Anatomy August 2017

Course: Anatomy and Histology
Instructor: Elfa Shabashvili, Ph.D.

Tel: 754-210-8374
E-mail: eshabashvili@DeVryMedical.org
*Office hours in the Anatomy lab: TBA
*Office Hours in faculty offices: TBA or by appointment via e-mail
Required Reading:
Anatomy and Histology Lecture Notes
Essential Clinical Anatomy (fourth edition) by Keith L. Moore and Anne M. Agur. (M&A)
Color Textbook of Histology (third edition) by Leslie Gartner and James Hiatt. (G&H)
Recommended Reading:
McMinn’s Clinical Atlas of Human Anatomy with DVD by Peter H. Abrahams, Jonathan D.
Spratt, Johanes Boon.
Any big Anatomy book: e.g. by Tortora (available in MERP library), or Martini, or Saladin or
Grey is strongly recommended if you did not have Anatomy course before or took it on-line.
Supplemental Material:
NetAnatomy website: www.netanatomy.com available on campus free of charge.
Visual Histology and additional MERP videos available via Mediasite.
Anatomy and Physiology Revealed, 3. (available in the library)
All our exams and quizzes are cumulative. You can be quizzed on all material covered from the
beginning of the semester to the time of the quiz.
*Schedule and hours are tentative and subject to change during the semester depending on
space and faculty availability. Please check “MERP Weekly,” e-mails and written notices for
corrections.
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Anatomy and Histology Schedule April to July 2017
Reading : Chapter (Pages):
Essential Clinical Anatomy (fourth edition) by Keith L.
Lect. Moore and Anne M. Agur. (M&A);
Date Title
# Color Textbook of Histology (third edition) by Leslie
Gartner and James Hiatt. (G&H);
Lecture notes (LN)
Aug 8 1 Intro to Micro and Micro Anatomy; Cell G & H 1 & 2; LN; M & A Introduction
Aug 9 2 Epithelial and Connective Tissues G & H 5 and 6
Aug 14 Quiz 1
Aug 15 3 Neural Histology G&H 9
Aug 16 4 Intro to Gross Anatomy; Skull M & A Introduction (1-11); 7 (496-502)
Aug 16 Workshop
Aug 21 Quiz 2
Aug 22 5 Muscle Tissue G&H8
Aug 23 6 Head and Neck Muscles M & A Introduction (16-22); 7 (519-520, 550, 565); LN
Aug 23 Workshops
Aug 28 Quiz 3
Aug 29 7 Cranial Nerves M & A 9 (644-660); 7 (540-544) A 9(660-672); LN
Aug 30 8 Spinal Cord Pathways; Cortex. M & A Introduction (31-46); 4 (292-297), 7 (512-517); LN
Aug 30 Workshop
Sept 4 Labor Day Holiday
Sept 5 9 ANS ; CSF M&A Introduction (31-42); 4 (276-301); 7 (503-511, 512)
Sept 6 Part 1 review AoA
Sept 8 Mini 1
Sept 11 10 Mediastinum; Heart M&A 1 (48-84); 4(275-301, 314-315)
Sept 12 11 Histology of Blood Vessels G & H 11
Sept 13 Workshop
Sept 18 Quiz 4
Sept 19 12 Thorax M&A 1 (80-106)
Sept 20 13 Lungs M&A 1 (68-80, 111-114); G & H 15; G&H 7
Sept 20 Thorax Workshop
Sept 25 Quiz 5
Sept 27 14 Abdominal Cavity; Kidneys M&A 2 (117-124, 136-138, 174-185)
Sept 28 15 Histology of Kidney G & H 19
Oct 2 Quiz 6
Oct 4 16 Liver and Pancreas M&A 2( 161-174)
Oct 6 17 Histology of Glands G & H 18
Oct 10 Part 2 review AoA
Oct 13 Mini 2
Oct 16 18 GI Tract M&A 2( 140-159) G & H 17
Oct 17 19 Bone Histology G&H7
Oct 18 20 Upper Limb I (Bones and Nerves) M&A 6 (407-417, 433-440)
Oct 18 Workshop
Oct 23 Quiz 7
Oct 24 21 Upper Limb II (Arm Muscles) M&A 6 (422-428, 440-447)
Oct 30 22 Upper Limb III (Hand Muscles) M&A 6 (446-492)
Oct 3 23 Lower Limb I (Bones and Nerves) M&A 5 ( 318-333)
Nov 1 25 Pelvic organs M&A 5 (205-217)(233-245)
Oct 25 and Nov 1 Workshops
Nov 6 Quiz 8
Nov 8 Workshop
Nov 2 24 Lower Limb II ( Muscles) M&A 5 (336-352)(357-403)
Nov 9-10 Part 3 Review AoA
Nov 16 Final Exam
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LEARNING OBJECTIVES
Part I: Head
Lecture 1: Introduction to Macro and Microanatomy; Cell
Introduction to Macro- and Microanatomy
1. Define anatomy and selected sub disciplines: surface, gross, micro (histology), systemic, regional,
radiographic, pathological, embryology and physiology.
2. Understand the principles of noninvasive diagnostic techniques.
3. Recognize the subjects of histology, cytology and cell biology.
4. Recognize the levels of human body organization.
Cell
1. Understand the nature of the tissues and principles of cell theory.
2. Describe the structure of the typical prokaryotic and eukaryotic cell.
3. Understand the purpose and significance of histological stains.
4. Recognize difference between light microscopy (LM), electron microscopy (EM), transmission EM (TEM)
and scanning EM (SEM).
5. Describe the structure of the nucleus: nuclear envelope, pores, heterochromatin and euchromatin.
6. Describe the major organelles and intracellular structures: Golgi, mitochondria, ribosomes, SER, RER,
lysosomes, microtubuli, etc.
Lecture 2: Epithelial and Connective Tissue
1. Recognize the four main types of tissue: epithelial, connective, muscular and neural.
2. Know the distinct characteristics of epithelia: polarity (basal lamina, apical vs. basal); cellularity; lack of
vasculature and recognize types of epithelia.
3. Know the distinct characteristics of connective tissue: types of cells, types of matrix and types of fibers
4. Compare and recognize types of loose and dense connective tissue proper.
Lecture 3: Neural Histology
1. Explain the function of neural tissue.

2. Discuss the structural and functional components of neurons: soma, dendrites, axons and axon hillock.
3. Discuss the location and function of organelles in neurons: nucleus, nucleolus, Golgi complex, RER and
Nissl bodies.
4. List types of neuroglial cells: Astrocytes, Oligodendrocytes, Microglial cells, Ependymal cells and Schwann
cells, and define their location and function.
5. Understand functional types of neurons: sensory, motor and neurons of association. List types of neurons
and be able to identify each type: multipolar, unipolar and bipolar and define their functions and location.
6. Identify and describe the structure of a peripheral nerve: perineurium, epineurium and endoneurium;
myelinated vs. unmyelinated axons.
7. Be able to identify histological images of the grey matter vs. white matter.
8. Explain the functional and structural characteristics of a synapse: pre-synaptic membrane, pre-synaptic
knob, post-synaptic membrane and receptors.
9. Discuss and recognize the consequence of neuronal injury: axonal degeneration, segmental axonal
demyelination, myopathy and reinnervation.
Lecture 4: Introduction to Gross Anatomy; Skull

Introduction to Gross Anatomy
1. Describe the anatomical position, supine and prone position.
2. Use anatomical terms, body sections, body regions, relative positions and directions to describe location
of structures and abnormalities.
3. Identify the body cavities and their subdivisions: dorsal cavity, cranial cavity, ventral cavity, thoracic cavity,
mediastinum and abdomino-pelvic cavity.
4. Differentiate the serous membranes: visceral vs. parietal, and indicate their common function.
5. Name the nine regions and four quadrants of the abdomino-pelvic cavity.
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6. Use anatomical terms of movement and laterality to describe action of the muscles: flexion, extension,
abduction, adduction, medial and lateral rotation, circumduction, supination, pronation, eversion,
inversion, protrusion, retraction, elevation and depression.
Skull
1. Identify the bones of the skull: 8 cranial vs. 14 facial bones.
2. Identify the bone markings of the skull.
3. Explain structural and functional divisions of the nervous system: central vs. peripheral, somatic vs.
autonomic, sensory vs. motor.
4. Know the parts of the brain.
5. Identify parts of the spinal cord and types of neurons located in these parts.
Lecture 5: Muscle Tissue

1. Describe the difference between three types of muscle tissue: ability to regenerate, voluntary vs.
involuntary and satellite cells.
2. Identify smooth muscle, cardiac muscle and skeletal muscle.
3. Identify the parts of the skeletal muscle: muscular fibers, endomysium, perimysium, epimysium, tendon,
and belly of the muscle.
4. Describe and identify the features of myofibril: sarcomere, thick and thin filaments, A-band, I-band, M-
line, Z-line, sarcoplasmic reticulum, T-tubules, triad and motor end plate.
5. Differentiate between motor pool and motor unit.
6. Describe and identify neuromuscular junction.
7. Discuss clinical applications of muscle and neural anatomy: Guillain-Barre syndrome, multiple sclerosis,
myasthenia gravis, muscular dystrophy, myocardial infarction and necrosis.
Lecture 6: Head and Neck Muscles, Reflexes

1. Identify the parts of the skeletal muscle and action of the skeletal muscle.
2. Compare and contrast the origin and insertion of muscles.
3. Compare and contrast tendons vs. ligaments and aponeuroses.
4. Identify types of movements skeletal muscles perform.
5. Identify the muscles of facial expression and muscles of mastication, their origin, insertion, action and
innervations.
Reflexes
1. Describe the steps in a neural reflex.
2. Classify the types of reflexes and explain the functions of each.
Lecture 7: Cranial Nerves

1. List the twelve pairs of cranial nerves and their locations.
2. Explain functions of the twelve pairs of cranial nerves.
3. Identify location of each cranial nerve and discuss clinical applications of cranial nerves impairment.
Lecture 8: Spinal Cord Pathways: Cortex.

Spinal Cord
1. Be able to identify the components of the spinal cord: dorsal, ventral and lateral grey horns, anterior,
posterior and lateral white columns, grey commissure and central canal. Describe their functional
significance and differences.
2. Explain the functional significance of the dorsal root ganglia.
3. Identify and differentiate between the three somatic sensory pathways: Dorsal Column – Medial
Meniscus Pathway, Anterolateral Spinothalamic Tracts, Spinocerebellar tracts.
4. Identify somatic motor pathway and discuss the difference between sensory and motor pathways.
Rationalize the types of function losses from spinal cord injuries.
Cortex
1. Differentiate the major areas of cerebral cortex: somatosensory cortex, motor cortex and selected
Brodmann’s areas.
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Lecture 9: ANS; CSF
ANS
1. Compare the somatic and autonomic nervous systems relative to effectors, efferent pathways, and
neurotransmitter released.
2. Explain anatomical and functional significance of the sympathetic and parasympathetic ganglia; identify the
location of the pre- and postganglionic sympathetic and parasympathetic neurons.
3. Compare and contrast the general functions of the parasympathetic and sympathetic divisions of ANS.
CSF
1. Identify the meninges and the contents of the spaces around the spinal cord and around the brain.
2. Describe the formation of cerebrospinal fluid (CSF) and follow its circulatory pathway: choroid plexus,
ventricles, apertures, central canal, subarachnoid space, arachnoid villi and sinuses.
3. Discuss congenital abnormalities and clinical applications related to CSF.
Part II: Thorax and Abdomen
Lecture 10: Mediastinum; Heart
Mediastinum
1. Identify divisions of thoracic cavity: mediastinum, pulmonary cavities, lungs, pleura, heart, pericardium
and other organs.
2. Use superficial landmarks and imaginary lines of thorax to identify location of wounds and underlying
organs.
3. Identify borders of superior, anterior, posterior and middle mediastinum and organs that belong to each.
Heart
1. Describe the external and internal anatomy of the heart.

2. Describe the internal location of the heart on the surface of the thorax.
3. Know the layers of the pericardium and heart wall.
4. Name the heart chambers and heart valves and describe their location, function, and mechanism of operation.
5. Explain the coronary circulation: identify the major coronary arteries and veins
6. Compare the pulmonary, systemic, and coronary circulations.
7. Describe the conducting system of the heart.
8. Explain variations of the coronary arteries and common pathologies of the heart: cardiac tamponade,
pericardiocentesis, coronary artery disease, ischemia, heart attack/myocardial infarction.
Lecture 11: Histology of Blood Vessels
1. Recognize three layers of the blood vessel: tunica intima, tunica media and tunica adventitia.
2. Recognize blood vessels vs. other tubular structures, e.g. ducts.
3. Distinguish arteries vs. veins, large vs. small vessels: conducting, distributing arteries, arterioles and capillary
vessels.
4. Recognize and understand clinical significance of arterial sclerosis and thrombosis.
Lecture 12: Thorax
1. Describe Thoracic Skeleton: sternum, vertebra and ribs.

2. Identify anatomical features of the sternum.
3. Be able to identify and differentiate between cervical, thoracic, lumbar and sacral vertebrae.
4. Explain the articulation and movements between the occipital bone and C1, between C1 and C2.
5. Compare and contrast the joints of the vertebral column; rib articulations; components of the intervertebral
discs.
6. Identify anatomical features of ribs; differentiate between different types of ribs: true, false and floating.
7. Recognize intercostal muscles and functional significance of the thoracic cage movement.
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8. Discuss the congenital abnormalities of the vertebral column: spina bifida occulta, spina bifida cystica,
meningocele and myelomeningocele.
9. Discuss clinical applications of injuries and diseases involving of the thoracic cage skeleton.
Lecture 13: Lungs
1. Describe the anatomy of the lungs: layers of the pleura, lobes, fissures, lingula, and branching pattern from
trachea to alveoli.
2. Explain the movements of the thoracic wall and the diaphragm during respiration.
3. Describe the contents of the hilus of the lungs.
4. Compare and contrast right vs. left lung.
5. Describe pleural recesses and common pathologies such as pleurisy.
6. Define the clinical terms associated with lung pathology: aspiration of foreign bodies, pulmonary embolism,
pleural effusion, pleuritis, pneumothorax, hydro/hemothorax; lung resections.
7. Describe histological features of the lung tissues.
8. Identify cartilage, components of cartilage, and types of cartilage: hyaline, elastic and fibrocartilage.
9. Explain clinical terms, diseases and pathological changes that affect structure of the lungs.
Lecture 14: Abdominal Cavity; Kidneys
Abdominal Cavity:
1. Describe the structure of anteriolateral abdominal wall: fascia, muscles and peritoneum.
2. Compare parietal vs. visceral peritoneum; Describe divisions of abdomonopelvic cavity: abdominal vs.
pelvic, intraperitoneal vs. retroperitoneal organs.
3. Describe structure and function of mesenteries and omentums.
4. Describe recesses and common pathologies such as peritonitis.
Kidneys:
1. Describe the location and structural features of the kidneys.
2. Identify the major blood vessels associated with each kidney and trace the path of blood flow through a
kidney.
3. Describe the structure of a nephron and outline the processes involved in the formation of urine.
4. Discuss the clinical associations related to kidney pathology and congenital malformations of kidney:
kidney stones, bladder cancer, ectopic kidney, bifid ureter, bifid kidney pelvis, horseshoe kidney and
renal transplantation.
Lecture 15: Histology of Kidney
1. List and describe the functions of the kidney.

2. Identify and describe the structural and functional components of the nephron: glomerulus, vascular vs.
urinary poles, podocytes, pedicels and filtration slits; proximal convoluted tubule, distal convoluted
tubule, collecting tubule, macula densa and JG cells.
3. Identify and describe the epithelia and specialized cells characteristic for parts of nephron.
4. Identify cortex vs. medulla.
5. Identify histological features of bladder and urethra.
Lecture 16: Liver and Pancreas

1. Describe the location and structural features of the liver..
2. Identify hepatic triad, lobes, ligaments and bare area of the liver.
3. Explain hepatic portal circulation: identify the hepatic artery, hepatic portal vein and hepatic vein and
trace the path of the blood flow through the liver.
4. Describe the location and structural features of the gall bladder, pancreas and spleen.
5. Explain the path of bile and pancreatic juice trough the ducts from the liver to duodenum.
6. Outline blood supply of the upper abdomen; identify the branches of celiac artery (trunk): left gastric,
common hepatic, splenic, superior and inferior pancreaticoduodenal arteries.
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7. Discuss clinical correlations of pancreas, spleen, liver and gall bladder pathology: liver rapture, spleen
rapture, jaundice, cirrhosis, gall stones, cholecystitis pancreatitis, liver cancer and pancreatic cancer.
Know the risk factors.
Lecture 17: Histology of Glands
1. Describe and explain glands’ structure and function: differentiate between mucous and serous glands,
between unicellular, multicellular simple and compound glands and endocrine and exocrine glands.
2. Describe liver as a compound gland.
3. Be able to identify cells and histological features that are characteristic for liver: hepatocytes, Kupffer
cells, space of Disse, sinusoids, canaliculi, triades, hepatic plates, lobules: classic and portal and hepatic
acinus.
4. Describe the pancreas as mixed endocrine and exocrine gland.
5. Be able to identify cells and histological features which are characteristic for pancreas: acini, ducts, septa
and islets of Langerhans.
6. Be able to recognize pathological changes: liver cirrhosis, diabetic pancreas.
Lecture 18: GI Tract
1. Describe the structure and function of the digestive tract and the role of each digestive organ in digestion and
absorption.
2. Describe the anatomical features of the esophagus.
3. Describe the histological features of the esophagus.
4. Discuss the clinical significance of the esophagus.
5. Describe the anatomical features of the stomach.
6. Describe the histological features of the stomach
7. Discuss the congenital abnormalities and pathology of the stomach.
8. Describe the blood supply of the stomach.
9. Explain the significance of each portion of the small and the large intestine in the digestion and absorption of
nutrients: duodenum, jejunum, ileum and colon.
10. Diagram the blood supply of the lower abdomen; identify the branches of the superior and inferior mesenteric
arteries.
Part III: Extremities and Pelvis
Lecture 19: Bone Histology
1. Recognize the variety of the components of connective tissue: ground substance, fibers and cells.
2. Review types of cartilage: hyaline, elastic and fibrocartilage.
3. Understand clinical significance of articular cartilage.
4. Identify types of bones: cartilaginous, dermal; long, short, flat, irregular and sesamoid.
5. Identify types of bone tissue (compact vs spongy) and components of bone: lacunae, lamella, periosteum,
osteon, trabeculae.
6. Identify types of bone cells: osteocytes, osteoblasts, osteoclasts.
7. Understand the patterns of ossification, healing of fractures and remodeling of bone.
8. Understand clinical significance of Vitamin C and D deficiency, osteoporosis, osteomalacia.
Lectures 20: Upper Limb I (Bones and Nerves)
1. List the bones of the upper girdle and extremity.

