
body size.
b Body proportions in differant stag.. of development. IL238l
Body size refers to the measurement from the crown of the head to
the soles of the feet (body length). In pediatrics. the postnatal period
development the body changes length continuously. (1) neonatal
period (the first two weeks of life), (Z) infancy (up to the end of the
first year of life), (3) early childhood (up to the end of the fifth year of
life), (41 school age (up to the onset of puberty), (51 puberty
(maturation into adult, length varies), (8) adolescence (completion of
the development and growth in length of the skeletal system up to (7)
adults. Sometimes the term 'old age' is later used in medicine for
elderly adults. At this point in time, the body length has decreased
through age appropriate degenerative processes.
c Percentile curves. [L1571

I Clinical Remarks
In order to assess correct body growth (standard) or divergent body renee are analysed separately in relation to age and using percentile
growth (variability) in children. body height. weight and head circumfe- tables (..,. Fig. t3c) for girls (left. ()-5 years) and boys (right. Q-5 years).

6
 Axes and Planes 0
3 '-... / 1
--t L
'---.::i
4, l 2

' i 2

1 Sagill:al plana
2LonglbJdlnal axis
3Sagill:al axis
4 Median sagittal plana
5 Transvanal plana
8 TraniMIIll& axis
7 Frontal plane
• b c

MajarAxea
Sagittal axis runs perpendicular to the transversal
and longitudinal axes
S8gill:al - - - - t -- runs perpendicular to the longitudinal
plane and sagittal axes
smum -----~~-=---~­
sagill:alis runs perpendicular to the sagittal and
transversal axes
smum----+~-~
coronalis

Median (sagittal) plane symmetry plane, divides the body into

two equal halves
Sagittal plane runs parallel to the median (sagittal)
plane
Transversal plane all cross-sectional planes of the body
Frontal plane parallel to the forehead

Fig. 1.48 to d Plane~~ and axes •• well •• n1dlologlcal tannL
IL127l
• The sagittal plane (Planum sagittala), between the sagittal and
longitudinal axes.
b The trBnsversal plane= horizontal plane (Planum transversale),
between the transversal and sagittal axes.
c The frontal plane= coronal plane (Planum frontale), between the
longitudinal and transversal axes.
d The coronal suture and sagittal suture (Sutura coronalis and Sutura
sagittalis) are used especially in radiology as terms of motion: the
sagittal layer corresponds to the sagittal plane, and the coronal layer
corresponds to the frontal plane.

Directions of Movement
Extension Extension of the trunk or extremities

Flexion Banding of the trunk: or extremities

Radiological Sactlonal Plan•
Abduction Pulling the extremities away from the body
Radiological tenn Anatomical tenn
Adduction Pulling the extremities towards the body Sagittal layer Sagittal plane
Elevation Lifting the arm above the horizontal plane
Coronal layer Frontal plane
Rotation Internal and external rotation of the extremities
Axial layer Transversal plane
about the longitudinal axis
Radiology terminology in imaging prooedures (computed tomography and magnetic
Circumduction Gyration, composite movement made up of, e.g. resonance imaging) defines the three main anatomical planes as layers with their
adduction, abduction, flexion and extension own nomenclature.

7
 Anatomical Planes and Positions

0 Terms of Direction and Position

> Alllltomi011l Terms of Movement

E
....,
0 Region Term Movement
co Limbs Extension Elongation
c
<( Flexion Bending

....coQ) Abduction
Adduction
Pulling away from the body
Pulling towards the body
c Elevation Elevation of the arm/shoulder above the horizontal plana
Q)
(.!) Depression Lowering the arm/shoulder from above the horizontal plane
Internal rotation Inward rotation
Outer rotation Outward rotation
Pronation Rotation movement of hand/foot with hand turned inwards or sole of foot turned outwards

Supination Rotation movement of hand/foot with palm of hand turned outwards or sole of foot turned
inwards
Radial abduction Swivelling hand/fingers towards the radius

Ulnar abduction Swivelling hand/fingers towards the ulna

Palmar flexionNolar Bending palm of hand towards back of arm
flexion

Plantar flexion Bending sole of the foot towards back of leg

Dorsiflexion Bending bacli: of hand/foot towards front of arm/leg
Opposition Placing the thumb opposite the little finger

Reposition Returning the thumb to the index finger

Inversion Lifting the inner side of the foot using the talocalcaneonavicular joint
Eversion Lifting the outside of the foot using the talocalcaneonavicular joint

Spine Rotation Rotation in the longitudinal axis

Lateral flexion Lateral tilt
Inclination (flexion) Forward tilt
Reclination (extension) Baclcward tilt
Palvla Flexion (anterior/Ventral Pelvic tilt towards the front
rotation)
Extension (dorsal Pelvic stretching towards the back
rotation)
Temperoman- Abduction Opening the jaw
dibular joint
Adduction Closing the jaw
Protrusi on/protrection Pushing forward the lower jaw