2. Identify upper limb bones markings.
3. Identify and compare and contrast the joints of the upper limb, their types and the types of movements
permitted in the upper limb.
4. Identify roots, trunks, divisions, cords and terminal branches of the brachial plexus.
5. Describe the path of six terminal branches of the brachial plexus: axillary, radial, ulnar, median,
musculocutaneous and long thoracic, as well as their relationship to the osteology.
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Lecture 21 and 22: Upper Limb II and III (Muscles)
1. Identify the muscles of the upper limb and groups where they belong.
2. List origin, insertion, action and innervations of the upper limb muscles.
3. Explain the pattern of motor innervation to the forearm; discuss the various common injuries and
clinical signs of damage to the upper limb nerves.
4. Explain the clinical signs of upper limb nerve damage and clinical tests for nerve integrity and functionality.
Lectures 23: Lower Limb I (Bones and Nerves)

1. Describe the bones of the lower girdle and extremity.
2. Identify lower girdle and lower limb bones markings.
3. Identify, compare and contrast joints of the lower limb, their types and the types of movements permitted in
the lower limb.
4. Describe the path of the nerves supplying lower limb: femoral, obturator, sciatic, tibial, common fibular
(peroneal), superficial and deep fibular and superior and inferior gluteal.
Lecture 24: Lower Limb II (Muscles)
1. Identify and list the muscles of the lower limb and groups where they belong.
2. List the origin, insertion, action and innervations of the lower limb muscles.
3. Explain the common injuries, pathologies and clinical signs of damage to the lower limb: compartment
syndrome, fasciitis, hip joint fractures repair and replacements, patelofemoral syndrome, unhappy triad
(p.338), heel spur, plantar fasciitis, femoral triangle, etc.
4. Discuss the clinical signs and tests to evaluate the lower limb nerve integrity and functionality.
Lecture 25: Reproductive Tract Anatomy
1. Outline the anatomy of the female reproductive tract. Be able to describe each components functional
significance.
2. Identify the layers of the uterus.
3. Describe the anatomy and function of the Fallopian tubes and Ovaries.
4. Explain common pathologies of the female reproductive tract including: chlamydia, gonorrhea, pelvic
inflammatory disease, infections of the female genital tract, ectopic pregnancy, infertility, and leiomyoma uteri.
5. Describe the anatomy of the male reproductive tract. Be able to describe each components functional
significance.
6. Explain common pathologies of the male reproductive tract including: chlamydia, gonorrhea, Reiter’s
syndrome, benign prostatic hyperplasia, and hydrocele.
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Part I
Lecture 1: Introduction to Macro and Microanatomy; Cell

Introduction to Macro- and Microanatomy
Objectives
3. Recognize the subjects of histology, cytology and cell biology.
Surface anatomy is the study of the configuration of the surface of the body by sight without dissecting
(sometimes in relation to internal parts).
Gross anatomy or macroanatomy is the study of the body without use of a microscope, as opposed to
microanatomy - histology and cytology. Gross Anatomy uses both invasive and noninvasive methods. The most
common traditional method of study is dissection. Contemporary methods of study include, but are not limited
to, X-ray, MRI, endoscopy and angiography.
Please refer to Blue Boxes (BB) in M&A pp.39-42 Imaging of Body Systems, Conventional Radiography,
Computed Tomography, Ultrasonography, Magnetic Resonance Imaging, Positron Emission Tomography.
Systemic anatomy is an approach when body is studied based on the structure of organ systems: e.g. nervous
system, skeletal system, cardiovascular, etc.
Regional anatomy is more classical, practical and clinical approach when the body is studied by regions, head,
thorax, leg etc.; it emphasizes the study of the relationship between different organs in this region.
Radiographic anatomy is the study of the body structures with X-rays, CT (computer tomography), MRI
(magnetic resonance imaging), etc.
Pathologic anatomy is the study of the changes that occur in the anatomical structures of the body during
disease.
Embryology is a science about the development of the embryo from the fertilized egg to the fetus stage (9
weeks of gestation) and usually includes organogenesis, which is important for understanding of adult body
structure and function.

Inspection is a critical examination of the patient and visual observations. Palpation is feeling the internal
organs or their parts by doctor’s fingers to determine the size, shape, density and conditions of the examined
structure. Auscultation is a listening for sounds of internal organs by ear or by stethoscope to amplify the
sounds. Percussion is tapping on a surface to determine the condition of the underlying structure.
3. Recognize the subjects of Histology, Cytology and Cell Biology.

Microanatomy is often referred to as histology (study of tissues) or cytology (study of cells). The latter closely
related to cell biology, cell physiology and biochemistry.

Human body is a very complex system made of other systems organized in hierarchical order. While all the
above mentioned disciplines study the structure of human body, they study it at different levels of organization:
Anatomy studies organs and anatomical regions of the body; Histology is the study of tissues that make up
organs; Cytology is the study of cells that make up tissues: and Biochemistry is a study of molecules that make
up organelles and cells.
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Cell
Objectives
1. Understand the nature of the tissues and principles of cell theory.
4. Recognize difference between light microscopy (LM), electron microscopy (EM), transmission EM (TEM) and
scanning EM (SEM).
5. Describe the structure of the nucleus: nuclear envelope, pores, heterochromatin and euchromatin.
1. Understand the nature of the tissues and principles of Cell Theory.

Cell theory is a corner stone of modern Biology, which is in turn a foundation of medicine. The name “cell” was
given by Robert Hooke, who published the first description of cells in his book Micrographia, in 1665. Major
ideas of cell theory were introduced two centuries later: In 1839 Theodore Schwann and Matthias J Schleiden
declared the cells as the smallest units of life. In other words, that the cell is the smallest entity, which presents
all characteristics of living things, such as metabolism, responsiveness (homeostasis) and death. In 1858, Rudolf
Virchow completed the theory with the famous statement: “cells come from cells” meaning that cells also
reproduce and inherit features of parent cells.
Cellular differentiation is a process by which less specialized cells become more specialized. The human
organism develops from one totipotent cell, fertilized ova (egg). Embryonic stem cells are pluripotent cells that
originate from this initial cell. Embryonic stem cells are undifferentiated (non-specialized) cells, which have the
capacity to mature into any of the different cell types. Descendants of embryonic stem cells give origin to all
tissues and organs in the adult body. Tissues in adult organisms maintain a constant size, therefore rates of cell
division and cell death must be roughly equal. Most of the tissues maintain multipotent stem cells (progenitor
cells), which undergo mitosis and differentiation to replenish lost cells. Progenitor cells in adult tissue can
differentiate into limited number of cell lines, e.g. hematopoietic cells can give rise to different blood cells but
not muscle cells. In neoplasms (tumors), cells tend to lose or reverse differentiations. Multipotent cells of
different types of tissues derive from different embryonic (germ) layers.
Multipotent cells of different types of

tissues derive from different germ layers.
There are three germ layers in the embryo:
ectoderm (outer layer), mesoderm and
endoderm (inner layer). The embryonic
body cavity between ectoderm and
endoderm is referred as coelom. Coelom is
lined by mesoderm.
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http://content.edgar-online.com/edgar_conv_img/2006/08/30/0001157523-06-008814_SLIDE7.JPGT

Prokaryotic cells are smaller and have a minimal set of organelles. Bacteria are typical prokaryotes.
The human body is made of approximately 1014

eukaryotic animal cells. Eukaryotic cells are bigger and have bigger variety of organelles.
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The thin structure of the
tissue is seen better when
the tissue is sliced in thin
sections to help light pass
through the tissue. Most of
the tissue slides require
additional staining to be
better seen in the
microscope. Hematoxylin
and Eosin dye (shown in the
LM image below) stains acids
blue and stains bases pink, it
allows differentiating
between acidic & basic
components of cell. In this
slide (mammary gland),
nuclei of cells are blue and
the cytoplasm and
extracellular matrix is pink.
The same tissue may look slightly different and can have different colors when stained by different dyes. Specific
dyes help to reveal specific structures.
Masson's Trichrome stain differentiates collagen (blue) and keratin (dense pink) from other fibers (skin).
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The image below shows part of the cell as it is seen in electron microscope. For electron microscopy tissues are
stained by heavy metals
mostly lead (Pb) citrate
and uranium (Ur) or silver
(Ag). Heavy metals
precipitated on strictures
reflect electrons and
appear as black in the
images. Parts that have
no affinity to heavy
metals appear
transparent, since they
are letting electrons
through. Silver stain and
other metal salts could be
also used in light
microscopy. M –
mitochondria, RER –
rough endoplasmic
reticulum, G – Golgi
vesicles, SG – secretory
granules and N – nucleus.
The images below show the case of a fungal infection of the lung, which was mistaken for lung cancer.
Chest radiograph and a CT scan showing a solitary mass over the right upper lung area.
Pulmonary cryptococcosis mimicking solitary lung cancer in an immunocompetent patient by E-T Chang, A H
Wang, C-B Lin, J-J Lee, S-H Liu Thorax 2008;63:478.doi:10.1136/thx.2007.079244
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Fungal infection inside the lung is confirmed with different stains shown in the image below.
Microscopic examination of the lung tissue showing pulmonary cryptococcosis (arrow). HE, haematoxylin-eosin
stain; GMS, Gomori methenamine silver stain.
Histochemistry and cytochemistry are special techniques that are used for localization of enzymes in tissues
and cells by selective staining in situ, e.g. the localization of acid phosphatases. In the blood smear image below,
Presence of chloroacetate esterase in neutrophils stains them blue, and presence of nonspecific esterase stains
monocytes red-brown. Histochemistry allows not only localize enzymes but also roughly measure their activity.
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http://www.pathologyoutlines.com/topic/stainsenzymecytochemistry.html
Immunocytochemistry (ICC) is a common laboratory technique that uses antibodies that target specific peptides
or other antigens in the cell via specific epitopes. Secondary antibody specific to primary antibody is usually
labeled with fluorophores.
http://www.celanphy.science.ru.nl/Bruce%20web/construction.htm
http://faculty.stcc.edu/cellbiology/lab/immunocytochemistry.htm
In the microscope, fluorophore labels help to recognize the presence and location of targeted molecules of
interest.
The image below demonstrates localization of Nestin using ab92391 on E16 rat hippocampal cell culture. The
image shows nestin positive rat hippocampal cells isolated from embryonic day 16. Primary antibody ab92391
was diluted 1/250 and incubated for 2h @ RT. Secondary antibody: donkey anti-rabbit Alexa Fluor 488 (1/2000).
DAPI (diamidinophenylindole fluorescent stain) in blue stains nuclei.
http://www.abcam.com/nestin-antibody-neural-stem-cell-marker-ab92391.html
15
4. Recognize difference between light microscopy (LM), electron microscopy (EM), transmission EM (TEM) and
scanning EM (SEM).
In light microscope (LM) the beam of light is passing through the specimen and the system of lenses to give a
magnified image of the specimen. Resolution of traditional light microscope is limited by optical diffraction to
about 0.2 micrometers (1×10−6 meter also referred as micron). Resolution is the smallest distance at which two
dots are seen as two dots. Cells and big organelles may be seen in light microscope. Electron Microscopy (EM) is
using an electron beam that is passing through the specimen in Transmission EM (TEM) or reflected from
specimen in Scanning EM (SEM). EM allows greater magnification and better resolution than light microscopy.
EM allows one to see big macromolecules (DNA, Myosin) and magnification in hundreds thousands times.
Transmission Electron Microscope (TEM) can give resolution down to 0.2 nm, requires very thin sections, 200-
300nm. Scanning Electron Microscope gives resolution about 10 nm (1×10-9 meter); it is smaller than in TEM.
For better imaging, specimens are cut to thin sections and placed on glass slides (for LM) or copper mesh (for
TEM).
For EM specimens, fixation prevents post mortal changes: glutaraldehyde or paraformaldehyde fix proteins;
osmium tetroxide or potassium permanganate fixes lipids. To allow further thin-sectioning dehydration of tissue
and embedding it in Epoxy resin is required.
16
TEM image is presented to the left; note black membranes (lipids), greyish cytoplasm and relatively empty
transparent extracellular space. SEM image is presented below.
SEM tissue preparation permits thin layer of heavy metal (gold or palladium) to be deposited on surface of
frozen and fractured tissue. SEM allows seeing 3D images of cells and organelles.
17
5. Describe the structure of nucleus: nuclear envelope, pores, heterochromatin and euchromatin.
Structure of nucleus: nuclear envelope, pores, heterochromatin and euchromatin. The Nucleus is most eye
catching spheroid organelle of the cell. It is usually just one nucleus per cell. The Nucleus contains cell's
chromosomes that code genetic information. The Nucleus is separated from cytoplasm by nuclear envelope that
consists of two membranes. The Nucleus controls cell division and growth: DNA replication preceding mitosis
and transcription that results in mRNA production occurs in the nucleus. Information generated by the nucleus
governs the formation of enzymes and other proteins that carry out all processes of body.
18
Electron micrographs show nuclear envelopes composed of two membranes and the nuclear pores (arrows).
The Nucleus may contain a nucleolus or few of them. Nucleolus is the site of rRNA (ribosomal) transcription.
LM (above) and EM (below) shows nucleoli.
19
Chromatin is a complex of DNA and proteins that fills nucleus. Chromatin takes two forms:
heterochromatin is tightly coiled and condensed; euchromatin is loosely arranged. Heterochromatin gives the
nucleus a darker appearance. Prevalence of heterochromatin suggests that the cell does not produce many
proteins, but is preparing for cell division. Cells with more heterochromatin are characteristic for young growing
tissues or malignant tumors. Compare the nuclei with heterochromatin and euchromatin in the images below
and next page.
20
21
CONTENTS OF CYTOPLASM CHARACTERISTICS OF CYTOPLASMIC COMPONENTS

Cytosol Contains mainly water
Contains chemicals dissolved and/or suspended in water
Cytoskeleton Consist of system of tubules & filaments
Give shape to cells
Provides mobility for cells & organelles
Creates intracellular pathways within cells
Inclusions Consist of metabolic by-products
Consists of storage forms of various nutrients
Inert crystals
Pigments
Organelles Metabolically active cellular structures
Execute specific functions
Some organelles are seen with LM
Most organelles require EM to be seen
Covered by phospholipid bilayer membranes
Membrane provides large surface area for biochemical reactions
Please refer to Chapter 2 in G & H for complete description of organelles. Make sure you are able to recognize
the organelle in the images and know its function.
Sample: Golgi apparatus (body) is involved in processing and packaging of proteins, lipids and carbohydrates
that are destined for secretion outside or inside the cell.
22
Lecture 2: Epithelial and Connective Tissue
Objectives
1. Recognize the four main types of tissue: epithelial, connective, muscular and neural.
2. Know the distinct characteristics of epithelia: polarity (basal lamina, apical vs. basal); cellularity; lack
of vasculature and recognize types of epithelia.
3. Know the distinct characteristics of connective tissue: types of cells, types of matrix and types of
fibers.
4. Compare and recognize types of loose and dense connective tissue proper.
1. Recognize four main types of tissue: epithelial, connective, muscular and neural.
There are four basic types of tissues: neural, muscular, epithelial and connective.
2. Know the distinct characteristics of epithelia: polarity (basal lamina, apical vs. basal); cellularity
(different types of cell junctions, communicating vs. non-communicating); lack of vasculature and
recognize types of epithelia.
Epithelium is an uninterrupted layer of cells that covers body surfaces, lines body cavities and forms
glands. Connective tissue connects body parts, fills spaces and supports other tissues.
Characteristics of epithelia: Cellular - uninterrupted layer of cells, attachments or cell junctions between
the cells; Polar - has apical side facing lumen (can be covered by cilia or mucus) and basal side attached
to flesh by basal lamina and connective tissue. Avascular - does not have blood vessels. Secretory -
often produce secretions that are released to the surface. Glands are formed by epithelial tissue.
Functions of Epithelia: 1. Barrier (protection) protects underlying tissues; 2. Secretion (glands) mucus,
hormones, enzymes, milk, bile and other; 3. Transport across an epithelium (respiratory, intestinal, &
23
urinary layers); 4. Absorption from the lumen (intestine); 5. Detection of sensations (specialized
epithelia which receive & transmit stimuli): taste buds, retina of eye, & hair cells in ear.
Epithelia are classified based on:

1. Number of cell layers: simple epithelium has a single layer; stratified epithelium has multiple layers.
2. Shape of cells: squamous (flat), cuboidal (square), columnar (tall).
3. Surface characteristics: microvilli or cilia. Surface Epithelia cover the exterior surface of the body or
the lumen of internal passages and cavities.
Main groups of epithelia: 1) Covering or lining epithelium and 2) Glands. (Glands will be discussed in lecture 17).
There are three types of lining:
Endothelium - very thin single layer (simple squamous epithelium) lines the entire circulatory system: heart,
arteries, veins, capillaries, sinusoids, and the lymphatics.
Mesothelium - incomplete thin layer lines the walls and covers the contents of closed body cavities, e.g.
pericardium
Epithelium – thick often multiple layers of epithelial cells which covers the outer surface of the body, the lumen
of alimentary canal, or other cavities open to the exterior.
Epithelium is often attached to the basement membrane (BM): thin sheet of collagen and glycoproteins;
substances are produced in part by the epithelial cells, and in part by underlying connective tissue (lamina
propria), and its cells (fibroblasts).
24
Regeneration of epithelial tissue: Epithelia undergo continuous renovation. In stratified epithelia the germ cells,
which are continuously multiplying are located in the layer closest to the basal lamina and blood supply –
stratum germinativum (aka stratum basale). As internal layers become crowded the outer layer of old cells
sloughs off and are replaced by new ones.
Identify these types of simple epithelia based on the description provided above
25
Identify different kinds of stratified epithelia: keratinized, non-keratinized, transitional. Identify
characteristic features of each type
4. Know the distinct characteristics of connective tissue: types of cells, types of matrix and types of
fibers.
Connective tissue has relatively few cells and some fibers scattered in the extracellular matrix.
Connective tissues can be classified based on the density of the matrix: liquid (like in blood or lymph);
solid (cartilage, bone); gel (connective tissue proper, e.g. one in tendons, ligaments, meninges and
fascia). The diverse population of cells in connective tissue consists of resident (sedimentary) cells that
are always present and wandering cells that may come and invade connective tissue or may be absent.
Resident cells of connective tissue are: fibroblasts that produce and maintain matrix and mast cells that
play important role in inflammation. They contain histamines, heparin granules, and cytokines which are
released in response to binding antibody or direct damage. Cytokines and various hormones released by
mast cells attract different types of white blood cells to connective tissue. Wandering cells in connective
tissue include but are not limited to: Eosinophils which are attracted to sites of allergic inflammation by
chemotactic factor and combat parasites by releasing cytotoxins; basophils (which are similar to mast
26
cells) release preformed and newly
synthesized chemical mediators;
monocytes which leave the blood
and take up residence in
connective tissue proper; and
macrophages which phagocytose
foreign substances and damaged or
senescent (old) cells, and they also
assist in immune response as
antigen presenting cells.
In the image to the left:

fibroblast nuclei are dark
round or oval structures;
Mast cells are bright red
cells with granules;
Collagen fibers are orange-
stained long, straight
profiles (they are thicker
than the elastic fibers);
Elastic Fibers are blue-
black, thin, long, branching
thread like structures.
Most of the cells of the CT

have mesodermal origin.
The cells that constantly
produce matrix substance
and different kind of fibers
are called fibroblasts (or
fibrocytes.) Fibroblasts are capable of mitosis and are essential for the healing of wounds. They can be
spindle-shaped, boxy, or star-shaped. The nucleus usually contains more than one nucleolus, and RER is
abundant; see the following EM images on the next page.
27
Note the nucleus. The cytoplasm of the
fibroblast is filled with RER and the
fibers are seen in the matrix of these
EM images. Fibers provide tensile
strength and elasticity to connective
tissue. There are three major types of
fibers that are usually seen and are
distinguishable in the light microscope:
1) Collagen fibers are seen as big
straight lines or tubes. They are not
elastic but very strong great tensile
strength.
2.) Elastic fibers (sometimes referred
as yellow fibers) are thin thread-like
fibers which are made of elastin and
provide elasticity to connective tissues.
When force is applied to them, they
can stretch up to 1.5 times their
length, but they coil back when
released.
3) Reticular fibers (type III collagen) are wavy

fibers that often form bundles and mesh-like
networks that fuse with connective tissue
forming external capsules and septa of the big
glands (e. g. liver, pancreas). They are also
present in adipose tissue, smooth muscles,
lymph nodes, etc. Reticular fibers are shown by
the arrows in the image of the lymph node to
the left.
28
Most of the connective tissue cells originate from undifferentiated mesenchymal cells. The family tree of
specialized connective tissue cells is shown above. Please note, that fibroblasts are close to
undifferentiated cells, they maintain their ability to reproduce and can differentiate into more
specialized cells of connective tissues: adipocytes (fat), chondrocytes (cartilage), osteocytes (bone) and
others.
4. Compare and recognize types of loose and dense
connective tissue proper.
There are few types of Connective Tissue proper:

dense, loose, reticular and adipose.
In small magnification and blurry pictures dense CT
looks more dense (dark) and loose CT looks more
loose (transparent) (image to the right).
29
In high magnification images (left image) Loose Connective Tissue (LCT) is characterized by the lack of
any pattern: very well seen individual
collagen fibers are scattered in the
ground substance along with the
fibroblasts; the collagen fibers are not
forming big bundles, they course in
different directions and make loose
meshwork. This type of tissue (aka
areolar connective tissue) is abundant
in the body, it fills in spaces,
underlines skin, lies below mesothelial
lining and lining of blood vessels,
surrounds parenchyma of glands and
forms lamina propria of mucous
membranes.
Dense Connective Tissue (DCT)

contains more fibers, fewer cells and
less ground substance than LCT.

Orientation and arrangement of fibers
make it resistant to stress and stretching
(individual fibers densely packed and
usually are not well distinguishable in
micrographs).
Dense Regular Connective Tissue (image

to the right) is characterized by fiber
bundles which are arranged in parallel or
organized fashion, it resists stress and
stretching in one direction.
There are two types of Regular Dense Connective Tissue
30
(1) Collagenous type of Dense
Regular CT is found in ligaments
and tendons. The image to the
left and the image on the
previous page present
collagenous type of dense
regular CT. Please note that the
collagen fibers are packed so
densely that they become
“invisible,” but you still can
identify their presence by
regularity of cells orientation.
(2) Elastic type of regular

connective tissue (image to the
left) can be found in the
structures that require more
elasticity: such as thin sheets or
membranes, walls of large blood
vessels, ligaments of vertebral
column.
31
Dense Irregular Connective Tissue is
characterized by densely packed
collagen fibers interwoven into a
meshwork; this arrangement helps to
resist stress from all directions. Dense
Irregular connective tissue is found in
superficial, deep and subserous fascia.
The adipose tissue commonly

known as fat is presented in the
image to the right. Each space
represents a large drop of lipid
before it was dissolved from the
cell during tissue preparation.
(Lipid droplets are removed during
routine histological techniques).
Each cell appears as a thin ring of
cytoplasm surrounding the vacuole
.Thus the cells have eccentric and
flattened nuclei.
32
Membranes in Macroanatomy (vocabulary)
Adventitia is a layer of connective tissue that connects and binds some internal organs (esophagus,
blood vessels).
Serous membrane (serosa) is a membrane made of connective tissue covered by a thin layer of
epithelial cells (mesothelium), which secrete serous fluid. Serous membranes line the closed cavities
filled with a thin lubricating fluid (serous fluid) which reduces friction between organs (peritoneum,
pericardium).
Mucous membrane (mucosa) lines cavities connected to exterior, it is covered by absorbing or secreting
epithelium which secretes mucus; e.g. respiratory tract, digestive tract.
Cutaneous membrane (skin) consists of multiple layers of epithelium and different layers of connective
tissue.
Synovial membranes produce synovial fluid which helps lubricate joints permitting smooth movement;
epithelial layer of synovial membrane is very thin and incomplete.
Fascia provide connective tissue framework of the body.
Superficial fascia (hypodermis, Camper's fascia) is a layer of connective tissue (mostly adipose)
underlying skin.
Deep fascia (fascia of Scarpa) invests all organs of the body wall and binds them together: e.g. bones,
muscles, joints’ capsules and ligaments.
Practice identifying types of tissues, cells, and fibers in the following images.
33
34
35
36
Lecture 3: Neural Histology
Objectives
2. Discuss the structural and functional components of neurons: soma, dendrites, axons and axon
hillock.
3. Discuss the location and function of organelles in neurons: nucleus, nucleolus, Golgi complex,
RER, Nissl bodies.
4. List types of neuroglial cells: Astrocytes, Oligodendrocytes, Microglial cells, Ependymal cells and
Schwann cells, and define their location and function.
5. Understand functional types of neurons: sensory, motor and neurons of association. List types
of neurons and be able to identify each type: multipolar, unipolar and bipolar and define their
functions and location.
6. Identify and describe the structure of a peripheral nerve: perineurium, epineurium, and
endoneurium; myelinated vs. unmyelinated axons.
7. Be able to identify histological images of the parts of the nervous system: brain (grey vs. white
matter), spinal cord, meninges, ganglia and peripheral nerves.
8. Explain the functional and structural characteristics of a synapse: pre-synaptic membrane, pre-
synaptic knob, post-synaptic membrane and receptors.
9. Discuss and recognize the consequence of neuronal injury: axonal degeneration, segmental
axonal demyelination, myopathy and reinnervation.
The major function of nervous system (NS) is body control and regulation, which can be broken down to
gathering signals, processing information and response. In contrast to the endocrine system, the NS is
able to give response within a fraction of a second.
Structurally, the nervous system consists of two major divisions: CNS (central nervous system) and PNS
(peripheral nervous system).
The CNS is made up of brain and spinal cord and resides in the dorsal cavity. The function of the CNS is
to integrate and coordinate neural signals and perform higher mental functions (thinking and learning).
The PNS is located outside of the dorsal cavity. It consists of peripheral nerves (cranial and spinal),
ganglia, receptors and enteric plexus. The function of PNS is to carry signals to and from CNS.
Sensory fibers conduct impulses from the receptors (sensors) to the CNS. Motor fibers conduct
impulses from the CNS to the effectors (muscles or glands).
The motor division of the nervous system consists of SNS - somatic nervous system (voluntary), which
controls skeletal muscles (soma - body), and ANS -autonomic nervous system (involuntary or visceral),
which controls cardiac muscle, smooth muscles and glands. ANS is divided into sympathetic and
parasympathetic.
37
2. Discuss the structural and
functional components of neurons:
soma, dendrites, axons and axon
hillock.
Neural cell (neuron) has a body

(soma) and projections: dendrites
and axons. The axon is usually the
biggest and longest projection that
propagates signals away from the
body of the neuron. There is usually
only one axon per neural cell, but it
can have a few branches (collaterals).
Dendrites (tree like – branchy)
gather signals and bring information
to the soma (body) of neuron.
Dendrites are usually smaller than
axon. A neuron can have many
dendrites.
The soma (bodies of neurons) is rich
in ribosomes and RER, which gives it
a dark (grey) color under the
microscope. Collections of these
bodies of neurons constitute the
“grey matter.” Axons are usually
wrapped in myelin, which is a lipid
and looks transparent or white under
the microscope. Collections of axons
constitute “white matter.”
New signal is generated at the axon

hillock and is propagated along the
axon away from the soma to the
axon terminal boutons and synapses. Impulses can be conducted along the neural cell in one direction
only: from the dendrites to the body of the neuron, from the body along the axon, and then to another
cell via a synapse.
Initiation and regulation of the impulses occur on the membrane of the postsynaptic cell. Action
potentials are usually initiated on the axon hillock part of the soma of the neuron, close to the axon’s
base. Action potential is propagated along the axon to the small branches at the end of the axon called
axon terminals.
38
Axon terminals have
synaptic bulbs (knobs,
boutons,) which are rich
with neurotransmitters.
Signals are transferred
between neurons via
synapses. A synapse is a gap
between two cells, where
signal is transferred from
the membrane of the first
cell (presynaptic) to the
membrane of the second
cell (postsynaptic). When
an action potential reaches
the synaptic bulb, a
neurotransmitter is released
from the synaptic bulb into
the synaptic cleft, the space
between cells.
When a neurotransmitter diffuses to the postsynaptic membrane it may open ion channels in it, and
initiate another signal on the postsynaptic cell’s membrane. The postsynaptic cell may be another
neuron, muscle cell, or the cell of glandular epithelium.
3. Discuss the location and function

of organelles in neurons: nucleus,
nucleolus, Golgi complex, RER, Nissl
bodies.
Body of the neuron is the large

structure in the middle of the picture,
nucleus (big round light structure with
chromatin clusters in the middle of
the body), nucleolus (very dark
triangular structure inside the
nucleus), Nissl bodies are clusters or
RER (dark structures in cytoplasm).
39
4. List types of neuroglial cells:
Astrocytes, Oligodendrocytes,
Microglial cells, Ependymal
cells and Schwann cells, define
their location and function.
Neural tissue contains neurons

and glial cells (specialized cells
that assist neurons). Examples
of glial cells in CNS are
astrocytes, oligodendrocytes,
microglia and ependimal cells;
in PNS Schwann cells and
satellite cells in ganglia.
Neurons are giant cells, all
other cells in neural tissue are
much smaller.
Astrocytes are the largest of the neuroglia, with long projections. They are present in both grey and
white matter. They form the
vascular feet that surround the
blood vessels and are next to pia
mater. They constitute a large
portion of the blood-brain barrier
(BBB). Astrocytes also form scar
tissue after cerebro-vascular
incident (CVI) or traumatic brain
injury (TBI).
40
In adults, 80% of brain tumors are
astrocytomas, uncontrollable reproducing
astrocytes (image to the left).
Confocal micrograph courtesy of Dr. Lotocki.

Image shows hippocampus after TBI.
Neurons (red) surrounded by activated
astrocytes (green), resulting in scarring
around the injury. (Image to the right).
Compare the size of the neurons with
astrocytes.
41
Oligodendrocytes (image to the
right) are found in the CNS (both
in grey and white matter). They
are characterized by the dense
cytoplasm, small nucleus and
fewer projections than
astrocytes. Their major function
is to make myelin sheath around
axons in the CNS; one
oligodendrocyte can wrap
multiple axons. Myelin sheath
electrically isolate axons from
extracellular fluid and make
propagation of signals along the
axon faster.
Ependimal cells are found at the

borders of neural tissue in the
CNS. Along with the capillaries
they form the choroid plexus
that is responsible for the
formation of CSF. Ependimal
cells are cuboudal epithelial-like
cells that form the internal lining
of the central canal of the spinal
cord and ventricles of the brain,
and the external limiting
membrane next to pia mater.
Some ependymal cells are
ciliated and assist in movement
of CSF.
42
Microglia (microglial cells)
function as phagocytes in
neural tissue. These cells
stain dark, they possess oval
or triangular nucleus and
projections shorter than in
astrocytes. Microglia is
abundant at the sites of
injury, because clearing
debris is their function.
43
Schwann’s cells are making the myelin
sheath around axons in the peripheral
nerves. They are different from
oligodendrocytes since they are found in
PNS and one Schwann’s cell puts myelin
layer around only one axon. Schwann’s
cell can cover few axons but not to put
myelin layers around them. Myelinated
and unmyelinated neural fibers will be
discussed further in this lecture along with
the structure of peripheral nerves.
5. Understand functional types of

neurons: sensory, motor and neurons of
association. List types of neurons and be
able to identify each type: multipolar,
unipolar and bipolar and define their functions and location.
Types of Neurons. Since signals can run along the neural cells
only in one direction, the same cell cannot bring signals to
the CNS and from the CNS; it must be two different cells. The
axons (and cells) that bring signals to the CNS are called
sensory (afferent). The axons (and cells) that carry signals
from the CNS to effectors are called motor (efferent). Neural
cells located in the CNS are responsible for integration and
processing of information; they are called interneurons or
neurons of association.
Structurally: Bipolar neurons have one dendrite and one
axon connected to the body of neuron at the opposite sides,
so the cell has two poles. Unipolar neurons also have one
dendrite and one axon, but the body of the neuron is
attached to the side of the axon, so it has just one pole. In
unipolar neurons the signal is initiated at the point where the
dendrite is connected to the axon. Both unipolar and bipolar
neurons are sensory.
Multipolar neurons have many dendrites and one axon. They

are usually neurons of association or motor neurons.
44
6. Identify and describe the structure of a peripheral nerve: perineurium, epineurium, and
endoneurium; myelinated vs. unmyelinated axons.
Peripheral nerves are usually bundles of axons (nerve fibers) connecting the CNS with a specific area
of the body. Most of peripheral nerves may carry both afferent and efferent fibers. Axons are
covered by myelin and gathered in bundles. Connective tissue holding the bundles together is
referred to as: endoneurium (between individual axons), perineurium (between bundles) and
epineurium around the entire nerve.
45
In the histological images of peripheral nerves axons look “empty”, they do not present nuclei, the only
nuclei that can be observed are the nuclei of the Schwann’s cells or nuclei of fibroblasts. The myelinated
axons are covered by myelin the multiple layers of cell membrane made by Schwann cells.
Unmyelinated axons are only protected by the cytoplasm of Schwann cell.
Schwann’s cells put layers of myelin around a single axon in peripheral nerve (see images above).
46
When a Schwann cell wraps around an axon without putting myelin layers around the axon the axon is
called an unmyelinated fiber. One Schwann’s cell can wrap few unmyelinated axons.
Schwann cells cover
both myelinated and
unmyelinated fibers
(axons) in PNS.
47
Femoral nerve; transverse section. BNF = bundles of nerve fibers, BV = blood vessel, Epn = epineurium,
arrows= septum formed by perineurium. Epn = epineurium (longitudinal section)
Peripheral nerve (high magnification), C = capillary,

A=axon, SS=Schwann cell nucleus, M=myelin, F=
fibroblast, NR = node of Ranvier, NF=nerve fiber, Neurilemma (NI) the outermost membrane of Schwann
cell in an axon’s myelin
48
7. Be able to identify histological images of the parts of the grey matter vs white matter.
Parts of the neural system that are rich in neural cell bodies (e.g. brain cortex and ganglia) look darker
due to the presence of numbers of Nissl bodies and nuclei- they are referred to as grey matter. Parts
rich in myelinated axons (e.g. peripheral nerves and CNS tracts) look lighter due to abundance of fat-
they are referred as white matter.
49
Images above show the soma of neurons
with Nissl bodies.
Ganglia are clusters of neuronal cell bodies

located outside the CNS; nerve fibers lead
to and from them.
Image to the right shows the human
ganglion at smaller magnification. Several
discrete bundles of nerve fibers (NF) are
seen as well as numerous large circular
structures, namely the cell bodies (CB) of
the neurons.
There are always some neural fibers seen
in grey matter along with neurons’ bodies.
Ganglia, cortex and other parts of neural
system that have cell bodies look similar in
histological images.
Peripheral nerves don’t have neural cell
bodies.
50
Image to the left shows
low magnification view of
the cerebral cortex (CC)
It includes the full
thickness of the gray
matter and a small
amount of white matter
(WM) at the bottom of
the micrograph
The white matter
contains considerably
fewer cells per unit area;
these cells are neuroglial
cells.
PM= pia mater
8. Explain the functional and structural characteristics of a synapse: pre-synaptic membrane, pre-
synaptic knob, post-synaptic membrane and receptors.
Synapse is a narrow cleft between two cells where signals are transferred from one cell to another.
Synaptic knob (aka bouton, aka bulb) is the enlarged end of an axon. Synaptic knob contains a lot of
vesicles filled with neurotransmitter.
When an action potential (AP) reaches the synaptic knob, synaptic vesicles fuse with the presynaptic
cell membrane and the neurotransmitter is released into the synaptic cleft between the two cells.
51
When the neurotransmitter reaches the postsynaptic membrane it binds to the receptors (proteins of
chemically regulated channels) and opens gates for ions. When the ions enter the postsynaptic cell, an
AP on the membrane of postsynaptic cell may be generated.
Note synaptic vesicles in

presynaptic knob and synaptic
cleft in EM image above.
EM image to the left shows

coronal section of synaptic
boutons. Note that the
appearance of vesicles in the knob
can vary based on the chemical
nature of neurotransmitter.
Mitochondria are often present in
synaptic knob.
52
9. Discuss and recognize the consequence of neuronal injury: axonal degeneration, segmental axonal
demyelination, myopathy and reinnervation.
Body response to peripheral nerve damage depends on the nature of the damaged cell: loss of the
Schwann cells leads to loss of myelin (segmental demyelination), damage to the axon leads to axonal
degeneration; degenerated axons are able to grow back if guided by Schwann cells (reinnervation).
Myopathy is the loss of signal between neural cell and muscular cell.
53
Lecture 4: Introduction to Gross Anatomy; Skull
Introduction to Gross Anatomy

Objectives
2. Use anatomical terms, body sections, body regions, relative positions and directions to describe
location of structures and abnormalities.
3. Identify the body cavities and their subdivisions: dorsal cavity, cranial cavity, ventral cavity, thoracic
cavity, mediastinum and abdomino-pelvic cavity.
4. Differentiate the serous membranes: visceral vs. parietal, and indicate their common function.
6. Use anatomical terms of movement and laterality to describe action of the muscles: flexion,
extension, abduction, adduction, medial and lateral rotation, circumduction, supination, pronation,
eversion, inversion, protrusion, retraction, elevation and depression.

Anatomical position is a standard position anatomists refer to when they are describing location of
structures or pathologies. A person in an anatomical position stands erect with their head and eyes
directed to the front, upper limbs by the sides, palms front, lower limbs close together and toes directed
to the front.
A person in a prone or supine position keeps body parts in the same relation to each other as the person
in an anatomical position. A person in a supine position lies flat on the back, face up. A person in a
prone position lies face down.
M&A p. 2
54
2. Use anatomical terms, body sections, body regions, relative positions and directions to describe
location of structures and abnormalities.
Some clinical terms are based on Greek or Latin words.
A plane is an imaginary flat surface that passes through the body.

A section is one of the two 2 surfaces (pieces) that results when the body is cut by a plane passing
through it.
Median or midsagittal plane passes vertically through the center of the body and divides body into
equal left and right halves. There is only one median plane. Planes that run parallel to the median plane
are called parasagittal. There can be many parasagittal planes.
Coronal (frontal) planes are passing vertically at the right angle to the median plane. Coronal planes
divide body to the anterior and posterior portion. There can be more than one coronal plane.
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Transverse planes are passing horizontally at the
right angle to the median and coronal plane.
Transverse plane divides body to the superior and
inferior portion.
Oblique planes are not parallel to the median,
coronal and transverse planes.
Terms of laterality: Symmetrical and paired structures
occurring on the both sides of the body or having left
and right members are called bilateral (kidneys,
nostrils).
Structures which only occur in one side of the body
are called unilateral (spleen, appendix).
Ipsilateral refer to the structure or event that occurs
on the same side of the body, e.g. injury to the
peripheral nerve in the right arm is causing muscle
paralysis in the right hand.
Contralateral means on the opposite side of the
body, e.g. paralysis of the right arm caused
hypertrophy of the muscles of the left arm.
M&A p.3
3. Identify the body cavities and their

subdivisions: dorsal cavity, cranial cavity,
ventral cavity, thoracic cavity, mediastinum,
abdomino-pelvic cavity.
Cavities are spaces inside the body.