Retrusion/retraction Pulling beck the lower jaw

Occlusion lntertocli:ing the upper and lower jaw teeth

Mediotrusion Lalrver jaw on one side facing ventromedial

L.aterotrusion Lower jaw on one side facing dorsolateral

8
 Terms of Direction and Position 0
t--....0,...- Unea medlana
postellor
n _ _,___ Msln line or the
.....,.."---- Unea lower limb
paravertebral ia
Proximal
+----+-.,..--- Unea scapularls
Proximal
Distal

Linea
stamalls Fibularllataral
DlstBI Mediel -f~i'-~-. c+:H-t-- TlblaVmedlal
Caudal -~r--+--! 1

Proximal

Distal

H----lr+- Main line of the

upper extremity

a b c

Fig. 1.5a to d Orientation lines and tenns of motion and

Main line or the hand
location. [L1271
\~=n line of the a Ventral view
---Radial b Dorsal view
Mediai .Y ~
. L.ataral c L...owar limb ventral, upper limb with supinated hand
d Uln d Hand palmar and view towards the back of the foot

T~m~~s of Motion and Location for Parts of the Body

cranial or superior towards the head apical directed or belonging to the top

caudal or inferior towards the tail bone basal towards the base

anterior or ventral towards the front dexter right

posterior or dorsal towards the back sinister left

lateral tCFvVards the side, sway from the proximal towards the torso
midline
medial in the middle, towards the midline distal towards the end of the limbs

median or medianus within the median plane ulnar towards the ulna

intermedius lying in between radial towards the radius

central towards the interior of the body tibial towards the tibia

peripheral towards the surface of the body fibular towards the fibula

profundus low-lying volar or palmar towards the palm

superficial lying on the surface plantar towards the sole

external or externus external dorsal (extremities) towards the back

(dorsum) of the hand or the foot
internal or intemus internal frontal towards the front

rostral towards the mouth or nose tip (only

for terms relating to the head)

9
 Anatomical Planes and Positions
0 Terms of Movement

>
E
....,
0
co
c
<(
....coQ)
c
Q)
(.!)
b
Oppoeition/nlpo8ition Abductionfadduc::tion Oppoeition
of the thumb of !he thumb (lhumb llt!Je 11nger sample)

Dorsal ext-lonfpalmar Adduction or the 'lingers Abduction of the flngen

flexion of the hand

-··

Circumduction Abductlonfedductlon l..8teral flexion

in the shoulder joint of the ann and leg of the trunk

F'~g. 1.68 to i Terms of movement. IL1261

10
 Terms of Movement 0

Flaonlaxtenslon Internal rotation In the External rotation In the

in tha knaa joint llhouldar joint shoulder joint

0 p
Arltaval"'ionlratrovarsion Flaxionlaxtansion in lha Invarsion of the foot Eversion of lha foot
ofthaarm elbow joint

Pronation
oftha hand

Fig.1.8j tor Tenns of movement. [L1261

11
 Anatomical Planes and Positions

0 Regions of the Body

>
E
....,
0
co
c
<(
....coQ)
c
Q)
(.!)

Raglo pactoralls

Reglo lnframammarla

Reglo cubital!& anterior,

FOIJ!Ja cubibilia

Ragio antebrachii anterior

Ragiopubic::a
[Hypclgasbium]

Reglo lrOQBnllalla

Fig. 1.7 Regions of the body; ventral view. [J803[

The body surface is divided into regions to allow description and facili-
tate orientation.
Regie: region; trigonum: triangle.

12
 Regions of the Body 0

Rsglo glutealla

Regio glilllue posblrior, - ---!-

FOIISS poplitaa

Splnalllaca
MICHAELIS rhomboid --+"""""'--+"*'i!JXJ posterlor
(Venua diamond; auparlor
Reglo cruris poertor
red and~
tr~arvol

Pienta

Fig. 1.8 Regions of the body; dorsal view. [J8031 fig_ 1.9 Rhombus of MICHAELIS (Venus diamond) and sacral tri-
The body surface is divided into regions to allow description and facili- angle; dorsal view. [L126]
tate orientation. Presentation of palpable and visible corners of the Rhombus of MICHA-
Regia: region; trigonum: triangle. ELIS (female) and sacral triangle {male).

13
 Surface Anatomy

0 Relaxed Skin Tension Lines

>
E
....,
0
co
c
<(
....coQ)
c
Q)
(.!)