Two major cavities are ventral cavity and
dorsal cavity.
Ventral cavity is derived from embryonic
coelom, in humans it is divided by diaphragm
into thoracic (above diaphragm) and
abdominopelvic cavities.
Dorsal cavity develops around embryonic
neural tube. In humans it is divided into
cranial cavity that is formed by the skull and
holds the brain and spinal (vertebral) canal
that holds the spinal cord.
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Body cavities are usually lined by connective tissue membranes. Dorsal cavity is lined by meninges.
Ventral cavity is lined by fascia and serous membranes. Serous membranes separate and wrap organs of
the ventral cavity.
Pleura is a serous membrane around lungs. Pericardium is a serous membrane around the heart.
Peritoneum is a serous membrane around the abdominal viscera.
There are two layers of serous capsule: visceral layer is the layer closest to the organ, it is difficult to
remove visceral layer and not damage the organ; parietal layer is the lining of the cavity. The space
between visceral and parietal layers usually contains a small amount of fluid produced by serous
membranes.
Thoracic cavity is filled with lungs and mediastinum - the space between lungs. Heart, esophagus,
trachea as well as important nerves and blood vessels are located in the mediastinum.
Abdominopelvic cavity is the largest. It is conventionally divided either into four quadrants or nine
regions.
Abdominal quadrants are defined by two planes: median and transumbilical, passing through the belly
button at a right angle to median. (RUQ –right upper quadrant, LUQ –left upper quadrant, RLQ –right
lower quadrant and LLQ –left lower quadrant).
Abdominal regions are defined by two vertical midclavicular planes: passing vertically from middle of
the clavicle, and two horizontal planes: subcostal plane, through the inferior border of 10th costal
cartilage (rib) and transtubercular plane through iliac tubercles (RH - right hypochondriac, E-epigastric,
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LH - left hypochondriac, RL – right lateral (lumbar), U-umbilical, LL – left lateral (lumbar), RI –right
inguinal, P –pubic (hypogastric), LI- left inguinal).
6. Use anatomical terms of movement and laterality to describe action of the muscles: flexion,
extension, abduction, adduction, medial and lateral rotation, circumduction, supination, pronation,
eversion, inversion, protrusion, retraction, elevation, depression.
Please learn terms of movement: M&A Fig. 1.4 pp. 6-7; Types of Joints Table 1.1 p. 15; Types of
Synovial Joints Table 1.2. p. 16 and Bone Markings p. 11.
Skull
Objectives
3. Explain structural and functional divisions of the nervous system: central vs. peripheral,
somatic vs. autonomic, sensory vs. motor.
5. Identify parts of the spinal cord and location of different types of neurons in spinal cord, and
spinal nerves.
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Identify these bones:
Cranial bones (neurocranium): frontal, parietal (2), temporal (2), occipital, sphenoid and ethmoid.
Facial bones (viscerocranium): nasal (2), maxilla (2), lacrimal (2), zygomatic (2), inferior concha (2),
palatine (2), mandible and vomer.
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Foramina and apertures: magnum (CN XI, medulla, vertebral arteries and spinal arteries), jugular (CN IX,
X and XI), carotid canal (internal carotid artery), ovale (CN V-mandibular), lacerum, rotundum (CN V-
maxillary), spinosum, stylomastoid, optic (CN II), hypoglossal canal (CN XII), superior orbital fissure (CN
III, IV, V-ophthalmic, internal acoustic meatus and external acoustic meatus.
Processes: occipital condyles, mastoid process, styloid pcs (of temporal bone); coronoid process
(mandible), mental protuberance, zygomatic arch, pterygoid process.
3. Explain structural and functional divisions of the nervous system: central vs. peripheral, somatic vs.
autonomic, sensory vs. motor.
Structurally, the nervous system consists of two major divisions: CNS (central nervous system) and PNS
(peripheral nervous system). The function of CNS is to integrate and coordinate neural signals and
perform higher mental functions (thinking and learning). The CNS is made up of brain and spinal cord.
Brain and spinal cord occupy the dorsal cavity and constitute the central nervous system. Brain occupies
the cranial cavity. Spinal cord occupies the vertebral canal. The PNS is located outside of the dorsal
cavity. It consists of peripheral nerves (cranial and spinal), ganglia, receptors and enteric plexus. The
function of PNS is to carry signals to and from CNS. Sensory fibers conduct impulses from receptors
(sensors) to the CNS. Motor fibers conduct impulses from CNS to the effectors (muscles or glands).
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Motor division of the nervous system consists of SNS - somatic (voluntary) nervous system, which
controls skeletal muscles (soma - body), and ANS -autonomic (involuntary or visceral) nervous system,
which controls cardiac muscle, smooth muscles and glands. ANS is divided into sympathetic and
parasympathetic divisions.
Neurocranium accommodates brain, which is the biggest organ of neural system. Floor of the cranium
has three fossae: anterior, middle and posterior. Please identify the bones that form these fossa and
contents of each fossa.
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There are 12 pairs of cranial peripheral nerves, which arise from the brain and exit the cranium through
foramina.
There are 31 pairs of spinal nerves, which arise from the spinal cord and exit the vertebral canal through
the intervertebral foramina.
Identify major parts of the brain: cerebrum, cerebellum, thalamus, hypothalamus, mesencephalon
(midbrain), pons, medulla, pituitary gland, corpus callosum and nuclei in different plans and sections.
The brain and spinal cord are easier to understand if you think of them as an embryonic neural tube
organized around the central canal that is filled with CSF (cerebrospinal fluid). During the development
the cranial parts of this canal turn into the chambers called ventricles. The biggest and most anterior
part of the brain is called the cerebrum. It consists of two hemispheres with lateral ventricles inside. The
next part, diencephalon, surrounds the third ventricle. Diencephalon consists of epithalamus (roof), two
thalami (walls) and hypothalamus (floor). The fourth ventricle is located between the pons and medulla
anteriorly and cerebellum posteriorly. The third and fourth ventricles are connected by the canal called
mesencephalic aqueduct that runs through the midbrain.
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https://upload.wikimedia.org/wikipedia/commons/d/d4/Blausen_0896_Ventricles_Brain.png
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Identify the parts of the brain in the following gross Anatomy images and CT scans.
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65
Ganglia (singular – ganglion) are
collections of the neural cell bodies
located outside of CNS.
Collections of the neural cell bodies inside

CNS are referred to as nuclei (singular
nucleus). Nuclei are made of gray matter.
The cerebral cortex is the layer of the

gray matter, which is situated along the
outer surface of the cerebral
hemispheres.
Blue Box in M&A pp. 497 Fractures of

Cranial Base.
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5. Identify parts of the spinal cord and l of neurons located in these parts.
Medulla oblongata of the brainstem is connected to the spinal

cord, a tube-like structure that continues down the spinal column.
Spinal cord is a part of CNS and consists of neural tissue. Neurons in
the spinal cord carry afferent (incoming) and efferent (outgoing)
signals between the brain and peripheral spinal nerves.
The central canal of the spinal cord is filled with CSF. The gray
(grey) commissure is a strip of gray matter that connects left and
right halves of the spinal cord and surrounds the central canal.
Anterior (ventral) gray horns contain bodies of somatic motor

neurons. Lateral gray horns contain bodies of autonomic,
presynaptic neurons. Motor neurons sending their axons via ventral
(anterior) roots. Posterior (dorsal) gray horns receive sensory
information from dorsal roots (axons of sensory neurons).
Anterior (ventral) white column (funiculus) is the white matter of

the spinal cord lying on either side between the anterior median
fissure and the ventral root. Lateral white column (funiculus) is the
white matter lying between the dorsal and ventral horns. Anterior
and lateral white columns contain both ascending and descending tracts. Dorsal white columns are
between dorsal horns. They contain only ascending tracts.
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Identify the following in the picture: the parts of spinal cord: anterior (motor) and posterior (sensory)
horns, ventral and dorsal roots; dorsal root ganglion; and the types of neurons (e.g., sensory, motor,
unipolar and multipolar).
The bodies of the sensory neurons are residing in the dorsal root ganglia (dorsal spinal ganglia.) There is
one such ganglion for every spinal nerve. The sensory neurons, which are located in these ganglia, are
unipolar.
The paravertebral sympathetic chain ganglia contain bodies of postganglionic sympathetic neurons that
will be discussed in chapter 9.
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Lecture 5: Muscle Tissues
Objectives
1. Describe the difference between three types of muscle tissue: ability to regenerate, voluntary
vs. involuntary, satellite cells.
2. Identify smooth muscle, cardiac muscle and skeletal muscle.
3. Identify the parts of the skeletal muscle: muscular fibers, endomysium, perimysium, epimysium,
tendon, and belly of the muscle.
4. Describe and identify the features of myofibril: sarcomere, thick and thin filaments, A-band, I
band, M-line, Z-line, sarcoplasmic reticulum, T-tubules, triad and motor end plate.
7. Discuss clinical applications of muscle and neural anatomy: Guillain-Barre syndrome, multiple
sclerosis, myasthenia gravis, muscular dystrophy, myocardial infarction and necrosis.
1. Describe the difference between three types of muscle tissue: ability to regenerate, voluntary vs.
involuntary, satellite cells.
There are three types of muscle tissue. The difference between them is summarized in this table.
Type Smooth Skeletal Cardiac

striations - + +
Voluntary control - + -
origin mesoderm mesoderm mesoderm
structure spindle shape, long boxy cells with 1-2
one nucleus per multinucleated nuclei, connected
cell cell (fiber) by intercalated
numerous nuclei discs
Regeneration + limited, Involves -
satellite cells
Location blood vessels, soma, except heart
viscera, dorsal and ventral
Skin, glands cavity
Please Read Table 1.4 Types of Muscle in M&A pp. 18-19
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2. Identify smooth muscle, skeletal muscle and cardiac muscle
Smooth muscle cells have spindle shape and one nucleus. They are not striated.
Longitudinal and transverse section of the smooth muscle (central nuclei, no striations.)
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Cardiac Muscle longitudinal and cross section (central nuclei, striations, intercalated discs)
Cross section of skeletal muscle has peripheral nuclei and less connective tissue between fibers.
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Longitudinal section of skeletal muscle (peripheral nuclei, striations)
Compare longitudinal section of smooth muscle to skeletal muscle.
Smooth muscle Skeletal muscle (note peripheral nuclei, striations)
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Compare skeletal muscle to cardiac.
Cardiac (note intercalated discs, central nuclei).
Myoblasts, Myocytes and Satellite Cells

Mature muscular cells of all three types are called
myocytes. Myoblasts are smooth muscle like progenitor
cells that differentiate into myocytes. In cardiac muscle
tissue myocytes form syncytia. In skeletal muscle
myoblasts completely fuse together forming polynucleated
muscle fiber. Myoblasts that fail to fuse remain in skeletal
muscle tissue as satellite cells which play important role in
repair.
http://diabetes.diabetesjournals.org/content/51/4/1052/F1.expansion
The light confocal microscopy image above shows growth of myoblasts in culture: A, B – growth, C ,D –
fusion into multinucleated tubular myocytes.
73
Image to the left shows
immunocytochemistry of embryonic rat
myoblast in culture: Vinculin – blue, Actin –
green, DNA - UV absorbent, Mitochondria –
red.
http://www.olympusfluoview.com/gallery/cells/a10/a10exlarge3.html
3. Identify the parts of the skeletal muscle: muscular fibers, endomysium, perimysium, epimysium,
tendon, and belly of the muscle.
Muscle consists of muscular
fibers imbedded in the layers of
connective tissue. Epimysium is
a layer of dense connective
tissue, which covers the entire
muscle. Perimysium is less
dense CT, it surrounds fascicles
(bundles of muscle fibers (cells).
Endomysium is composed of
loose reticular fibers and
surrounds individual muscle
cells (fibers). At the end of the
muscle the layers of connective
tissue fuse together and form a
tendon, band of CT that
attaches muscle to bone. When
muscular fibers contract they
pull connective tissue which
pulls the bone and generates
movement.
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The command to contract is an action potential that comes from the motor neuron via an axon. The
synapse between the axon
terminal and the membrane
of a muscular cell
(sarcolemma) is called the
neuromuscular junction. On
the muscular side the
sarcolemma has a folded
appearance to increase the
receptor covered surface.
This site is referred to as the
motor end plate. The AP
generated on the motor end
plate propagates along
entire sarcolemma and the
T-tubes which are
extensions of sarcolemma.
See images below.
The cytoplasm of the

muscular fiber (cell) is
referred to as sarcoplasma.
The sarcoplasma is filled
with myofibrils. The
myofibril contains thick and
thin filaments which are
organized in repeating
structures called
sarcomeres.
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4. Describe and identify the features of myofibril: sarcomere, thick and thin filaments, A-band, I band,
M-line, Z-line, sarcoplasmic reticulum, T-tubules, triad, motor end plate.
The Sarcomeres are made of thin and thick filaments. Thin filaments are made of actin; they are
attached to Z-line.
I-band (light stripe) is contains only
thin filaments (made of actin).
Thick filaments are made of myosin;
they are attached to M-line.
A-band (dark stripe) has both thick and
thin filaments.
When muscle contracts thin filaments
slide between the thick: I-band and H-
band (thick only) become more
narrow, total sarcomere becomes
shorter.
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For effective contraction of the entire muscle it is extremely important that all of the sarcomeres
contract at the same moment. To trigger
sarcomere contraction calcium must be
released from the sarcoplasmic reticulum
in the sarcoplasm.
Calcium is released from the sarcoplasmic

reticulum (SR) when the action potential
that is generated on the sarcolemma
propagates down to the transverse tubules
(T-tubule). T-tubules are tubular
extensions of the cell membrane that are
wrapping around myofibrils and compose
triads with terminal cisternae of SR. The AP
is generated on the motor end plate of the
sarcolemma when enough of ACh from
synaptic bulb of the motor axon is binding
to the receptors. The junction between the
axon and the muscular fiber is referred to
as neuromuscular junction.

Follow the process of muscle contraction from motor neuron in CNS to filaments in the image below.
http://www.andrew.cmu.edu/user/jessicaz/molecular_data/NMJ_files/image002.jpg
77
The EM image to the left demonstrates
motor end plates with a part of muscular
fiber and axon terminal.
Please identify synaptic cleft, note the

folds of motor end plate of sarcolemma.
Identify Z-lines and sarcomeres of
myofibrils. Note abundance of
mitochondria between myofibrils and in
nerve end.
http://131.229.114.77/microscopy/images/ElkeP1.jpg
EM image to the right shows

neuromuscular junction at large
magnification. Please identify:
axon terminal, folds of sarcolemma,
and synaptic cleft, note a T-tubule in
the right lower corner.
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The force of muscular contraction

depends on number of motor units
engaged. Motor unit (MU) includes
all muscular fibers (cells) that are
controlled by same neural cell.
When AP reaches these fibers they
all contract simultaneously. It can be
from few to few hundred muscular
fibers in one motor unit. The more
motor units involved in the
contraction the stronger contraction
of the muscle.
Motor neuron pool (MNP) includes
all motor neurons that control the
same muscle. Axons from the same
MNP usually travel together through
spinal cord and peripheral nerves.
Please appreciate and follow the

sensory and motor signals leading to
muscular contraction in the image to
the right.
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7. Discuss clinical applications of muscle and neural anatomy: Guillain-Barre syndrome, multiple
sclerosis, myasthenia gravis, muscular dystrophy, myocardial infarction and necrosis.
Guillain-Barre Syndrome is a rare peripheral nerve autoimmune disease that is a disease of

demyelination. Antibodies attack Schwann’s
cells but not oligodendrocytes. Symptoms
are usually bilateral weakness or loss of
sensation starting in your feet and legs and
spreading to your upper body and arms. The
paralysis may progress, and can rarely cause
death due to paralysis of respiratory muscles.
Most symptoms subside in 2-4 weeks and
never occur again. Risk factors: viral and
bacterial infections, other autoimmune
diseases.
Demyelination of peripheral nerve is

demonstrated in the image to the left.
Multiple sclerosis (MS) is a loss or damage of the myelin coating in the CNS. MS disrupts the
transmission of signals between the brain, spinal cord and the rest of the body. Specific symptoms of MS
vary from one person to another and over time for any given individual, depending on the part of CNS
where the damage occurs, they may range from mild sensory disturbances, to motor problems to
complete loss of memory and thinking ability. The most common type of MS is called relapsing-remitting
MS (RRMS). Relapse is acute exacerbation of symptoms believed to be caused by inflammation in CNS.
Relapses are followed by remissions as the inflammatory process subsides. Remission doesn’t
necessarily mean that the symptoms totally disappear, patient may or may not have some symptoms in
remission.
In MS, antibodies cross blood-brain barrier and attack oligodendrocytes. Myelin repair in CNS is
dependent on oligodendrocytes and their precursors, oligodendrocyte precursor cells (OPCs). Brain
imaging allows researchers to measure the amount of myelin in the white matter of the brain. Analysis
of such images from MS patients shows multiple cycles of demyelination and remyelination in the same
sites of the white matter, but remyelination has been less and less complete after each cycle.
MS risk factors are viral infections, autoimmune reactions, family history and vitamin D deficiency. There
is currently no cure for MS, but there are therapeutic options including anti-inflammatory therapy,
interferons, receptor modulators and folk medicine. These therapies can significantly improve quality of
life and life expectancy of MS patients.
Please refer to Blue Boxes in M&A: pp. 638 Demyelinating Diseases and the Optic Nerve
80
In gross pathology multiple
sclerosis presents as
multiple disseminated
hardened plaques
(lesions) that are
resemble small
vessel’s diseases of
the brain.
Dissemination of
lesions in space and
time is characteristic
for MS. MS lesions
are typically found in
corpus callosum,
around ventricles,
temporal lobes,
brainstem, cerebellum and spinal cord. Juxtacortical lesions (touching the cortex) are specific for MS.
MRI is the preferred method of MS diagnosis. For positive diagnosis, multiple lesions should be seen on
the MRI, while some of the lesions may be asymptomatic. Spinal tap and a subsequent test of CSF for
antibodies are also used for diagnostic of MS.
http://www.radiologyassistant.nl/en/p4556dea65db62/multiple-sclerosis.html
Myastenia Gravis (MG) is also an autoimmune disease. Antibodies attack Ach receptors on postsynaptic
membrane of neuromuscular junction.
http://www.bmb.leeds.ac.uk/illingworth/muscle/gravis.htm
http://jama.ama-assn.org/content/293/15/1940.full
Compare EM image of Normal Neuromuscular junction (NMJ) (left) and NMJ with myasthenia gravis
(right). Note exhausted axoplasm with vacuoles (AX) and large synaptic cleft (SC) in the myasthenia.
81
Risk factors for development of myasthenia gravis are infections, allergies, and stress. Symptoms of MG
may include ptosis, difficulty speaking, swallowing, maintaining posture, keeping balance, & breathing.
Ptosis –drop of the eyelid, is one of the common symptoms of myasthenia gravis.
Muscles may become dystrophic due to lack of stimulations, exercise, malnutrition, genetic disorders,
poor blood supply etc.
Dystrophic muscles are characterized

by discoloration and thinning of
muscular fibers, abundance of nuclei in
extracellular space. Dystrophy is
usually a chronic condition.
82
The triangular
("angulated")
appearance of these
shrunken skeletal
muscle fibers is
characteristic of
neurogenic atrophy,
when the nerve was
severed.
http://www.pathguy.com/~tdemark/0012.htm
Acute injury to the muscle can cause death of multiple cells and is characterized by presence of multiple
nuclei of dead
cells as well as
WBC in the
extracellular
space. See
image of
coagulative
necrosis of
cardiac muscle
in acute
myocardial
infarction to the
left.
83
Muscular tissue can be replaced by
connective tissue in further stages of
repair. Healed myocardial infarction is
presented by wavy fibrotic tissue.
Healed MI tissue in the image to the

right.
84
Lecture 6: Head and Neck Muscles; Reflexes
Objectives
5. Identify the muscles of facial expression and muscles of mastication, their origin, insertion,
action and innervations.
Skeletal muscle mostly consists of skeletal muscular tissue and connective tissue proper. In the skeletal
muscle, individual skeletal muscle fibers are wrapped in loose connective tissue called endomysium, the
bundles of these fibers, known as fascicles are wrapped in the membranes of connective tissue called
perimysium and the whole muscle is wrapped in dense connective tissue called epimysium which is a
part of deep fascia. At the ends of the muscle, these layers of connective tissue do not end; instead,
they are fused together to make tendons (or aponeuroses), which in turn are strongly attached to the
bones, other muscles, or other body parts.
When the muscular fibers contract within a muscle, they pull connective tissue, which pulls the tendon
that pulls the bone (or another organ attached to the tendon). When muscular fibers relax, the elasticity
of connective tissue returns the muscle to the initial position.
Origin and insertion of
the muscle are the sites
where connective tissue
attaches muscle to the
bone. Insertion is
usually the more
moveable part;
normally, insertion is
pulled toward the origin
rather than vice versa.
There is usually only one
insertion, while there
can be few origins
(heads; e.g. two heads
of the biceps bracii).
Origin is usually more
proximal than insertion
and can be wider than
insertion.

Tendons are stripes or sheets of dense connective tissue that attach skeletal muscles to bones or other
moveable parts. Aponeuroses attach muscle to muscle. Ligaments attach bone to bone. Ligament may
be also be used to referred to other attachments; e.g. visceral organs to the abdominal wall, or to each
other.
85
Most of the skeletal muscles are attached to the bones and move the bones that they are attached to.
To move a bone, the muscle must bypass at least one joint. When describing movement, anatomists
usually name the joint or the bone that is moving and the type of movement which occurs in this joint;
e.g. flexion of elbow, or flexion of ulna (forearm). Muscles that have the same action are called
synergists; e.g. biceps and brachioradialis both flex the elbow. Muscles that perform opposite
movements are called antagonists; e.g. biceps and triceps.
86
87
5. Identify the muscles of facial expression and muscles of mastication, their origin, insertion, action
and innervations.
Most of the muscles of facial expression have their origin on the bones of the skull and insertion in the
skin of the face. When they contract they move the parts of the face and give different expressions.
Muscles of facial expression: Galea aponeurotica (epicranial aponeuroses) connects frontalis and
occipitalis, orbicularis ocili, levator labii superioris, zygomaticus major and minor, risorius, platisma
depressor anguli oris, sternocleidomastoid, mentalis, depressor labii inferioris, orbicularis oris,
orbicularis oculi, buccinators, corrugator supercilii, levator palpebrae superioris, nasalis.
http://www.oxford174.com/diagram-of-facial-muscles/
88
TABLE 7.3 MAJOR FUNCTIONAL MUSCLES OF FACE AND SCALP
Musclea Origin Insertion Main Action(s)
Occipitofrontalis
Frontal belly Epicranial aponeurosis Skin and Elevates eyebrows and

subcutaneous wrinkles skin of
tissue of eyebrows forehead; retracts scalp
and forehead (indicating surprise or
curiosity)
Occipital belly Lateral two thirds of Epicranial Retracts scalp;

superior nuchal line aponeurosis increasing effectiveness
of frontal belly
Orbicularis Medial orbital margin; Skin around Closes eyelids: palpebral

oculi (orbital medial palpebral margin of orbit; part does so gently;
sphincter) ligament; lacrimal bone superior and orbital part tightly
inferior tarsi (winking)
(tarsal plates)
Orbicularis Medial maxilla and Mucous Tonus closes mouth;

oris (oral mandible; deep surface membrane of lips phasic contraction
sphincter) of peri-oral skin; angle compresses and
of mouth protrudes lips (kissing)
or resists distension
(when blowing)
Buccinator Mandible, alveolar Angle of mouth Presses cheek against

(cheek processes of maxilla (modiolus); molar teeth; works with
muscle) and mandible, orbicularis oris tongue to keep food
pterygomandibular between occlusal
raphe surfaces of teeth and
out of oral vestibule;
resists distension (when
blowing)
Platysma Subcutaneous tissue of Base of mandible; Depresses mandible

infraclavicular and skin of cheek and (against resistance);
supraclavicular regions lower lip; angle of tenses skin of inferior
mouth; orbicularis face and neck
oris
89
(conveying tension and
stress)
Zygomaticus Zygomatic arch Angle of the Elevates angle of the

Major mouth mouth (smile)
Zygomaticus Zygomatic arch Upper lip Elevates upper lip

Minor
Risorius Fascia (connective Angle of the Retracts angle of the

tissue) of the cheek mouth mouth (false smile)
near ear
Depressor Mandible Angle of the Depresses angle of the

anguli oris mouth mouth
Mentalis Mandible Lower lip (inferior) Protracts lower lip
All facial muscles are innervated by the facial nerve (CN VII) via its posterior auricular branch or
via the temporal, zygomatic, buccal, marginal mandibular, or cervical branches of the parotid
plexus.
90
91
Muscles of
mastication:
masseter,
temporalis,
pterygoid medial
and pterygoid
lateral.
92
Muscle Origin Insertion Main Action(s)
Masseter Zygomatic arch Angle of the mandible Bilateral - elevates and protracts
mandible, unilateral – turns jaw
contra-laterally
Temporalis Temporal bone Coronoid process of Elevates mandible

the mandible
Pterygoid Pterygoid pcs Medial surface of Elevates and protracts mandible

medial of sphenoid mandibular angle and Unilateral - side to side
ramus
Pterigoid Pterygoid pcs Mandibular condyle Depresses and protracts

lateral of sphenoid mandible
Unilateral - side to side
All muscles of mastication are innervated by the mandibular nerve branch of trigeminal (CN V) via
it’s branches.
M&A pp. 538-539 Fig.7.41 and 7.42.
93
Muscles that move the tongue: Genioglossus, Hyoglossus, Styloglossus, Palatoglossus. Intristic
muscles: vertical, longitudinal and transverse fibers.
Genioglossus Posterior mental Ventral surface Bilateral- depresses and

protuberance of the of the tongue protrudes the tongue
mandible Unilateral – turns the tip of
the tongue contra-laterally
Genioglossus is supplied by the Hypoglossal nerve (CN XII).
Sternocleidomastoid muscle moves the head.
Sternocleidomastoid Manubrium of the Mastoid Bilateral- flexes cervical vertebrae

sternum pcs and extends head
Medial clavicle Unilateral – flexes the neck laterally
and rotates face to contralateral
side
Sternocleidomastoid muscle receives motor signals from the Accessory (spinal accessory) nerve (CN
XI). Sensations from this muscle perceived via cervical plexus.
94
95
Reflexes
Objectives
1. Describe the steps in a neural reflex
1. Describe the steps in a neural reflex
http://www.answers.com/topic/reflex-arc"Reflex arc." The Oxford Dictionary of Sports Science. Oxford

University Press, 1998, 2006, 2007. Answers.com 10 Dec. 2010.
A reflex is a specific motor reaction to a specific stimulus. A reflex arc is the pathway followed by nerve
impulses that produce a reflex. An ideal reflex arc consists of 5 steps: 1) receptor,
2) afferent fiber, 3) interneuron(s),
4) efferent fiber and 5) effector.
1. Receptors convert external or internal stimulus (e.g. light, heat, pressure, chemical changes) into the
action potentials.
2. Afferent (sensory) fibers transmit these signals to the interneurons in CNS.
3. Interneurons integrate and process the signals; it may be one or few interneurons or no interneuron
at all.
4. Motor fibers transfer the AP from CNS to the effector.
5. Effectors (e.g. skeletal muscles, smooth muscles, glands) perform the response.
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Reflexes can be classified by the site of processing: e.g. spinal, brain stem, cerebral, etc.
Spinal reflexes are processed at the level of the spinal cord. This allows the faster motor reaction
because the motor neuron is activated without sending signals to the brain and back. Although, the
brain still receives the signal while the motor reaction is occurring: e.g. myotatic stretch reflexes.
Brain reflexes are processed at the level of the brain. Their absence indicates brain death; e.g. pupillary,
pharyngeal, cough reflexes. Cough reflex is coughing in response to irritation of the airway linings.
Pupillary reflex is a contraction of the pupil in response to the light. Pharyngeal reflex is a contraction of
pharyngeal constrictor muscle in response to touching the back of the pharynx.
Reflexes can be classified by the number of synapses: polysynaptic vs. monosynaptic. Polysynaptic
reflexes involve more than one synapse. They are often complex and take a longer time. Monosynaptic
reflexes involve just one synapse. There are no interneurons involved and processing occurs in the
motor neuron. These reflexes are the most simple and fastest.
Myotatic stretch reflexes are an example of a

spinal monosynaptic reflex. A stretch reflex is the
contraction of the muscle in response to the
stretching of the muscle spindles. Muscle
spindles are receptors inside the muscle that lie
parallel to muscle fibers. When a muscle spindle
is stretched the sensory neuron sends the signal
to the motor neuron in the ventral horn of the
spinal cord which in turn sends the signal back to
the muscle and the muscle contracts. Stretch
reflexes are very important to maintain posture
and balance. For the testing purposes the
myotatic stretch reflexes can be checked by brisk
taping of the tendon of the corresponding
muscle: knee jerk reflex (patellar ligament) ,
ankle jerk reflex (Achilles tendon), biceps reflex
(biceps tendon), brachioradialis reflex, jaw jerk,
finger jerk, etc.
http://thebrain.mcgill.ca/flash/d/d_01/d_01_cr/d_01_cr_fon/d_01_cr_fon.html
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Hyporeflexia – absent or low response to tapping (weak reflexes). Hyperreflexia – repeating or too
strong response. Even if the reflex is monosynaptic information is actually sent to the cortex as a
reference.
The Golgi tendon organ (GTO) reflex
prevents overstretching of the muscle. ,
Illustration of the Stretch Reflex GTO is another receptor located
between the muscle and the tendon.
When muscle contraction is too strong
GTO sends the signal to the spinal cord
and synapses on an inhibitory
interneuron that is causing relaxation of
the muscle. Another neuron may cause
contraction of antagonist to stretch the
first muscle.
Reflexes can be classified by their

development: innate vs. acquired.
Inborn or innate reflexes are involuntary
13-16 and unlearned. Withdraw reflex is
pulling your body part away from pain
(e.g. hand away from a hot surface when touched). Palatine reflex is a swallowing in response to
stimulation of the palate. Grasp reflex is a flexion of the fingers (grasping) in response to stimulation of
the palm (in infants). Rooting reflex; when an infant's cheek is stroked, the baby responds by turning his
or her head in the direction of the touch and opening their mouth for feeding. Learned or acquired
reflexes are often complex, learned motor patterns acquired during the lifetime; e.g. walking on two
extremities, biking, swimming, driving the car, reading, writing, speech, languages, following the traffic
rules, etc.
Reflexes can be classified by the effector organs: somatic vs. autonomic (visceral). Somatic Reflexes:
involve contractions of the skeletal muscles. Examples: Knee Jerk reflex, biking. Babinski's
reflex dorsiflexion of the big toe results from firmly stroking the lateral outer margin of the sole. In
adults positive Babinski is a sign of the lesions in the cortex or in the pyramidal tract, although it is a
normal reflex in infants, since their cortex and tracts are not completely developed yet.
Autonomic or visceral reflexes: involve glands, smooth and cardiac muscles, and generally are not
consciously perceived. The main integrating centers for most autonomic reflexes are located in the
hypothalamus and brain stem. Some autonomic reflexes, e.g. for urination and defecation, have
integrating centers in the spinal cord. Peristaltic reflex, when a portion of the intestine is full (stretched
and irritated), the area just proximal contracts and the area just distal relaxes. Pilomotor reflex, when
stroking or tickling the skin causing the activation of arrector pili with formation of goose bumps.
Baroreceptor reflex, the response to stimulation of baroreceptors of the carotid sinus and aortic arch,
regulating blood pressure by controlling heart rate, strength of heart contractions, and diameter of
blood vessels.
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Babinski test is an example
of testing the brain reflexes.
To perform Babinski’s test,
the sole of the foot must be
firmly stroked on the lateral
side in the direction from
heel to toes as it shown in
the image.
http://medical-dictionary.thefreedictionary.com/Babinski+reflex
A and B normal adult plantar reflex causes a flexion of the hallux and toes ( Negative Babinski’s sign).
C is positive Babinski’s sign, when the big toe moves
toward the dorsum of the foot and the other toes fan out in response to the foot stroke.
Positive Babinski’s is normal in babies. Positive Babinski’s after age 2 is a sign of damage to the nerve
paths connecting the spinal cord and the brain (the corticospinal tract).
Underlying causes of positive Babinski’s test may be head trauma, stroke, meningitis, multiple sclerosis,
brain tumor etc. A Babinski's reflex can occur on one side or on both sides of the body. Patients with
positive Babinski’s may complain of poor coordination and muscle spasms or weakness.
http://what-when-how.com/neuroscience/the-upper-motor-neurons-motor-systems-part-3/
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Please refer to Blue Boxes in M&A: p. 436 Bicipital Myotatic Reflex, p. 362 Calcaneal Tendon Reflex,
p.333 Patellar Tendon Reflex, p. 369 Plantar Reflex.
Label and list the action of the musles in the image above.
100
Lecture 7: Cranial Nerves
Objectives
1. List the twelve pairs of cranial nerves.
2. Explain functions and types of the twelve pairs of cranial nerves.
3. Identify location and function of each cranial nerve and discuss clinical applications of cranial
nerve impairments.
1. List the twelve pairs of cranial nerves.

I – Olfactory
II – Optic
III –Oculomotor
IV – Trochlear
V – Trigeminal
VI – Abducens
VII – Facial
VIII – Vestibulocochlear
IX – Glossopharyngeal
X – Vagus
XI – Accessory (Spinal Accessory)
XII – Hypoglossal
2. Explain functions and types of twelve pairs of cranial nerves.

Cranial nerves, like spinal nerves, contain sensory or motor fibers, or a combination of these fibers.
Cranial nerves innervate muscles or glands or carry impulses from sensory receptors. They are called
cranial nerves because they emerge from foramina or fissures in the cranium and are covered by tubular
sheaths derived from the cranial meninges.
Cranial nerves carry one or more of the following five main functional components:
Motor (efferent) fibers
1. Motor fibers innervating voluntary (striated) muscle: Somatic motor (general somatic efferent) axons
innervate the striated muscles in the orbit, tongue, and external muscles of the neck
(sternocleidomastoid and trapezius) as well as striated muscles of the face, palate, pharynx, and larynx.
The muscles of the face, palate, pharynx, and larynx are derived from the pharyngeal arches and their
somatic motor innervation is CN III, IV, VI, VII, XI, & XII.
2. Motor fibers involved in innervating glands and involuntary (smooth) muscle (e.g., in viscera and
blood vessels). These include visceral motor (general visceral efferent) axons that constitute the cranial
outflow of the parasympathetic division of the autonomic nervous system. The presynaptic
(preganglionic) fibers that emerge from the brain synapse outside the central nervous system in a
parasympathetic ganglion. The postsynaptic (postganglionic) fibers innervate glands and smooth muscle
throughout the body: CN III, VII, IX, & X.
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Sensory (afferent) fibers
3. Fibers conveying sensation from the viscera. These include visceral sensory (general visceral afferent)
fibers conveying information from the carotid body and sinus, pharynx, larynx, trachea, bronchi, lungs,
heart, and gastrointestinal tract: CN X.
4. Fibers transmitting general sensation (e.g., touch, pressure, heat, cold) from the skin and mucous
membranes. These include somatic (general) sensory fibers: mainly CN V, but also CN VII, IX, & X).
5. Fibers transmitting unique sensation. These include special sensory fibers conveying taste and smell
and those serving the special senses of vision, hearing, and balance: CN I, II, & VIII.
I – Olfactory: special sensory (smell).
II – Optic: special sensory (vision)
III –Oculomotor: somatic motor, visceral motor, general sensory (proprioceptive).
IV – Trochlear: somatic motor.
V – Trigeminal: mixed - general sensory and somatic motor.
VI – Abducens: somatic motor.
VII – Facial: mixed - somatic motor, visceral motor, general sensory, special sensory (taste).
VIII – Vestibulocochlear: special sensory (hearing and equilibrium).
IX – Glossopharyngeal: mixed - somatic motor, visceral motor, general sensory, special sensory (taste).
X – Vagus: mixed - somatic motor, visceral motor, general sensory, special sensory (taste).
XI – Accessory: somatic motor.
XII – Hypoglossal: motor.
3. Identify location and function of each cranial nerve and discuss clinical applications of cranial nerve
impairments.
Olfactory Nerve: (CN I)
Loss of smell is referred to as

anosmia. It occurs naturally
with aging. Temporary anosmia
may result from infectious or
allergic inflammation of the
nasal mucosa.
Injury to the nasal mucosa,
olfactory nerve fibers, olfactory
bulbs, or olfactory tracts may
also impair smell. In severe
head injuries, the olfactory
bulbs may be torn away from
the olfactory nerves, or the
olfactory nerve fibers may be
torn as they pass through a
fractured cribriform plate. If all the nerve bundles on one side are torn, a complete loss of smell occurs
on that side. Consequently, anosmia may be a clue to a fracture of the cranial base. Rhinorrhea is a
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leakage of cerebrospinal fluid (CSF) through the nose from the subarachnoid space. Olfaction disorders
are also linked with psychiatric illnesses (e.g., schizophrenia) and epilepsy. These patients may
experience distortion of smell (parosmia) or perceive an odor when there is none present (olfactory
hallucination). Smoking or sniffing drugs also affects olfaction.
Optic nerve (CN II)

The optic nerve passes posterior in the orbit, exits through the optic canal (optic foramen) to enter the
middle cranial fossa, where it forms the optic chiasm. Here, fibers from the nasal (medial) half of each
retina decussate in the chiasm
and join uncrossed fibers from
the temporal (lateral) half of
the retina to form the optic
tract. The partial crossing of
optic nerve fibers in the
chiasm is a requirement for
binocular vision, allowing
depth-of-field perception
(three-dimensional vision).
Thus, fibers from the right
halves of both retinas form
the right optic tract, and those
from the left halves form the
left optic tract. The
decussation of nerve fibers in
the chiasm results in the right
optic tract conveying impulses
from the left visual field and
vice versa.
The visual field is what is seen by a person with both eyes wide open and looking straight ahead. Most
fibers in the optic tracts terminate in the lateral geniculate bodies (nuclei) of the thalamus. From these
nuclei, axons are relayed to the visual cortices of the occipital lobes of the brain.
Visual field defects may result from a large number of neurologic diseases. It is clinically important to
be able to link the defect to a likely location of the lesion.
Demyelinating Diseases and the Optic Nerve
Because the optic nerves are actually CNS tracts, the myelin sheath that surrounds the fibers from the
point at which they penetrate the sclera is formed by oligodendrocytes rather than by Schwann cells.
Consequently, the optic nerves are susceptible to the effects of demyelinating diseases of the CNS, such
as multiple sclerosis (MS).
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104
105
106
Occulomotor Nerve (CN III)
Cranial nerve III originates
from the mesencephalon, and
supplies somatic motor
innervation to four of the six
extra-ocular muscles
(superior, medial, and inferior
rectus and inferior oblique)
and to the levator palpebrae
superioris. It also supplies
proprioceptive innervation to
aforementioned muscles, and
visceral (parasympathetic)
motor innervation to the
smooth muscle of the
sphincter pupillae. The visceral
innervation causes
constriction of the pupil and
ciliary muscle to produce accommodation (allowing the lens to become more rounded) for near vision.
Characteristic signs of a complete lesion of CN III are: Ptosis (drooping) of the superior eyelid caused by
paralysis of the levator palpebrae superioris. Eyeball (pupil) abducted and directed slightly inferiorly
(down and out) because of unopposed actions of the lateral rectus and superior oblique.
No pupillary (light) reflex
(constriction of the pupil in
response to bright light) in the
affected eye.
Dilation of the pupil resulting
from the interruption of the
parasympathetic fibers to the
sphincter pupillae leaves the
dilator pupillae unopposed.
No accommodation of the
lens (adjustment to increase
convexity for near vision)
because of paralysis of the
ciliary muscle.
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Trochlear Nerve (CN IV)
Cranial nerve IV originates between mesencephalon and pons. The trochlear nerve (CN IV) provides
somatic motor and
proprioceptive
innervation to the
superior
oblique.
CN IV is rarely
paralyzed alone.
The characteristic
sign of trochlear
nerve injury is
diplopia (double
vision) when
looking down (e.g.,
when going down
stairs). Diplopia occurs because the superior oblique normally assists the inferior rectus in depressing
the pupil (directing the gaze downward) and is the only muscle to do so when the pupil is adducted.
Trigeminal Nerve (CN V)

Originates from the pons and is the largest of the cranial nerves, (except Vagus) fibers extend from pons
to face and forms three divisions (trigeminal—threefold) ophthalmic, maxillary, and mandibular
divisions.
The trigeminal nerve is major general sensory nerve of the face transmitting afferent impulses from
touch, temperature, and pain receptors. Cell bodies of sensory neurons of all three divisions are located
in large trigeminal (also called semilunar or gasserian) ganglion. The mandibular division also contains
some motor fibers that innervate chewing muscles.
Ophthalmic division
(V1) fibers run from
face to pons via
superior orbital fissure
along with CN III, IV
and VI. Bring senses
from the superior eye
lid and nose (corneal
and sneezing reflexes).
Carries out
sympathetic fibers to
dilator pupillae and
some other smooth
muscles.
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Maxillary division (V2) fibers run from face to pons via foramen rotundum. Bring senses from the
inferior eye lid and maxillary face.
Mandibular division (V3) fibers pass via foramen ovale. Mixed! (Sensory to mandible and motor for
mastication).
The trigeminal nerve (CN V) emerges from the lateral aspect of the pons by a large sensory root and a
small motor root. CN V is the principal general sensory nerve for the head (face, teeth, mouth, nasal
cavity, and dura of the cranial cavity).The fibers of the motor root of CN V are distributed exclusively via
the mandibular nerve (CN V3) to the muscles of mastication, and some other muscles.
Injury to Trigeminal Nerve
CN V may be injured by trauma, tumors, aneurysms, or meningeal infections causing: Paralysis of the
muscles of mastication with deviation of the mandible toward the side of the lesion, loss of the ability to
appreciate soft tactile, thermal, or painful sensations in the face, loss of the corneal reflex (blinking in
response to the cornea being touched) and the sneezing reflex.
Trigeminal Neuralgia. Trigeminal neuralgia (tic douloureux) is the principal disease affecting the
sensory root of CN V. It produces excruciating, episodic pain that is usually restricted to the areas
supplied by the maxillary and/or mandibular divisions of CN V.
Abducens Nerve (CN VI)