Fig. 1.10a and b Relaxed akin t.naion lin•. opment is dependent on age, nutritional status, general condition and
a Ventral view, b dorsal view. [JB03] anatomical peculiarities.
Tension lines (syn. LANGER's lines) are caused by the alignment of
collagen and elastic fibres in the reticular layer of the skin. Their devel-

I Clinical Remarks
Anv injury to the skin leaves traces to varying degrees, e.g. a scar on
the knee after a crash, or on the abdomen after removal of the appen-
dix (appendectomy]. A scar is the physiological end state of tissue re-
pair. It consists of coarse collagenous connective tissue and differs
from the surrounding skin by the lack. of hair, sebaceous and/or sweat
glands. If scars appear at an exposed location or become hyperplastic
(keloid formation), they can be aesthetically intrusive. In order to make
a scar in planned surgical procedures on the body as discrete as pas-
sible, the incision is made along tension lines of the skin. On the
edges of wounds that run perpendicular or at an angle to the tension
lines, there is significantly higher tension than on the edges of wounds
that run parallel to the lines. Wherever possible, therefore, surgical in-
cisions are made in the direction of the tension lines. This reduces the
risk of the wound margins spreading (dehiscence) as well as the devel-
opment of extensive scars.

14

Fig. 1.11a and b Segmentallnlltii'VIItlon of 111e skin ldennlltome•l.
a Ventral view, b dorsal view. [L126]
A dennatome is an area of skin innervated autonomously by the sen-
sory fibres of a spinal cord nerve [spinal nerves..... Fig. 1.45). Each spi-
nal nerve can thus be assigned to an area of skin. However, the inner-
vation areas of adjacent spinal nerves overlap and. in addition. many
cutaneous nerves are composed of the sensory fibres of several spinal
nerves joined together (Rami ventrales of spinal nerves develop bran-
ches in the neck and lumbar sacral area [plexus) ..... Fig. 1.46), so that the
dermatomes differ from the innervation fields of the cutaneous nerves.
Wrth the exception of the midline. where the overlap is very low. the
autonomous arH of each individual spinal nerve (skin area exclusively
innervated by a particular sensory nerve) is much smaller than the total
skin area innervated by it. For reasons of clarity, the derrnatomes are
r- Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
Damage to a spinal nerve typically leads to loss of sensitivity in its
autonomous area. Heepes zo..., is a viral disease that is associated
with an extremely painful sl<:in rash with blisters. The virus affects a
spinal nerve. The virus triggers inflammation which spreads from the
nerve to the associated dermatome and triggers the skin symptoms
[colloquially: shingles). The disease is caused by the verieella zoster
Dermatomes 0
C8
C8
represented alternately for the right (green) side of the body and the left
(blue) side of the body. Thus, e.g. T7 is visible on the left side in blue, TB
on the right side in green and T9 again on the left side in green, etc.
Regions where no colour is assigned (e.g. the area between C4. T2 and
T3 around the midline), are areas in which an extraordinarily high varia-
bility and a very strong interindividual overlap occurs. so that no clear
assignment is possible. Presentation of the darmatomes is based on an
evidence-based dermatome card according to LEE and coworkers
(2008). In order to keep the figure clear and understandable, the derma-
tomes 53, 54 and 55 are not shown (they cover the area of the perine-
um including the anus and the external genitalia). The skin of the face is
not innervated by spinal nerves but by the cranial nerva (N. trigeminus
IVIJ. Similar to the spinal nerves, its three branches also have autono-
mous sensory skin innervation areas (yellow).
virus, belonging to the herpes virus family, which is transmitted in
99% of casas in childhood and triggers chickenpox after infection, if
the child has not previously bean vaccinated against it. The virus per-
sists in the body (spinal ganglion) and can be reactivated in cases of
immunodeficiency.
15
 Surface Anatomy
0 Internal Organs, Surface Projection

>
E
....,
0
co
c
<(
....coQ)
c - -----"- - - - - - Ol~r~diAa lhyt'oldea
Q) - - - ' i r- - -- ---:,------ Trachea
(.!)
Qeeoph1QJ8

-;.-~----;----- Olaphragma - - - --.r-----oo

-:::!:1111'(--7,.,~--- Hepar -------;-:.--;:-:-,...::~~;\,1.:
...-=-:t :-- - - - - Galltlir
:,......__- - - - Splan [Lian)
+-----=----- Pancreas -----~u

~~~C~~~E~====-ouodenum
1.. Jajuoom - - - - -L....I
---- - -r-- Ran
Colan - - - - -+-
VI..'~U"-7-=---=:;;---""""[::~::t-----7----- Ileum - - -- - : - - - - - ---:--'-;--;---'-';'"- -;;-;:-:;;

\----1h~~~~':'I---T-- AppendP:wrmifonnill --;---''-;----..-~~~~·

II b

Fig. 1.12a and b Prvjection of the irrbtmal organs onto the body deal, trachea, lungs {Pulmo), heart {Cor), diaphragm, liver {Hepar), sto-
surface.(L275) mach (Gaster), spleen (Splen (Lien)), pancreas, duodenum, jejunum,
Projection of the internal organs onto the ventral trunk wall (al and onto kidney (Ren). colon, ileum, appendix (Appendix vermiform is) and rectum.
the dorsal trunk wall (b): oesophagus, thyroid gland (Glandula thyroi-

I Clinical Remarks
Even without technical instruments, it is possible to gain an insight
on individual organs and their projection onto the body surface
through practice. The term au..:ultatlon (from Latin auscultare =lis-
ten) refers to the monitoring of the body, typically with a stetho-
scope. Auscultation is part of the physical examination of a patient.
Percussion (from Latin percutere = beat) refers to tapping the body
surface for diagnostic purposes. Underlying tissue is hereby set in
vibration. The resulting acoustic sounds provide information about
the state of the tissue. Thus, the size and position of an organ {e. g.
liver) or the air content of the tissue (e. g. lung) can be assessed.

16
 Internal Organs, Surface Projection 0

~----- Hepar
G~ ----------~~~~~

Vesica balrts