Originates between pons and medulla.
The abducens (abducent) nerve (CN

VI) provides somatic motor to and
proprioceptive information from one
extra-ocular muscle, the lateral rectus.
CN VI has a long intracranial course. So, it
is often stretched when intracranial
pressure rises.
A space-occupying brain
tumor may compress CN VI
causing paralysis of the
lateral rectus muscle.
Complete paralysis of CN VI
causes medial deviation of
the affected eye due to the
unopposed action of the
medial rectus.
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Facial Nerve (CN VII)
Cranial nerve VII originates between pons and medulla. The motor part and sensory part of the facial
nerve enters the temporal bone via the internal auditory (acoustic) meatus close to the inner ear and CN
VIII. Then it emerges from the stylomastoid foramen and passes through the parotid gland where it
divides into five major branches.
Somatic (Branchial) Motor: as the nerve of the second pharyngeal arch, the facial nerve supplies the
striated muscles derived from its mesoderm, mainly the muscles of facial expression.
Visceral
(Parasympathetic)
Motor: the
parasympathetic
fibers of CN VII
provide innervation of
the lacrimal, nasal,
pharyngeal, and
palatine glands and to
the submandibular
ganglion for
innervation of the
sublingual and
submandibular
salivary glands.
Parasympathetic
fibers synapse in these
ganglia, whereas
sympathetic and other
fibers pass through
them.
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Somatic (General) Sensory: some fibers from the geniculate ganglion supply a small area of skin close to
the external acoustic meatus.
Special Sensory (Taste): fibers carried by the lingual nerve convey taste sensation from the anterior two
thirds of the tongue and soft palate.
Injury to Facial Nerve
A lesion of CN VII is accompanied by a loss of motor, gustatory (taste), and autonomic functions. The
motor paralysis of the facial muscles involves upper and lower parts of the face on the ipsilateral (same)
side (Bell palsy) causing dry eyes and drooping lower eye lead.
Because it passes through the facial canal, CN VII is vulnerable to compression when a viral infection
produces inflammation of the nerve (viral neuritis).
Corneal Reflex
Loss of the corneal reflex may occur if either the ophthalmic nerve (CN V1) or the facial nerve (CN VII)
has a lesion. The corneal reflex is tested by touching the cornea with a cotton wisp. A bilateral blinking
response should result.
Vestibulocochlear nerve (CN VIII)

Originates between pons and medulla.
The vestibulocochlear nerve

(CN VIII) is a special sensory
nerve of hearing and
equilibrium. The
vestibulocochlear nerve
emerges from the junction
of the pons and medulla and
enters the internal acoustic
meatus. Here, it separates
into the vestibular and
cochlear nerves. The
vestibular nerve is
concerned with equilibrium.
The cochlear nerve is
concerned with hearing.
Injuries of the Vestibulocochlear Nerve:

Although the vestibular and cochlear nerves are essentially independent, peripheral lesions often
produce concurrent clinical effects because of their close relationship. Hence, lesions of CN VIII may
cause tinnitus (ringing or buzzing of the ears), vertigo (dizziness, loss of balance - ataxia), and
impairment or loss of hearing. Central lesions may involve either the cochlear or vestibular divisions of
CN VIII.
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Glossopharyngeal Nerve (CN IX)
The glossopharyngeal nerve (CN IX) emerges from the lateral aspect of the medulla and passes
anterolaterally to leave the cranium through the jugular foramen.
Somatic (Branchial) Motor: motor fibers pass to one muscle, the stylopharyngeus.
Visceral (Parasympathetic) Motor: parasympathetic fibers provide for innervation of the parotid gland.
Somatic (General) Sensory: The pharyngeal, tonsillar, and lingual branches supply the mucosa of the
oropharynx, soft palate, and posterior third of the tongue. Stimuli determined to be unusual or
unpleasant here may evoke the gag reflex or even vomiting. Via the tympanic plexus, CN IX supplies the
mucosa of the tympanic cavity, pharyngotympanic tube, and the internal surface of the tympanic
membrane.
Special Sensory (Taste): taste fibers are
conveyed from the posterior third of
the tongue to the sensory ganglia.
Visceral Sensory: the carotid sinus
nerve supplies the carotid sinus, a baro-
(presso-) receptor sensitive to changes
in blood pressure, and the carotid
body, a chemoreceptor sensitive to
blood gas (oxygen and carbon dioxide)
levels. If a person is hyperventilating
the blood is alkaline. If a person is
hypoventilating, the blood is acidic.
Lesions of Glossopharyngeal Nerve:
Isolated lesions of CN IX or its nuclei
are uncommon. Injuries of CN IX result
from infection or tumors are usually
accompanied by signs of involvement
of adjacent nerves. Because CN IX, CN X, and CN XI pass through the jugular foramen, tumors in this
region produce multiple cranial nerve palsies—the jugular foramen syndrome.
An isolated lesion would result in absence of taste on the posterior third of the tongue, difficulty in
swallowing, absent gag reflex on the side of the lesion, and palatal deviation toward the unaffected
side. The afferent (sensory) limb of the gag reflex is via the glossopharyngeal nerve (CN IX) and the
efferent (motor) limb is via the vagus nerve (CN X). The gag reflex is absent in about 37% of normal
individuals (Davies, 1995).
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Vagus Nerve (CN X)
The vagus nerve (CN X) arises by a series of rootlets from the lateral aspect of the medulla that merge
and leave the cranium through the jugular foramen positioned between CN IX and CN XI.
Visceral (Parasympathetic)
Motor fibers from the posterior
(dorsal) nucleus of the vagus
nerve supply the thoracic and
abdominal viscera to the left colic
(splenic) flexure.
Somatic (Branchial) Motor fibers

supply: pharyngeal muscles via
the pharyngeal plexus with fibers
of the glossopharyngeal nerve;
muscles of the soft palate and all
muscles of the larynx.
Somatic (General) Sensory: from
dura mater of posterior cranial
fossa; skin posterior to the ear;
external auditory canal; palate.
Special Sensory (Taste): carry
sense of taste from the root of the tongue and the taste buds on the epiglottis.
Visceral Sensory: convey sensory fibers from mucosa of the inferior pharynx at the esophageal junction,
epiglottis, and epiglottic folds; mucosa of larynx; baroreceptors in the aortic arch; chemoreceptors in the
aortic bodies; thoracic and abdominal viscera.CN X continues inferiorly in the carotid sheath to the root
of the neck, supplying branches to the palate, pharynx, and larynx.
Injury of a recurrent
laryngeal nerve (branch of
CN X) may be caused by
aneurysms of the arch of
the aorta and may occur
during neck operations.
Injury of the recurrent
laryngeal nerve causes
hoarseness and dysphonia
(difficulty in speaking)
because of paralysis of the
vocal folds (cords).
Paralysis of both recurrent
laryngeal nerves causes
aphonia (loss of voice) and
inspiratory stridor (a harsh,
high-pitched respiratory sound). Because of its longer course, lesions of the left recurrent laryngeal
113
nerve are more common than those of the right. Proximal lesions of CN X also affect the pharyngeal and
superior laryngeal nerves causing difficulty in swallowing and speaking.
Thyroidectomy
During a total thyroidectomy (excision of a thyroid gland with malignant tumors) the parathyroid glands
are in danger of being inadvertently damaged or removed. These glands are safe during subtotal
thyroidectomy because the most posterior part of the thyroid gland usually is preserved. Variability in
the position of the parathyroid glands, especially the inferior ones, puts them in danger of being
removed during surgery on the thyroid gland. If the parathyroid glands are inadvertently removed
during surgery, the patient suffers from tetany, a severe convulsive disorder. The generalized convulsive
muscle spasms result from a fall in blood calcium levels.
Lesions of Vagus Nerve
Isolated lesions of CN X are uncommon. Injury to the pharyngeal branches of CN X results in dysphagia
(difficulty in swallowing). Lesions of the superior laryngeal nerve produce anesthesia of the superior part
of the larynx and paralysis of the cricothyroid muscle. The voice is weak and tires easily. Proximal lesions
of CN X also affect the pharyngeal and superior laryngeal nerves, causing difficulty in swallowing and
speaking. Tachycardia and cardiac arrhythmia may occur. Severity of both Vagus nerves may result in
death due to a large parasympathetic deficit.
Accessory Nerve (CN XI)

The spinal accessory nerve (CN XI) is somatic motor innervation to the sternocleidomastoid
(SCM) and
trapezius
muscles.
Injury to Spinal
Accessory Nerve
Because of its nearly
subcutaneous passage
through the posterior
cervical region, CN XI is
susceptible to injury
during surgical
procedures such as
lymph node biopsy,
cannulation of the
internal jugular vein, and
carotid endarterectomy.
Lesions of CN XI produce weakened ability to shrug and atrophy of the upper part trapezius and
impairment of rotary movements of the neck and chin to the opposite side as a result of weakness of
the SCM.
Clinical signs are dropped shoulder and difficulty in rotating the neck.
114
Hypoglossal Nerve (CN XII)
The hypoglossal nerve (CN XII) is somatic motor to intrinsic and extrinsic muscles of the tongue
(styloglossus, hyoglossus,
genioglossus). The hypoglossal nerve
arises as a purely motor nerve by
several rootlets from the medulla and
leaves the cranium through the
hypoglossal canal.
Injury to Hypoglossal Nerve
Injury to CN XII paralyzes the ipsilateral
half of the tongue. After some time,
the tongue atrophies, making it appear
shrunken and wrinkled. When the
tongue is protruded, its apex deviates
toward the paralyzed side because of
the unopposed action of the
genioglossus muscle on the normal side of the tongue.
Blue Boxes in M&A p. 515 Trigeminal Neuralgia, p.516, Lesions of Trigeminal Nerve, Bell’s Palsy; p. 518
Fractures of the Orbit, p. 536 Pupillary Light Reflex, Corneal Reflex, Paralysis of Extra-ocular
Muscles/Palsies of Orbital Nerves, Oculomotor Nerve (CN III) Palsy, Abducent Nerve (CN VI) Palsy; p. 557
Gag Reflex, Paralysis of Genioglossus, Injury to Hypoglossal Nerve. pp. 638 Demyelinating Diseases and
the Optic Nerve.
M&A pp. 628-656 Review of Cranial Nerves.
115
Location of cranial nerves related to brain (review)
http://en.wikipedia.org/wiki/Cranial_nerve
116
Location of cranial nerves related to skull (review)
http://www.waltr.net/oncology/html/cns/cns-general.html
117
Lecture 8: Spinal Cord Pathways; Cortex.
Spinal Cord and Pathways
Objectives
1. Be able to identify the components of the spinal cord: dorsal, ventral and lateral grey horns,
anterior, posterior and lateral white columns, grey commissure and central canal. Describe their
functional significance and differences.
2. Explain the functional significance of the dorsal root ganglia.
3. Identify and differentiate between the three somatic sensory pathways: Dorsal Column – Medial
Meniscus Pathway, Anterolateral Spinothalamic Tracts, Spinocerebellar tracts.
4. Identify somatic motor pathway and rationalize the types of function losses from spinal cord
injuries.
1. Be able to identify the components of the spinal cord: dorsal, ventral and lateral grey horns,
anterior, posterior and lateral white columns, grey commissure and central canal. Describe their
functional significance and differences.
Review the role of white matter and gray matter in processing and relaying sensory information and
motor commands.
118
2. Identify the parts of the spinal cord and location of different types of neurons in spinal cord,
spinal nerves and adjacent ganglia.
4. Identify and differentiate between the three somatic sensory pathways: Dorsal Column –
Medial Lemniscus Pathway, Anterolateral Spinothalamic Tracts, Spinocerebellar tracts.
The somatosensory system is a division allowing the perception of different sensations from the body
(e.g. light touch, pain, pressure, temperature and proprioception). Different sensations are referred to
different areas of the brain via three different somatosensory (afferent) pathways:
1. Dorsal Column – Medial Lemniscus Pathway carries the signals of discriminative touch, which is a
perception of touch, pressure, vibration and texture. It allows for the feeling of shape and texture of the
object.
2. Anterolateral Spinothalamic Tracts carry signals of pain, temperature, tickling and itching.
3. Spinocerebellar tracts carry signals from joints, tendons and muscles (proprioception). It allows
feeling the position of the body parts (stretch, tension, movement) without looking at them. These
signals are referred to
the cerebellum which
receives second-to-
second feedback about
the movement of the
body.
1. Dorsal (posterior)
white column
(funiculus) is the white
matter of the spinal
cord lying between the
posterior median sulcus
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and the dorsal root. It contains only ascending (sensory) tracts: fasciculus gracilis and fasciculus
cuneatus.
Fasciculus gracilis (slender one) brings sensory signals from the legs and lower part of the body.
Fasciculus cuneatus (wedge-shaped)
brings sensory information from the
arms and upper body. The fasciculus
gracilis’ axons synapse in the gracile
nucleus, and the cuneate’s axons
synapse in the cuneate nucleus.in
medulla oblongata.
Dorsal Column – Median Lemniscus
Pathway is presented in the picture
to the right. The key to the picture is
summarized in the table below.
Dorsal column –Medial Lemniscus
pathway carries discriminative touch
signals from all the parts of the body
except face. These types of signals
from the face are carried by the
cranial nerves V and VII.
The signals from the upper part of
the body including hand and arm are
going through the fasciculus
cuneatus of dorsal column; the
signals from lower part of the body
are coming through f. gracile. In
medulla axons synapse in
corresponding nuclei and the signals
proceed via medial lemniscus
pathway, which decussates in
medulla.
Dorsal Column – Median Lemniscus Pathway consists of three neurons:

nd rd
1st order neuron (red in the 2 order neuron (blue) 3 order neuron
image) (violet)
Sensation comes via sensory Receives signals from 1st Receives signals from
axon of unipolar neuron. 2nd
Body is located in Dorsal Root Body of the neuron is located in Body is located in
Ganglion. medulla: Nucleus gracile or cuneate thalamus (clearing
nuclus. house of sensory info)
Primary afferent axons synapse Axon (secondary afferent) decussate Axon synapse in
in medulla (gracile fasciculus in crosses to the opposite side of cerebral cortex
gracile nucleus, cuneate medulla and then goes to synapse in
fasciculus in cuneate nucleus) thalamus.
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2. Anteriolateral Spinothalamic pathway carries signals of pain and temperature.
Anterolateral Spinothalamic Tracts ( Pain and Temperature) consists of three neurons:
1st order neuron 2nd order neuron 3rd order neuron

Collect signals from receptors Receives signals from 1st Receives signals from
of pain and temperature. 2nd
Body in dorsal root ganglia Body is in dorsal horns. Body is located in
thalamus (clearing
house of sensory info)
Synapse in dorsal horn of the Axon (secondary afferent) Axon synapse in
spinal cord. crosses to the opposite side of cerebral cortex
spinal cord to synapse in
thalamus.
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Compare discriminative touch pathway (left) to pain and temperature pathway (right) in the image
above.
3. Spinocerebellar tracts carry signals of proprioception (position of parts).
Compare discriminative touch pathway to proprioception pathway (blue) in the image above.
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Spinocerebellar Tracts (proprioception) consists of two neurons only:
nd
1st order neuron 2 order neuron
Collect signals from muscles and tendons in Receives signals from 1st
limbs and trunk
Body in dorsal root ganglia Body is in dorsal horns
Synapse in dorsal horn of the spinal cord. Axon synapses in the cerebellum on the
same side
IPSILATERAL
Please identify locations of the three sensory pathways (blue) in the image of spinal cord below.
In the summary:
Dorsal column - medial meniscus pathway decussates high in the medulla oblongata, thalamo-cortical
afferents go through internal capsule to primary somatosensory cortex at postcentral gyrus.
Anterolateral spinothalamic tracts (pain and temperature) decussates low in the spinal cord.
Spinocerebellar tracts do not decussate at all.
5. Identify somatic motor pathway and rationalize the types of function losses from spinal cord
injuries.
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Somatic motor pathways (red in the image above) carry signals from the CNS to skeletal muscles.
Initiation of movement is controlled by the prefrontal cortex, supplementary motor area, premotor
cortex and basal ganglia in the brain. Then the signal (“the command to do”) is communicated to the
primary motor cortex. Then the neurons in primary motor cortex send the action potentials via their
axons to the muscles required to perform the action, as well as a copy to the cerebellum. The neuron
that have their body in the head are called upper motor neurons.
The axons of upper motor neurons travel down through the brainstem and spinal cord (primarily via the
cortico-spinal tract, in the white matter) until they reach the spinal segment corresponding to the
muscle(s) they innervate. Most of these axons decussate “high” in the brain before they reach the
spinal cord. The axons of upper motor neurons synapse with the cell bodies of their corresponding
lower motor neurons (LMN) in the anterior or lateral grey horns of the spinal cord. The axons of LMN
travel out through the ventral roots to their destination, where they stimulate the muscle fibers to
contract.
http://medchrome.com/wp-content/uploads/2010/07/UMN-and-LMN.jpg
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Upper motor neurons (UMN) have their bodies in the motor cortex. Their axons synapse in the medulla
oblongata or in the spinal cord. UMN are completely inside the CNS. Damage to the UMN leads to
spasticity, increased muscular tone and exaggerated reflexes. About 90% of the axons of UMNs
decussate to the contralateral side in the medulla oblongata; the remaining 10% eventually cross over at
the spinal cord level when they synapse with an interneuron or LMN.
Lower motor neurons (LMN) receive the signals from UMNs and carry these signals to the skeletal
muscles via peripheral nerves (cranial or spinal).
Hyporeflexia – absent or low response to tapping (weak reflexes) usually indicate the damage of the
motor neuron within the reflex arc (lower neuron damage). Hyperreflexia – repeating or too strong
response to tapping indicates damage to the descending tracts of the corticospinal pathway (upper
neuron damage).
It is clinically important to distinguish between upper and lower motor neuron weakness. The signs of
UMN damage versus LMN damage are summarized in the table on the following page.
Lower motor neuron weakness (LMN) Upper motor neuron weakness (UMN)
Flaccid Spasticity
Decreased tone Increased tone
Decreased muscle stretch reflexes Increased muscle stretch reflexes
Profound muscle atrophy Minimal muscle atrophy
Fasciculations present Fasciculations absent
May have sensory disturbances May have associated sensory disturbances
http://www.neuroanatomy.wisc.edu/SClinic/Weakness/Weakness.htm
Fasciculations are irregular contractions of a group of muscle fibers that belong to one fascicle.
Clinically, this appears as a small muscle twitch.
It is also helpful, to differentiate between the sites of the LMN or muscle damage: body of neuron in the
anterior horn, myelination of axon (neuropathy), NMJ (myestenia gravis) or muscle itself (myopathy).
Practice questions:
Where would the sensory loss be, if you cut:

1). The left gracile fasciculus?
2). The left dorsal columns (gracile & cuneate)?
3). The right medial lemniscus, in the medulla?
Where the motor loss will be if the damage is:

4). In right side of the brain?
5). In the right anterior grey horn?
Answers:
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1) The left leg and lower left trunk. 2) The left side of the body below the level of the cut. 3) The entire
left body, from the neck down. 4) The left side of the body. 5). Muscles controlled by the peripheral
nerve at this level.
Cortex
Objective
1. Differentiate the major areas of the cerebral cortex: somatosensory cortex, motor cortex and
selected Brodmann’s areas.
The brain cortex is a thin (2-4mm

thick) layer of gray matter
overlying white matter. The cortex
forms convex folds (gyri) and
concave grooves (sulci or
fissures).
A longitudinal fissure separates

the left & right cerebral
hemispheres. A big sulci divides
each hemisphere into 5 lobes: frontal, parietal, temporal, occipital and insula. The Central sulcus
separates the frontal and parietal lobes. The Parieto-occipital sulcus separates the parietal and occipital
lobes. The Lateral sulcus separates the temporal lobe from the frontal and parietal lobes. The Insula (or
insular lobe) is a portion of the cortex that sits in the fold of the lateral sulcus between the frontal and
temporal lobes.
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The precental gyrus (anterior to the central sulcus) is the primary motor area. The postcentral gyrus
(posterior to the central sulcus) is the primary sensory area.
The primary sensory area receives input from the thalamus which is a major relay station. The two
cerebral hemispheres usually receive information from the contralateral side of the body. The special
senses (vision and hearing) are referred to special areas of the cortex on the contaralateral side.
Early in the twentieth century, Dr. Brodmann created a map of the areas of the cerebral cortex. These
studies were based on electrical stimulation of differrent areas of the cortex during the surgery of
epileptic patients and recording their physiological and behavioral reactions. Brodmann assigned
numbers to the areas with different functions. Now these areas are known as Brodmann’s areas.
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Please note the location and function of: Primary somatosensory area: postcentral gyrus = 1,2,3;
Primary visual area = 17, Primary auditory area = 41 and 42; Primary gustatory area = 43. Wernicke’s
area 39-40, speech interpretation.
Reflection of the body parts in primary

sensory area (postcentral gyrus). The
size of the area is proportional to the
number of receptors in the
corresponding part of the body rather
than the size of this body part: e.g. lips
are better represented than the leg.
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The motor areas of the cerebral cortex control voluntary movements. This control is usually
contralateral.
Please note the location and function of: Primary motor area (precentral gyrus = 4). The primary motor
area controls voluntary contractions of skeletal muscles on the contralateral side; Motor speech
(Broca’s) area = 44 & 45. Upper motor neurons are located in this area.
Reflection of the body parts in

primary motor area depends on the
number of motor units controlled
by this area
M&A pp. 576- 579 Medical