~~~~~~--------=~~~
.; COlen _-----------t~s=~~
__ _ _......:........,f---J..._-:....J..

~~~~~~------------- Ren -----------~4-~~~~~l

Fig. 1.13a and b Prvjection of intamal organs onto the body mal, liver (Hepar), stomach (Gaster), gallbladder (Vesica biliaris), spleen
surface.IL275) (Splen (Lien)), large intestine (Colon), kidney (Ren), small intestine (ln-
Projection of the internal organs onto the right trunk walllal and onto testinum tenua), appendix (Appendix vermiformis) and rectum (Rec-
the left trunk walllbl: lungs (Pulmo), heart (Cor), diaphragm (Diaphrag- tum).

, Clinical Remarks-------------------------____,
Through knowledge of the pro]ecdon of the internal organs onto the medical history. For example, appendicitis (inflammation of the ap-
body surface, disease symptoms can be linked to specific organs pendix [Appendix vermiform is)) is usually associated with discomfort
during an initial physical examination and without reference to the in the lower right abdomen.

17
 Development

0 Development

>
E
....,
0 f
• d
co
c c
<( ~0
'0
....co
Q)
/ ~ b _,

c • - - Q \ .
Q)
(.!)
0 - -- - - - - - - - - - - - • 0

Fig. 1.148 to i Rrst week of embryonic development: fertilisation
and Implantation. [E838]
Normally within 24 hours after ovulation, a) fertilisation (b) occurs in
the ampulla of the oviduct. Fusion of the nuclei of the ovum and sperm
creates a zygote (c). Subsequent cell division (2-, 4-, 8- and 16-call
stages; d-h) generates a cell aggregate (morula) which is transported
into the uterine cavity. Approximately on the Sill day after fertilisation. a
fluid-filled cyst develops in the morula (blastocyst, 1), which on the SilL
!fh day implants in the prepared lining of the uterus.

•
JJ:fl!.~~~--- Epiblast} Embryoblasl
'---+.+--- Hypoblast

~--- Cytotrophatllasl
b d

- - Uter1ne lumen

c •

Fig. 1.15a to e Rrst and second week of embryonic development:
bllamlnar germ (embryonic) diiC. IE8381
Upon differentiation of the morula (a) into the blastocyst, the latter ge-
nerates an inner cell mass (embryoblast) and a larger fluid filled (blasto-
cyst cavity) outer cell layer (trophoblast)(b). Interactions between the
trophoblast and matemal tissues form the uteroplacental circulation
(c-e). lhe embryoblast develops into the bilaminar embryonic dlec
with ectoderm (columnar cells at the dorsal surface of the embryoblast)
and endoderm (cuboidal cells at the ventral surface). The ectoderm
forms a cavity dorsally. which becomes the amniotic cavity. lhe
blastocyst cavity in front becomes the primary yolk sac. which is lined
by the endoderm. On the 12111 day the actual yolk sac forms out of the
ectoderm; the original blastocyst cavity is lined by extnrembryonic me-
soderm.

18
 Development 0
Prlmi!Mt node
Primitiw 8lr9ak
Chorionic villus

Growing amniotic cavity

(axpanllion diraclion indicatad
by arrow heads)

Sticky stem

a Entoderm
Yolk sec:

b Chor1onle cavity

Cholda dorsalis
Umbllk:al cord
Cloacal membrana (with amniotic sac)

Umbilical cord

Entoderm
b Ectoderm Meaodenn
RemnantB of the
yolk sac

Chorion la.eve
Fig. 1.16& and b Third week of embryonic development gasbula-
tlon. [E8381
Development of the trilaminar germ disc begins with the appearance of
the primitive streak at the dorsal surface of the ectoderm. The primitive
streak is demarcated by the primitive node Ia). Cells migrate out of the
primitive streak and form the intraembryonic mesodenn between the
top of the yolk sac and the ectoderm of the amniotic cavity (gastrula-
tion). Some of the cells protrude cranially as a chordal pruJactlon to-
wards the cranial part of the embryo. Here, in the ectoderm, the
prHhordal plrrbt (adhesion surface between ectoderm and endoderm
-there is no mesoderm located between the two layers) evolves. The Fig. 1.17a to d Further d8¥81opmant. [E347-<l91
chordal projection develops a lumen and becomes a Chorda dorsall• a condition as presented in ... Fig. 1.1Sa. 3r11 week: the amnion covers
(primitive stabilising structure of the embryo), which recedes later in the dorsal surface of the embryo; the chorionic cavity is still very large
development (b). Only the Nuclei pulposi of the intervertebral discs re- at this early stage.
main as relics of the Chorda dorsalis. Some mesoderm cells migrate bIn the 41h week the amnion envelops the entire embryo with the ex-
cranially past the prechordal plate and form the heart. The threa germ ception of the umbilical cord. c In the period that follows the amnion
layers (ectoderm. mesoderm. endoderm) are the building blocks for grows rapidly. The slower growth of the chorion cavity and yolk sac
the development of all organ•. For further information on which or- makes these smaller. d Finally the amnion displaces the chorionic cavi-
gans emerge from which germ layer, see textbooks on embryology. ty completely and forms the amniotic aac. The yolk sac has receded to
remnants.

19
 Musculoskeletal System

0 Skeleton

>
E
....,
0
co
c
<(
....coQ)
c
Q)
(.!)

"""+-:-------'1:-T'c:T-- Os coxaa
~~-,..;~---\lt--\+-Os&aerlftl

Ossa carpi~
Olea metacarpalia •
4
' '

Osaa clgtton.n [Phalangaa] l

Fig. 1.11 Skeleton, akeletal 8fSt8m; ventral view. IL1271
The bones of the skeleton are grouped according to their shape and
structure into:
• long bones (Ossa longa). e.g. hollow bones of the extremities. such
as the femur and humerus
• •hort bona• (Ossa brevia). e.g. carpal bone and tarsal bona
• flat bonae (Ossa plana), e.g. ribs, sternum, scapula, ileum and bones
of the sk:ull
• aerated bonae !Ossa pneumatical, e.g. frontal bone, ethmoid bone,
sphenoid bone, maxilla and temporal bone
• irregular bones (Ossa irregularia, cannnot be assigned to other
bones). e.g. vertebrae and mandible
• sesamoid bones {Ossa sesamoidea, bones embedded in tendons),
e.g. patella and pisiform bone
• accaaory bonae {Ossa accessoria, not normally found in all human
skeletons), e.g. sutural bone of the skull, cervical rib

20

.\:': . -:·
Epiphysis proximalia -..........._ ; _·./
,...;..• .•• ' _ / Metaphysis pn»dmalls
.:
Metaphysis prwdrnalls
< ',:...
Diaphylill-----1
Epiphysis diltal is
Fig. 1.198 Sbucblre of a long tubular bone, os longum; section
through the proximal part of the right thigh bone (femur) of an adult. In
the area of the diaphysis (bone shaft) the periosteum (bone membrane)
is raised and to the side; dorsal view.
a Macroscopically, two different types of bone tissue can be distin-
guished. merging together without sharp margins: Substantia compacta
or corticalis (compacta or compact bone is very thin in the epiphysis
lend piece of the bone] and solid in the diaphysis) and Substantia spon-
giosa, (spongiosa, spongy or cancellous bone is only well-<leveloped in
the epi- and metaphysis [bone portion between dia- and epiphysis)).
The compact bone in the diaphysis appears as a solid mass; the can-
cellous bone in the epi- and metaphysis forms a three-dimensional
system of fine, branching rod-like bones (trabaculaa), which are distin-
guished by the amount of stress into either a tension or compression
trabecula. The special cancellous structure is only clearly visible in the
Structure of the Bone 0
/ Linea eplphyslalls
"" . \( - Apaphy&is
3) ·. '
" •· • •\!>. •
Substantia spongiosa
- Periosteum
epi- and metaphysis. The space in between the trabeculae is filled with
blood-forming red marrow (young person) or yellow marrow (old per-
son). The orientation of the individual trabeculae is parallel to the lines
of tensile and compressive stress generated within the bone. (In the
femur, these forces are proximal and eccentric, adding additional ben-
ding stress to the bone.) In a long evolutionary process. bones have
developed the greatest possible mechanical robustness with the least
possible amount of material and weight.
The Foramen nutritium to which the Canalis nutritius (pulling diagonally
through the compact bone) is attached, is the entry point for the ves-
sels into and out of the bone marrow (blood supply to the diaphysis). In
tl'le area of the meta- and epiphysis there are also numerous different
sized holes in the thinner cortical bone, that in particular supply blood to
the epiphyses.
21
Another random document with
no related content on Scribd:
Sauf le je ne sais quoi qui fait que l’on se sauve ;
Et, croyant démasquer les procédés du fauve,
Pastiche les fureurs et les rébellions,
Singe qui ne veut pas que l’on croie aux lions !

Et quand Hercule voit le lion apocryphe

Se chercher gravement des poux avec sa griffe,
Un rire absurde et bas qui le prend malgré lui
Le secoue et le tient plié.

L’œil du nain luit.

Quel bonheur d’avoir fait le vainqueur de Némée
Rire de son lion devant sa bien-aimée !

Celle-ci n’attendait que ce rire fatal,

Une quenouille est prête.

Elle est toute en cristal.

Elle a l’air d’un glaçon que coiffe un peu de neige.
Le rire, pénétrant dans l’âme qu’on assiège,
La livre.

Hercule a pris la quenouille. Il se rend.

Mais tout d’un coup : « Et l’Hydre ?… »

Et, glaive transparent,

La quenouille dans l’air coupe des têtes. « L’Hydre ! »
La quenouille se brise en brisant la clepsydre
Où la reine marquait déjà combien de temps
Hercule filerait. « L’Hydre ! »… En débris tintants
La quenouille retombe : Hercule aux pieds d’Omphale
A redécapité l’Hydre polycéphale.
— « Douze ! »… murmure Omphale.

Alors, Hercule a peur.

Il a peur. Car il sent que, si l’être trompeur
Possède, ayant prévu que toute gloire s’use,
Une quenouille encor dans sa boîte de ruse,
Il n’a plus un exploit dans son sac de fierté.

Hélas ! de douze exploits lorsqu’on s’est contenté,

Il faut craindre qu’un jour les quenouilles soient treize !
Hercule le comprend, et qu’à l’heure mauvaise
Où la vie aux plus grands veut imposer des plis
On n’a jamais assez de travaux accomplis ;
Il le comprend, que, lorsque vient cette heure triste,
Ce n’est jamais qu’avec son œuvre qu’on résiste ;
Que, puisqu’il faut combattre à ce mur adossé,