Imaging of Head.
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Lecture 9: ANS; CSF
The Autonomic Nervous System (ANS)
Objectives:
1. Compare the somatic and autonomic nervous systems relative to effectors, efferent pathways
and neurotransmitter released.
2. Explain the anatomical and functional significance of the sympathetic and parasympathetic
ganglia; identify the location of the pre- and postganglionic sympathetic and parasympathetic
neurons.
3. Compare and contrast the general functions of the parasympathetic and sympathetic divisions
of the ANS
1. Compare the somatic and autonomic nervous systems relative to effectors, efferent pathways and
neurotransmitter released.
The peripheral nervous system is divided functionally into somatic (voluntary) and autonomic
(involuntary) systems. The somatic division is responsible for innervating skeletal muscles and the
autonomic division regulates the activity of glands and cardiac and smooth muscles. The cell bodies of
somatic motor neurons are usually located inside the CNS (brain or spinal cord) and their axons travel
long distances to reach the effector organ resulting in voluntary contraction of skeletal muscle. The
autonomic nervous system pathway consists of two motor neurons: one inside the CNS called
“preganglionic” and one outside the CNS called “postganglionic”. Pre-ganglionic neurons will synapse
with postganglionic neurons in autonomic ganglia located outside the CNS. Post ganglionic neurons will
then synapse on a target organ in the periphery. It is important to note that nerve signals for both
systems travel inside peripheral nerves to reach their respective destinations.
The autonomic nervous system is subdivided into sympathetic and parasympathetic divisions based on
the origin of cell bodies, peripheral pathway and desired response in the body.
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In the sympathetic pathway, the cell bodies of preganglionic neurons originate in the lateral gray horns
of the spinal cord from vertebral levels T1-L2. These neurons have short axons which exit the cord using
the ventral root of spinal nerves and soon after synapse in autonomic ganglia located outside the CNS.
In the parasympathetic pathway, the cell bodies of preganglionic neurons originate in the brainstem or
sacral division of the spinal cord. These neurons have long axons which exit the CNS at specific levels:
cranial nerves III, VII, IX, X and spinal nerves S2-4. The axons will synapse in parasympathetic ganglia
located very near or directly inside target organs.
Neurotransmitters of the ANS
There are two main

neurotransmitters acting on
target organs in the
autonomic nervous system:
Acetylcholine (ACh) and
Epinephrine (EPI). Please
note that ACh is also a
primary neurotransmitter of
the somatic nervous system,
however the effect and
targets for ACh are different
in the autonomic system. In
the somatic nervous system,
ACh causes contraction of skeletal muscles by binding at the neuromuscular junction. In the autonomic
nervous system, ACh binding causes a wide variety of responses discussed in objective #3 of this
chapter.
Acetylcholine (ACh) is released by: Epinephrine (EPI)/Norepinephrine (NE) is

released by:
(1) All preganglionic fibers = both sympathetic
and parasympathetic (1) The majority postganglionic sympathetic
fibers acting on glands and smooth muscle and
(2) All postganglionic parasympathetic fibers will cardiac muscle.
release ACh. This leads to the activation of
nicotinic ACh receptors on peripheral targets. (2) The adrenal medulla will also release NE and
Epinephrine into the bloodstream when
All nerve fibers that release ACh are referred to stimulated by pre-ganglionic sympathetic fibers.
as ‘cholinergic’.
All nerve fibers that release NE/EPI are referred
to as “adrenergic”.
Exception:
Postganglionic sympathetic fibers will release ACh instead of NE in two locations: sweat glands in the
skin and smooth muscles surrounding hair follicles.
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Receptors of the ANS
The response of the receptor on the post-synaptic cell depends on the nature of the receptor, not the
neurotransmitter. There are two distinct types of receptors that bind acetylcholine: muscarinic and
nicotinic.
Muscarinic acetylcholine receptors are

activated by the binding of ACh or a water
soluble toxin called muscarine. This toxin
is derived from the mushroom: Amanita
muscaria. Muscarine has the capacity to
cause substantial activation of the
parasympathetic nervous system resulting
in convulsions and even death.
Muscarinic receptors are involved in a
large number of physiological functions
including, decreasing the heart rate and
inducing contraction of smooth muscles.
There are 5 subtypes of muscarinic
receptors based on pharmacologic activity
(M1-M5). The differences between these
subtypes will be discussed in greater detail
in future courses.
These receptors are located in two distinct areas:
1. Post-synaptically on parasympathetic targets (binding of ACh will either increase or decrease

the activity of effector cells).
2. Post-synaptic sympathetic stimulation of sweat glands (binding of ACh will result in increased
sweating).
Nicotinic acetylcholine receptors are characterized by their interaction with two substances:
Acetylcholine and Nicotine. These receptors are located post-synaptically in all autonomic ganglia and
additionally at all neuromuscular junctions in the somatic nervous system. These receptors can be
blocked by the plant toxin ‘curare’ and some snake venoms. Competitive binding of these toxins to the
receptor will lead to weakness of skeletal muscles and eventual death due to paralysis of the diaphragm.
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2. Explain the anatomical and functional significance of the sympathetic and parasympathetic ganglia;
identify the location of the pre- and postganglionic sympathetic and parasympathetic neurons.
The Sympathetic Division “Thoraco-lumbar outflow”
Preganglionic myelinated axons originate inside the lateral grey horns of the spinal cord from segments
T1-L2, often referred as a “thoraco-lumbar outflow”. These axons leave the spinal cord via ventral roots
of spinal nerves and soon synapse in peripheral ganglia. Anatomically, there are three kinds of
sympathetic ganglia: paravertebral, pre-vertebral and the adrenal medulla. The cell bodies of post-
ganglionic sympathetic neurons originate in both paravertebral and pre-vertebral ganglia.
The paravertebral ganglia are located beside the vertebral column linked together in a ‘chain’ sequence;
for this reason they are commonly called the sympathetic chain. These chains extend along the entire
length of the vertebral column from cervical spine to the coccyx. Axons of preganglionic sympathetic
neurons enter paravertebral ganglia via small nerve bridges called White Rami Communicantes (White
ramus); once inside the ganglion, the preganglionic axon will synapse on postganglionic cell bodies.
Axons from postganglionic sympathetic neurons will exit the paravertebral ganglia to re-enter spinal
nerves using nerve bridges known as Gray Rami Communicantes (Gray ramus).
There are a few possible routes that preganglionic sympathetic axons can travel when they enter the
sympathetic chain:
1. The axon will enter the chain and synapse within the sympathetic chain ganglion at the same
level that the nerve emerges off the spinal cord. (left image above)
2. The axon will ascend or descend using the chain to travel to sympathetic chain ganglia which are
responsible for providing sympathetic innervation to the head/neck or genitourinary system.
(right image above)
3. The axon will pass through the sympathetic train to travel as part of a nerve plexus that
synapses in pre-vertebral ganglia located close to the target tissue (discussed on next page)
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Alternatively, Pre-vertebral ganglia are situated anterior to the vertebral column and abdominal aorta.
They are usually solitary structures located between the target organ and the vertebral column. These
ganglia are named after the main arterial branches of the abdominal aorta: Celiac, Superior Mesenteric
and Inferior Mesenteric. Preganglionic sympathetic fibers that are responsible for innervation of
abdominal viscera will pass through the sympathetic chain at several levels and synapse in the three pre-
vertebral ganglia mentioned above. This arrangement is referred to as the Thoracic and Lumbar
Splanchnic nerves; this is a unique nerve plexus comprised only of autonomic nerve fibers responsible
for innervating internal organs.
In addition, there is a cardiopulmonary splanchnic nerve plexus that is comprised of post-ganglionic
sympathetic neurons which exit the sympathetic chain at several levels and travel together to reach the
heart and lungs.
One final exception involves the adrenal glands which are located above the kidneys. These organs act
as specialized sympathetic ganglia because they receive direct innervation from preganglionic
sympathetic fibers. In this case, there are no postganglionic sympathetic fibers; instead the medullary
cells of the adrenal glands release neurotransmitter directly into the blood flow, causing a widespread
systemic sympathetic response.
The Parasympathetic Division “Cranial – Sacral Outflow”
Preganglionic parasympathetic neurons originate in two

distinct locations: grey matter of brain stem and sacral
spinal cord. The preganglionic axons exit the brainstem
via cranial nerves III, VII, IX and X as well as sacral spinal
cord levels S2-4.
Cranial nerves containing parasympathetic outflow will

have long preganglionic neurons that synapse within
peripheral ganglia that are located close to or within
target organs. The postganglionic fibers will travel short
distances to influence target organs for the
parasympathetic system.
Cranial nerves III, VII, and IX provide parasympathetic

innervation to the head, while CN X provides innervation
to the majority of thoracic and abdominal viscera
(making up approx. 85% of the parasympathetic
outflow).
The chart on the following page indicates the target organs that are associated with the
parasympathetic outflow from cranial nerves 3, 7, 9, 10. In this case, parasympathetic outflow travels
with cranial nerves to peripheral ganglia (no rami are involved here).
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CRANIAL NERVE TARGET ORGAN
CN III PUPILLARY CONSTRICTOR MUSCLES
CN VII LACRIMAL GLAND
SUBMANDIBULAR AND SUBLINGUAL GLANDS
CN IX PAROTID GLAND
CN X DIRECT TARGET ORGAN STIMULATION
The preganglionic parasympathetic fibers from S2-4 travel as pelvic splanchnic nerves and synapse in
intrinsic ganglia located in pelvic organs such as bladder, colon and genitalia.
3. Compare and contrast the general functions of the parasympathetic and sympathetic divisions of
the ANS.
Overall the autonomic nervous system supplies organs and glands of the head, thorax, abdomen and
pelvis, while it does not reach the body walls or limbs. The two divisions of the ANS innervate the same
targets and have coordinated effects in order to provide constant involuntary modulation of organs and
tissues. In general, the sympathetic division is catabolic “fight or flight” and the parasympathetic
division is anabolic “rest and digest”.
TARGET SYMPATHETIC Division PARASYMPATHETIC Division

EYES Pupillary dilation Pupillary constriction
GLANDS (Tear duct and Salivary) Minimal change Increased gland secretion
SWEAT GLANDS Increased sweating Minimal change
LUNGS Bronchodilation Bronchoconstriction
HEART Increase heart rate and Decrease heart rate
contractile force
VASCULATURE Vasoconstriction Minimal change
(skin)
VASCULATURE Vasodilation Minimal change
(to skeletal muscles)
GI SYSTEM Decreases peristalsis Increases peristalsis
Sphincter contraction Sphincter relaxation
LIVER Encourages glycogenolysis Stimulates bile production,
stimulates pancreas secretion
URINARY Inhibits urination (bladder Stimulates urination
relaxation, sphincter Stimulates defecation (sphincter
contraction) relaxation)
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ANS innervation of the Eye:
The sympathetic innervation to the eyeball

arrives using the following pathway:
postganglionic neurons exit the superior
cervical ganglion and ascend by way of the
carotid plexus to innervate two important
eye structures: superior tarsal muscle and
the pupillary dilator muscle. The result of
sympathetic innervation to these structures
results in maintaining an open eye (superior
tarsal muscle) and dilation of the pupil for
distance vision (pupillary dilator muscle).
Damage at any point along this pathway
would result in ptosis (eyelid drooping) and
miosis (permanent pupillary constriction).
The parasympathetic innervation

to the eyeball results from the
following pathway: preganglionic
neurons carried in CN III travel
towards eye and synapse on a
ganglion located in the orbit.
Postganglionic fibers travel a short
distance to innervate the pupillary
constrictor muscles = results in
constriction of the pupil. Damage
to this pathway would result in
mydriasis (permanent pupillary
dilation).
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Cerebrospinal Fluid (CSF)
Objectives:
1. Identify the meninges and the contents of the spaces around the spinal cord and around the
brain.
2. Describe the formation of cerebrospinal fluid and follow its circulatory pathways: choroid
plexus, ventricles, apertures, central canal, subarachnoid space, arachnoid villi and sinuses
3. Discuss congenital abnormalities and clinical applications related to CSF
1. Identify the meninges and the contents of the spaces around the spinal cord and around the brain.
There are several layers of

protection around the brain
and spinal cord: bone,
connective tissue and fluid. The
connective tissue layer is
referred to as the ‘meningeal
layer’. There are three
meningeal layers that wrap,
isolate and protect the entire
CNS: dura mater, arachnoid
mater and pia mater.
In the cranium the dura mater

consists of two layers: outer periosteal layer which is fused to the periosteum of the skull bone and the
internal meningeal layer which lies adjacent to the meningeal layer below. The inner layer of dura mater
forms dural reflections that fold inward and divide the cranial cavity into compartments and act as a
layer of support between parts of the brain: the falx cerebri is found between the cerebral hemispheres
and tentorium cerebelli is between cerebrum and cerebellum. Travelling within the dural folds there
are large veins known as dural venous sinuses. These sinuses are filled with carbon dioxide rich blood
that drains from the brain into the internal jugular vein. Around the brain and spinal cord the dura
mater is separated from the arachnoid mater by a potential space: the subdural space. In a normal
healthy brain this space is not real because the pressure of the cerebrospinal fluid (CSF) usually presses
the arachnoid mater against the dura. However, if injury is sustained then blood may fill this space
causing a subdural hematoma. In a dry cadaver the arachnoid will easily fall away from the dura mater
because they are not attached to each other normally.
In the cranium the middle meningeal layer: the arachnoid mater is a delicate avascular membrane
composed of fibrous and elastic membranes resembling a spider web. The arachnoid mater has small
extensions or protrusions called: arachnoid granulations (arachnoid villi). These extensions allow
cerebrospinal fluid (CSF) to diffuse out of the sub-arachnoid space and enter the dural venous sinuses.
137
The pia mater is the thin, delicate, transparent layer that is tightly adhered to the surface of the brain
and spinal cord. It is difficult to remove the pia without damaging the underlying tissue.
The subarachnoid space is the space between the pia and arachnoid mater and it is normally filled with
cerebrospinal fluid that cushions and nourishes neural tissue in both brain and spinal cord.
The meningeal layers around the spinal cord differ slightly from the brain. The internal meningeal layer
of dura mater exits the skull via the foramen magnum and together with the arachnoid, forms a loose
‘sac-like’ outer-covering known as the dural sac around the spinal cord. This loose outer covering is
separated from the vertebral column by the epidural (extradural) space which is filled with adipose
tissue and has a rich blood supply (note that this space is not in the cranium). The dural sac is anchored
to the periosteum of the skull at the foremen magnum and to the coccyx. The dural sac extends inferior
to the end of the spinal cord termination, surrounding the cauda equina and filum terminale.
In the spinal cord, there are extensions of
pia mater that anchor the cord inside the
dural sac called denticulate ligaments.
These ligaments leave the cord in pairs
between the origin of the dorsal and
ventral roots, anchoring the cord within
the dural sac. The filum terminale is
another extension of pia mater that
functions to anchor the cord and the
dural sac to the coccyx.
Note: The spinal cord is shorter than the

vertebral canal (ending at L1/2 disc in
adults)
In the image above you can see the dural sac (black lined tube)
surrounding the cauda equina of the spinal cord. You can also
see the filum terminale extending from the conus medullaris
all the way down to the coccyx.
In the image to the left, you can see the dural sac which has
been opened to reveal the denticulate ligaments (purple)
found between the spinal nerve roots.
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2. Describe the formation of cerebrospinal fluid and follow its circulatory pathways: choroid plexus,
ventricles, apertures, central canal, subarachnoid space, arachnoid villi and sinuses.
Cerebrospinal fluid (CSF) is a clear liquid that is functionally similar to blood. It carries nutrients, gases
and other important chemicals. However, normally it does not contain RBC, has very little WBC and has
a low concentration of proteins. CSF constantly circulates around the brain and spinal cord via the
subarachnoid space. Primary functions of CSF include acting as a shock absorber mechanically
protecting the delicate tissue of the brain and spinal cord. Essentially the brain and spinal cord “float”
inside the cranial and spinal cavities. CSF also helps to maintain homeostasis and provides a healthy
chemical environment for precise neuronal signaling. Minor changes in the ion composition can disturb
the electrical status of the neuronal cell membrane and influence the generation of action potentials.
Lastly, CSF plays a role in the exchange of nutrients and wastes produced inside the CNS.
In addition to the subarachnoid space, CSF circulates inside cavities found deep in brain tissue known as
ventricles. There are four ventricles that are filled with CSF: two lateral ventricles, the third ventricle
and the fourth ventricle. The ventricular spaces are connected by small canals which allow CSF to flow
from one compartment to another. The interventricular foramina connect lateral ventricles with the
third ventricle and the cerebral aqueduct connects the third ventricle with the fourth ventricle.
CSF is produced within the ventricular system via a capillary network in the lateral ventricles known as
the choroid plexus at a rate of 500ml per day. The total amount of CSF in one person is normally 130-
150 ml.
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Flow of CSF through the CNS is unidirectional:
Once CSF arrives at the fourth ventricle, the fluid will drain into the central canal of the spinal cord and
also exit into the subarachnoid space via three openings (apertures) in the 4th ventricle: 1 median
(Magendie) and 2 lateral (Luschka). Once CSF has circulated in the subarachnoid space, it will drain into
the venous blood flow via the arachnoid granulations (arachnoid villi). These are extensions of the
arachnoid mater which allow CSF to diffuse from the subarachnoid space to the dural venous sinuses
(primarily the superior sagittal sinus). This sinus is located within the dural folds of the falx cerebri.
Once CSF is in the venous sinus, it can be transported out of the brain by the venous system.
140
3. Discuss congenital abnormalities and clinical applications related to CSF.
Hydrocephalus is a condition caused by the

excessive accumulation of CSF in the skull or
cranium. Normal flow and absorption
through the cranium is dependent on proper
CSF pressure in the head. A build-up of CSF
often causes a dangerous increase in
intracranial pressure. The combination of
CSF build up and the subsequent increase in
pressure can stress the brain tissue and
produce a characteristic set of signs and
symptoms.
Hydrocephalus is categorized as either “communicating” or non-communicating depending on the cause

of CSF buildup.
Communicating Hydrocephalus Non-Communicating Hydrocephalus
Caused by disruption of CSF reuptake into Also called “obstructive” hydrocephalus because
subarachnoid space. the flow of CSF has been blocked at some
Also called “non-obstructive” hydrocephalus location in the ventricular pathway.
because the CSF can flow freely through the
ventricular spaces. CONGENITAL CAUSES:
Aqueductal stenosis (narrowing)
CONGENTIAL CAUSES: Stenosis of 4th ventricle aperture
Cytomegalovirus, Rubella, Toxoplasmosis,
Hemorrhaging as a result of birth trauma ACQUIRED CAUSES:
Brain tumor
ACQUIRED CAUSES: Cyst
Prior infection, Meningitis, Subarachnoid Abscesses
Hemorrhage, Cerebral Aneurysm Brain trauma
141
The characteristic symptom often seen in infants is enlargement of the
head which is due to the open sutures in an infant’s skull that allow
expansion to accommodate the excess amount of CSF. In older
children and adults, the skull bones are fused so intracranial pressure
increases and compresses brain tissue. Characteristic symptoms of
hydrocephalus in adults include: severe headache, nausea, dizziness,
poor coordination, ‘sun setting eyes’ and blurred vision. The rapid
increase in intracranial pressure will actually push the eyes downward
producing a ‘sun-setting’ eye appearance.
If hydrocephalus develops, the CSF must be drained from the ventricles

as soon as possible. The most common procedure is known as a
hydrocephalus shunt. The purpose of this procedure is to relieve the pressure on the brain and redirect
fluids. Another short term solution is an external ventricular drain (EVD) also known as a
venticulostomy catheter. This procedure places a catheter in the ventricle and the fluid is drained into a
vial by the bedside. A long term solution for chronic hydrocephalus is the ventriculoperitoneal shunt:
where fluid is drained to the abdomen and reabsorbed.
Cerebral Trauma
Fractures of the cranial base can cause rupture of the dura mater and leakage of CSF from inside the
cranial cavity to the outside. One specific example is CSF Otorrhea which is leakage of CSF from the
external acoustic meatus. This results from a fracture of the middle cranial fossa. Another example is
CSF Rhinorrhea which is leakage of CSF through the nose which results from a fracture of the anterior
cranial fossa specifically involving the ethmoid.
Intracranial hemorrhages are also a result of cerebral trauma. Blood can escape into the spaces
between the meningeal layers, producing a characteristic appearance on CT and MRI (see chart below).
These hemorrhages are classified based on their location within the meningeal layers: epidural, subdural
and subarachnoid.
Hemorrhage Origin Etiology