Douze exploits, c’est trop peu pour construire un passé !
Le nombre de grandeurs qu’il faut rêver, c’est toutes !
Enfant, s’il n’eût voulu boire que douze gouttes,
Eût-il éclaboussé le ciel d’étoiles ? Non !
Il faut mordre la Gloire au sein, comme Junon !
Ah ! que n’a-t-il tué le Vautour du Caucase !
Lorsqu’on s’endort sur ses lauriers, on les écrase.
Il aurait dû tuer Cacus ! Il aurait dû…

Qu’elle ait une quenouille encore, il est perdu !

Triste, affaibli par un long bonheur sans histoire,

Il sent que l’héroïsme est nourri de victoire,
Et que, si grand qu’on fût, et quoi qu’on ait osé,
On n’est plus un héros quand on s’est reposé !

Et soudain, comme un bœuf qui meurt, il s’agenouille :

Car dans les yeux d’Omphale il a vu la quenouille.

— Soit. Elle l’a. Mieux vaut finir. Puisqu’elle l’a,

Qu’elle la donne. Il la demande : « Donne-la. »
Il pourrait essayer encor de la détruire ;
Mais il sent, dans son âme, introduits par le rire,
Grouiller et pulluler les « A quoi bon ? » du nain.
Des quenouilles, grands dieux ! le désir féminin
Étant plus patient qu’une source filtrante.
S’il faut en avoir trente, Omphale en aura trente.
Et toutes, désormais, pour lui, sont en acier.

La quenouille est en verre.

Il la prend. Il s’assied.
Dans le creux de sa main il la sent mal reçue
Par les callosités qu’a faites la massue.
Mais il file ! Il file à merveille ! On croirait qu’il
Veut égaler déjà Lucrèce et Tanaquil !
Comment la lourde main s’est-elle résignée
A ces légèretés glissantes d’araignée ?
Ah ! si vous pouviez voir les gouttes de sueur
Qui tombent, l’enduisant d’une étrange lueur,
Sur le terrible fil dont le fuseau s’engraisse,
Comme vous pleureriez, filandières de Grèce !
Et tandis qu’humble, adroit, il file, — de quel droit,
Lorsque l’on est plus fort, refuser d’être adroit ? —
Tout le peuple secret de l’impur gynécée,
Ceux par qui fut Omphale et coiffée et massée,
Et, goûtant sur leurs doigts encore le festin,
Les affreux cuisiniers, — tous, pour voir ce Destin
Sombrer, splendide nef, comme un obscur pamphile,
S’amassent entre les piliers. Hercule file.
Ah ! que rapidement cette nouvelle court !
Il y a tout de suite, au fond de cette cour,
Pour voir s’humilier ainsi le Mâle énorme,
Tout un rassemblement d’eunuques qui se forme.
On fait, pour voir sa honte, entrer des inconnus.
C’est un délire.

Et douze Amours viennent, tout nus,

Soulever la Massue à l’effroyable écorce ;
Et quand, joyeux de voir s’écrouler une force,
— Car ce sont les Amours et ce n’est pas l’Amour, —
Les douze porteurs blonds, dansant sous le poids lourd
Avec une gaîté que l’effort rend bossue,
Miment l’enterrement gamin de la Massue,
Le rire, autour d’Hercule, en cris toujours plus forts,
Monte. Il baisse la nuque. Il file.

Et c’est alors
Qu’Omphale, dont les yeux disent : « Nous triomphâmes ! »
Fait ce geste de trop que font toujours les femmes
Lorsqu’elles ont marché sur des peaux de lions.

Heureusement pour nous qui nous humilions,

Elles sauront toujours se perdre par ce geste.
Elle avance, et, d’un pied soudain vulgaire et leste,
Pour s’affirmer devant ses coiffeurs, se poser
Dans l’estime du nain, pour le plaisir d’oser
Voir jusqu’où peut aller ce que cet homme accepte,
Elle met sur sa nuque une sandale inepte.

Mais à peine un tel pied prend-il un tel appui

Qu’un long rugissement, suppléant à celui
Que ne sait plus avoir le fauve débonnaire,
Est, au fond du ciel bleu, poussé par le Tonnerre.

Jupiter de son fils a brusquement souci.

Tout frissonne, se tait, se courbe. Et c’est ainsi
Que, lorsqu’un peu trop loin les choses sont allées,
La montagne interrompt le rire des vallées.

Un grand nuage noir dans l’azur se formant

Descend sur le palais. Il vient rapidement.
Entre les quatre murs de la cour blanche il entre.
Les Amours sous le lit se cachent à plat ventre.
Le nuage descend. On se met à genoux.

Hercule file.

On crie : « Hercule, sauve-nous !

Tu peux, d’un bras levé, l’empêcher de descendre ! »
Hercule file, et n’a pas l’air de les entendre.
Le nuage, effaçant la corniche, effaçant
La métope, effaçant l’architrave, descend.
La Reine et le Bouffon rampent aux pieds d’Hercule.
Et la Reine dit : « Roi ! » — « Géant ! » dit l’Homoncule.
Il leur fait signe qu’il ne sait plus que filer.
Tout est noir. On étouffe. On commence à hurler.
Et, parfois, quand l’éclair bleuit le péristyle,
On voit Hercule, assis dans l’éclair bleu, qui file.

Mais, jetant sa quenouille, il se lève, au moment

Où, descendu plus bas, le noir floconnement
Des chapiteaux déjà cache les astragales.
Il marche vers le pin où chantaient les cigales,
L’empoigne par le tronc, plus calme, semble-t-il,
Qu’un berger qui d’une herbe expurge son courtil ;
Et, tandis qu’il le tord d’une main et l’arrache,
De l’autre, l’émondant ainsi que d’une hache,
Il fait de l’arbre un mât, plus calme, dirait-on,
Qu’un pâtre qui se fait d’une branche un bâton.

Puis, maniant comme un gymnaste cette perche

Et l’enfonçant au cœur du nuage qu’il cherche,
Il saisit, tire, allonge un des flocons qui pend,
Et, de ce filament terrible enveloppant
Son poignet qui devient le fuseau de l’orage,
Se met, au bout du pin, à filer le nuage.

En un câble de brume aussi tremblant qu’un fil

On voit à ce poignet s’enrouler le péril,
Et de l’enroulement du long câble qui tremble,
Un peloton se forme et s’évapore ensemble :
Ainsi, le fils d’Alcmène au péplos étoilé
File ce que jamais personne n’a filé,
Le nuage. Et quand le nuage n’est plus qu’une
Nue, il file la nue, obscure laine brune
Que l’éclair quelquefois rattache au pin craquant
Avec sa bandelette éblouissante. Et quand
La nue, au bout de l’arbre encor diminuée,
N’est plus qu’une nuée, il file la nuée.
Et le ciel, peu à peu, peu à peu, peu à peu,
Redevient gris, redevient blanc, redevient bleu ;
Tout rentre dans l’azur, dans le jour, dans la règle ;
On entend les trois cris favorables d’un aigle ;
Et satisfait d’avoir pu filer aujourd’hui
Une quenouille enfin qui fût digne de lui,
Hercule jette l’arbre où fume un brin de foudre
Dans un reste de brume en train de se dissoudre.
Des lèvres sur ses mains veulent balbutier ;
Mais lui, sans se laisser même remercier
Par ceux qui, lorsqu’il fut douloureux, furent drôles,
Pousse la Reine au loin par ses belles épaules
Avec une hauteur douce qui l’abolit ;
Et faisant les Amours sortir de sous le lit,
Rattrapant le Bouffon qui passe sous les tables,
L’Amphytrioniade aux mains inévitables
Lance dans le bassin — qui n’est pas très profond,
Il s’en est assuré d’un coup d’œil, — le Bouffon,
Et, les gratifiant chacun d’une fessée,
Lance les douze Amours au fond du gynécée
Où des bras éperdus les reçoivent au vol ;
Sur les baigneurs courant la serviette au col
Il lance les flocons d’onguents et de vinaigre ;
Lance la flûte blanche à la tête du nègre ;
Puis lance les gâteaux sur les mitrons blafards ;
Sur les coiffeurs tremblants lance les pots de fards ;
Et, quand il ne voit plus que des dos et des nuques,
Sur les femmes en fuite il lance les eunuques.

Il reprend sa stature, alors, d’un coup de rein ;

Rouvre d’un coup de pied la porte aux gonds d’airain ;
D’un long reniflement animal et superbe
Rentre en possession de la senteur de l’herbe ;
Respire, en le trouvant divinement léger,
L’air libre qu’assainit le souffle du danger
Et qui rend l’appétit des agapes frugales ;
Se ressouvient de tous les noms que les Cigales
Chantaient quand il croyait ne pas les écouter ;
Se dit que, lorsqu’on put s’amuser à planter,
Pour borner ses exploits, des colonnes d’Hercule,
Ces bornes ne sont là que pour qu’on les recule ;
Sent qu’il est reconnu là-bas par son Destin ;

Ici manquent deux vers.

On ne sait quelle mort qui rend le ciel tout rouge ;

Désire cette pourpre, accepte cette mort,
Jette sa grande peau sur son épaule, et sort.

Et pendant qu’il s’en va du côté des montagnes

Et que la Reine pleure en griffant ses compagnes,
Comme il ne se peut pas qu’un homme aussi divin
Ait filé de la laine et que ce soit en vain,
Comme il faut que toujours d’une âme vraiment haute
Serve chaque souffrance, — et même chaque faute, —
Le déplorable fil resté sur les carreaux,
Ce fil qui, malgré tout, est l’œuvre d’un Héros
Dont l’âme s’est tordue avec sa laine torse,
Et qui, filé dans le malheur, prit tant de force
Qu’il ne pourra jamais dans l’ombre être cassé,
Ce fil mystérieux, Vénus l’a ramassé ;
Et, l’enroulant autour de son doigt diaphane,
Elle emporte ce fil, et dit : « Pour Ariane. »

Cambo, septembre 1909.

 NOTES

Pour la Grèce, page 29. — Ce poème a été dit par l’auteur, au

Théâtre de la Renaissance, le 11 mars 1897, au moment de la
guerre entre la Turquie et la Grèce.

La Touche, page 75. — Ces strophes ont été écrites pour le

catalogue des œuvres de Gaston La Touche, en mai 1908.

A Sarah, page 85. — Sonnet dit par l’auteur, sur la scène du

Théâtre de la Renaissance, à la Manifestation des Poètes en
l’honneur de Mme Sarah Bernhart, le 9 décembre 1896.

La Fête au Manège, page 92. — Vers écrits pour la fête donnée

par la Société « L’Étrier », le 4 juin 1898.

Aux Élèves du Collège Stanislas, page 98. — Vers dits par

l’auteur, le 3 mars 1898, à la « Matinée extraordinaire de Cyrano de
Bergerac », donnée par le Théâtre de la Porte Saint-Martin, pour le
Collège Stanislas.
 TABLE

Pages.
I. Le Cantique de l’Aile 1
II. Premier Passage sur mon Jardin 18
III. Rome 19
IV. L’Alouette 20
V. Le Printemps de l’Aile 21
VI. Les Deux Chevaux 27
VII. Les Rois Mages 28
VIII. Pour la Grèce 29
IX. A Sa Majesté l’Impératrice de Russie 41
X. A Krüger 56
XI. Fabre-des-Insectes 67
XII. La Touche 75
XIII. A Sarah 85
XIV. Le Verger 86
XV. A Coquelin 90
XVI. Ce que je fais 91
XVII. La fête au manège 92
XVIII. Aux Élèves de Stanislas 98
XIX. La Tristesse de l’Éventail 104
XX. Les Mots 108
XXI. La Journée d’une Précieuse 139
XXII. Un Soir à Hernani 172
XXIII. Le Bois Sacré 201
XXIV. Les Douze Travaux 227
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