Epidural Arterial Usually follows trauma, i.e., fracture of skull bone, that causes tearing of
meningeal arteries.
“Disc Shape” on CT Blood accumulates between the layers of dura and the cranial bone,
scan leading to brief loss of consciousness followed by a “lucid interval”,
followed by deterioration of brain function and eventual to coma.
Occlusion of the bleeding vessels and removal of the blood is required
as an emergency treatment.
Subdural Venous Often occurs with cerebral contusions which cause tearing of the
bridging veins between dura and arachnoid.
142
“Crescent Shape” Blood slowly seeps into potential space and bleeding is typically not as
on CT scan extensive as epidural.
Symptoms appear slowly over a period of days post injury (headache,
confusion, dizziness, weakness and lethargy)
Subarachnoid Arterial Results from a ruptured arterial aneurysm. Blood flows into
subarachnoid space.
Blood seen A Characteristic sign is sudden severe “thunderclap” headache, severe
“pooling” in nausea and vomiting, pain around the orbit and dizziness.
subarachnoid space A secondary complication is often non-obstructive hydrocephalus due
on CT to the presence of blood in the subarachnoid space.
A spinal tap or lumbar puncture is a procedure is performed to
obtain a sample of CSF from the subarachnoid space. The
needle is inserted between L3 and L4, traveling through skin,
ligaments, epidural space, dura mater, subdural space and
arachnoid to reach the CSF. Reasons to perform a spinal tap
include sampling CSF for infections, measuring the pressure of
CSF and checking for bleeding in subarachnoid space. In an
adult the spinal cord ends at L1/2, therefore the procedure is
performed below the level of the spinal cord to avoid serious
injury.
An epidural block is a procedure in which an anesthetic agent

is injected into the epidural space through a needle that is
passing between lumbar vertebrae or through the sacral
canal. An epidural block inhibits the sensory signals coming
via peripheral nerves before they can enter the central
nervous system. Unlike a spinal tap, an epidural injection can
be performed at any level in the spinal column to achieve
segmental anesthesia.
143
BLUE BOXES: in M&A pp. 508-509 Occlusion of Cerebral Veins and Dural venous Sinuses. Metastasis of
Tumor cells to Dural Sinuses, Fractures of the Cranial base, Dural Origin of Headaches. pp 511 Head
injuires and Intracranial Hemorrhage; pp 514 Cisternal Puncture, Hydrocephalus, Leakage of CSF.
144
Lecture 10: Mediastinum and Heart
Objectives
Mediastinum
1. Identify divisions of thoracic cavity: mediastinum, pulmonary cavities, lungs, pleura, heart,
pericardium and other organs.
2. Use superficial landmarks and imaginary lines of the thorax to identify location of wounds
and underlying organs.
3. Identify borders of anterior, posterior, superior and inferior mediastinum and organs that
belong to each.
1. Identify divisions of thoracic cavity: mediastinum, pulmonary cavities, lungs, pleura, heart,
pericardium and other organs.
The thorax is the superior part of the trunk between the neck and the abdomen. It is separated from the
abdominal cavity by the diaphragm.
145
The thoracic cavity contains the heart, lungs and thymus, as well as, parts of the esophagus, trachea,
thoracic duct, aorta, blood vessels and nerves. The thoracic cavity has three compartments: two lateral
compartments are the pulmonary cavities that are covered by pleura and contain lungs and a medial
compartment, the mediastinum that contains all other thoracic structures. Walls of the thoracic cavity
are lined by endothoracic fascia. Pulmonary cavities are also lined by parietal (costal, cervical,
diaphragmatic) pleura. The surface of the lungs is covered with visceral (pulmonary) pleura. Pleura
separate lungs from the mediastinum. There is a pleural cavity filled with a small amount of fluid
between two layers of pleural membranes. The heart is also covered by two layers of serouse
membranes: parietal pericardium and visceral pericardium. The pericardial cavity is filled with
pericardial fluid. Please identify the layers of thoracic wall and cavities in the images.
146
2. Use superficial landmarks and imaginary lines of thorax to identify location of wounds and
underlying organs.
Jugular notch, sternal angle, midclavicular line, midsternal line, anterior, medial and posterior axillary
lines, scapular line, midvertebral line.
Yellow Box pp. 61-64 in M&A Surface Anatomy of Thoracic Wall (except breasts section).
147
3. Identify borders of superior, anterior, medial and posterior mediastinum and organs that belong to
each.
Mediastinum is defined anteriorly by sternum and ribs, posteriorly by vertebrae and associated
structures and laterally by lungs.
An imaginary plane passing from the sternal angle to the T4-T5 intervertebral disc separates superior
mediastinum from the rest of mediastina, which is sometimes referred to as inferior mediastinum.
Inferior mediastinum is further divided to middle mediastinum (that contains heart with pericardium
and associated structures), anterior mediastinum (between medial mediastinum and sternum) and
posterior mediastinum (between middle mediastinum and vertebrae). See next page.
148
Green - Superior mediastinum; Blue - Posterior mediastinum; Purple - Anterior mediastinum;
Yellow - Middle mediastinum.
Please note that the borders between mediastina are conventional, mostly for descriptive purposes.
Also, some structures run through both superior and posterior mediastinum. Here is the list of some
organs found in the mediastinum:
Superior Mediastinum: thymus*, superior vena cava (SVC), aortic arch with branches, trachea,
esophagus, thoracic duct, sympathetic chain, phrenic nerves, vagus nerves. Anterior Mediastinum: fat.
Middle Mediastinum: heart, phrenic nerves. Posterior Mediastinum: descending (thoracic) aorta,
azygos vein**, esophagus, thoracic duct, sympathetic chain, vagus nerves.
*Thymus grows until puberty when increased concentration of sex hormones triggers degeneration of
thymus.
** Azygos vein is an anastomosis. Anastomosis is the blood vessel that provides the loop reconnecting
two blood vessels. Azygos vein drains blood from intercostal spaces (between the ribs) and connects
superior and inferior vena cava.
149
Heart
Objectives

4. Name the heart chambers and heart valves and describe their location, function, and
mechanism of operation.
5. Explain the coronary circulation: identify the major coronary arteries and veins
6. Compare the pulmonary, systemic, and coronary circulations.
8. Explain variations of the coronary arteries and common pathologies of the heart: cardiac
tamponade, pericardiocentesis, coronary artery disease, ischemia, heart attack/myocardial
infarction.

The heart has 4 chambers: the left atrium and left ventricle which pump oxygenated blood into the
systemic circuit, and the right atrium and right ventricle which pump deoxygenated blood into the
pulmonary circuit.
Anterior View
150
Posterior view
The heart occupies the middle mediastinum. The heart has a base, an apex, and three surfaces: anterior,
inferior, and
posterior; as well as
two borders: the
right and left. The
base of the heart is
located behind an
imaginary line drawn
from the 2nd left
intercostal space to
the 3rd right costal
cartilage. It is where
the great vessels
enter and leave the
heart. The apex of
the heart is the tip of
the left ventricle that
is directed anteriorly,
151
inferiorly, and to the left. In a supine person the apex is located approximately between the fifth and
sixth left ribs (5th intercostal space) proximal to the midclavicular line.
The anterior surface of the heart is directly behind the sternum and the ribs. It is mostly made up of the
right ventricle, but it has some of the left ventricle and right atrium. The inferior surface rests on the
diaphragm; it is made up of the right and left ventricles with a prevalence of the right. The posterior
surface is formed mostly by the left atrium. The right border can be drawn from the articulation of the
xiphoid process and sternum to the right 3rd costal cartilage (faces the right lung). It is formed by the
right atrium. The left border is from the 5th left costochondrial joint to the 2nd left intercostal space
(faces the left lung). It is formed mostly by the left ventricle with a small amount of the left atrium at the
superior end.
http://en.wikipedia.org/wiki/File:Slide11gggg.JPG
Please identify the following structures in the images of the heart provided within this lecture: right
atrium, right ventricle, left atrium, left ventricle, auricles, arch of the aorta, brachiocephalic artery, left
common carotid artery, left subclavian artery, pulmonary trunk, left and right pulmonary arteries, left
and right pulmonary veins, inferior and superior vena cava.
152
Question:
Where do you place your stethoscope on the chest wall to listen to the different heart sounds?
Yellow Box in M&A pp. 88- 89 Surface Anatomy Heart.

The heart is covered by fibrous pericardium
and serous pericardium. The fibrous
pericardium is made of dense irregular
connective tissue that anchors the heart
and protects it from overstretching.
The serous pericardium is a thin

delicate membrane consisting of two
layers: the outer parietal layer and the
inner visceral layer which is attached to
the muscle of the heart (also known as
epicardium because it makes up the
outermost heart layer). The layers of
the serous pericardium are separated
by a pericardial cavity which has
pericardial fluid that lubricates and
allows for smooth movement of the
heart.
The middle layer of the heart wall (thickest layer) is the myocardium. It is made of cardiac muscle tissue.
The innermost layer of the heart is called the endocardium. It is a thin layer of epithelium, which lines
the chambers of the heart.
153
4. Name the heart chambers and heart valves and describe their location, function and mechanism of
operation.
Chambers and Cardiac Sulci:
The heart is divided into four chambers: two atria and two ventricles. The cardiac sulci are grooves on
the surface of the heart containing the coronary blood vessels and fat. The sulci superficially mark the
borders between chambers. The coronary sulcus encircles the heart and marks the boundary between
the atria and the ventricles. The anterior Interventricular sulcus marks the boundary between the left
and right ventricles
anteriorly. The
posterior
Interventricular
sulcus marks the
boundary between
the ventricles
posteriorly.
Within the heart,

the interatrial
septum partitions
the atria. The
depression within
the interatrial
septum is called the
fossa ovalis. It is a remnant of the fetal foramen ovale which connects the right and left atria in the
fetus. It normally closes soon after birth. The right atrium receives blood from 3 sources: the superior
vena cava, the inferior vena cava, and the coronary sinus.
The tricuspid valve separates the right atrium and the right ventricle. It allows the blood to flow in only
one direction, from the atrium to the ventricle. The tricuspid valve has three cusps composed of dense
connective tissue covered by endocardium.
The right ventricle forms most of the anterior surface of the heart. Papillary muscles are attached to the
cusps of the AV valves by strands of chordae tendineae. The chordae tendineae are connective tissue
cords between the valve cusps and the papillary muscles. Trabeculae carneae are the muscular columns
within the ventricle that strengthen contractions of the heart wall and prevent suction between the
ventricular walls. The interventricular septum partitions the ventricles. The pulmonary semilunar valve
allows blood flow in one direction: from the right ventricle into the pulmonary trunk. The infundibulum
is a smooth area (no trabeculae, no papillary muscles) of the RV leading to the pulmonary valve.
154
The Left Atrium forms most of
the posterior wall of the heart.
It receives blood from the lungs
through four pulmonary veins:
two right and two left. The
bicuspid valve (mitral) allows
blood to pass from the left
atrium into the left ventricle. It
has two cusps. A mnemonic is
LAMB: Left Atrioventricular,
Mitral, or Bicuspid valve.
The left ventricle forms the apex of heart. It is longer, narrower and more conical shaped than the right
ventricle. Chordae tendineae connect the bicuspid valve to the papillary muscles. The LV also has
trabeculae carneae like the RV. The aortic vestibule in the LV leads to the aortic semilunar valve and the
ascending aorta. The aortic semilunar valve allows blood to pass from the LV into the ascending aorta.
Just above the valve are the openings to the coronary arteries.
Myocardial Thickness and
Function: The thickness of
the myocardium varies
according to the function
of the chamber. The atria
are thin walled and deliver
blood to the adjacent
ventricles. The ventricle
walls are much thicker and
stronger. The left ventricle
wall is the thickest
because the LV pushes
blood to supply the
systemic circulation.
Therefore the blood travels a great distance within this higher pressure system. The right ventricle wall
is thinner because it supplies blood to the lungs (smaller flow resistance).
155
Atrio-ventricular Valves Open
When the atrium

contracts, fluid
pressure opens the
atrio-ventricular
(AV) valve. In the
image, the AV valve
opens and allows
blood to flow from
the atrium into the
ventricle (when the
ventricular pressure
is lower than the
atrial pressure).
When the ventricle
is relaxed, the papillary muscles are relaxed and the chordae tendineae are slack.
When the ventricle contracts the AV valve closes, preventing the backflow of blood into the atrium.
Increased fluid pressure in the ventricle pushes the valve cusps closed, while the papillary muscles
contract and pull the chordae tendinae to prevent the cusps from everting.
156
Semilunar Valves
The semilunar (SL)
valve cusps look
like pockets and
they open in the
direction opposite
to the normal
blood flow. The
pulmonary and
aortic SL valves
open with the
ventricular
contraction and
allow blood to
flow into the pulmonary trunk and aorta respectively. The SL valves close with ventricular relaxation.
High blood pressure that builds in the aorta after the ventricular contraction will try to push blood back
into the ventricle, but the “pockets” of the SL valve accept the blood and close the lumen of the aorta
preventing backflow. Thus the SL valves prevent blood from returning to the ventricles: blood fills the
valve cusps which tightly close the SL valves. Dense connective tissue rings surround the valves of the
heart. These rings fuse and merge with the interventricular septum and make up a strong plate, which
supports the heart valves. It also serves as the “skeleton” for insertion of cardiac muscle bundles. This
connective tissue plate also provides electrical insulation between the atria and the ventricles, thus
preventing direct propagation of action potentials from the atria to the ventricles.
Please review the blood flow through the heart

and major vessels in the picture to the left.
157
Please cover the answer key to the right and try to recognize and review the thoracic structures in the
chest radiograph below.
http://www.ceessentials.net/article25.html Film Critique - Part 1: Chest, Discussion of the diagnostic

criteria for routine chest x-rays with emphasis on exposure technique, positioning, pathology, and clinical
correlation. Author: Nicholas Joseph
Jr. RT(R) B.S. M.S
Structures that should be

demonstrated on the left lateral chest
radiograph include: esophagus (A),
trachea (B), lung hili (C), heart
silhouette (D), lung apices (E),
scapulae (F), thoracic vertebra (G),
thoracic intervertebral foramen (H),
superimposed posterior ribs (I), costo-
phrenic angles (J), and diaphragm
(yellow arrows).
5. Explain the coronary circulation: identify the major coronary arteries and veins, RCA branches, LCA
branches, great and small coronary veins, and the coronary sinus.
The coronary circulation is the circulation of blood in the myocardium. The heart is a very active muscle;
hence it needs lots of oxygen. The vessels that deliver oxygenated blood to the heart muscle are
referred to as coronary arteries. The vessels that drain the deoxygenated blood from the heart muscle
are coronary veins. The coronary arteries, when healthy, are capable of autoregulation to maintain
coronary blood flow at levels appropriate to the needs of the myocardium.
Coronary arteries are often affected by artherosclerosis (narrowing), and can even become completely
blocked (occluded); causing ischemia, angina and myocardial infarction. There are a lot of anastomoses
between the coronary arteries, which help to maintain blood supply to cardiac muscle via alternative
routes when arteries become occluded.
158
The right coronary artery
(RCA) supplies blood to
the right atrium, right
ventricle, sinoatrial node
(sinuatrial node, sinus
node, SAN, SA node),
atrioventricular node (AV
node) and the posterior
third of the
interventricular septum.
The SA node is located in

the right atrium near the
entrance of the superior
vena cava. The AV node is
located in the posterior-
inferior part of the
interatrial septum near the
opening of the coronary
sinus. The right coronary
artery (RCA) originates from the right aortic sinus, runs to the right in the coronary sulcus and gives the
following major branches (arteries): 1) SA nodal branch, 2) right marginal branch, which passes along
the inferior border of the heart to the apex, 3) AV nodal branch, and
4) posterior interventicular artery (posterior descending artery, PDA), which runs to the apex in the
posterior IV sulcus in 67 % of people (right dominant).
The left coronary artery supplies blood to most of the left atrium, left ventricle and anterior two-thirds
of the interventricular septum. The left coronary artery originates from the left aortic sinus, runs to the
left in the coronary sulcus and gives the following major branches: 1) anterior interventricular (left
anterior descending, LAD), which passes down the anterior interventricular groove to the apex,
2) circumflex artery, which runs to the left in the coronary sulcus to the posterior of the heart, 3) left
marginal, which runs along the left border of the heart, and 4) posterior interventicular artery
(posterior descending artery, PDA), which runs to the apex in the posterior IV sulcus in 15% of people
(left dominant).
When the PDA is supplied by the right coronary artery, the coronary circulation is called “right
dominant” (most often 67%). If the PDA is supplied by the left coronary artery it is called “left
dominant” (15%). If the PDA is supplied by both it is called “codominant” circulation (18%).
There are typically anastomoses between the circumflex artery and the right coronary artery; and
between the anterior and posterior interventricular arteries.
159
When the left ventricle relaxes, the high pressure of the blood in the aorta pushes blood back into the
aortic sinuses at the root of the aorta and the pressure in the aortic sinuses forces the blood into the
left and right coronary arteries.
Note the coronary artery starting from the left aortic sinus in the image below.
http://www.radiologyassistant.nl/images/thmb_49463f94961d2AO-valves.jpg
Coronary veins collect waste

from the myocardium and
drain into the coronary sinus.
The coronary sinus then
drains into the right atrium.
The great cardiac vein drains
blood from the left atrium
and left ventricle. The small
cardiac vein drains blood
from the right atrium and
right ventricle. The middle
cardiac vein drains blood
from the left ventricle, right
ventricle and intraventricular
septum.
160
6. Compare pulmonary, systemic and coronary circulations.
There are three closed circuits: the systemic, pulmonary and coronary. Please review the images above
and identify to which circuit each vessel belongs.
Systemic circulation: The left side of the heart

pumps oxygenated blood through the body.
The left ventricle pumps oxygenated blood into the
aorta. The aorta then branches into many arteries
that travel to the organs. These arteries then
branch into many arterioles in the tissue.
Arterioles will then branch into thin-walled
capillaries where exchange of gases and nutrients
occurs.
Deoxygenated blood then begins its return in small
venules. The venules then merge into veins which
return the blood to the right atrium.
Pulmonary circulation:
The right side of the heart pumps the
deoxygenated blood to the lungs. The right atrium
receives blood from the systemic circuit.
161
The right ventricle pumps the blood to the pulmonary trunk. The pulmonary trunk branches into
pulmonary arteries. The pulmonary arteries carry the blood to the lungs for exchange of gases.
Oxygenated blood then returns to the left atrium in the pulmonary veins.
Coronary circulation (similar to systemic circulation):
The left ventricle contracts and pushes oxygenated blood into the aorta. The ventricles relax and aortic
resistance pushes blood back to the aortic sinuses. From the aortic sinuses the blood is pushed into the
coronary arteries. The coronary arteries branch into smaller arteries in the myocardium. Thin-walled
capillaries exchange gases and nutrients in the myocardium. Deoxygenated blood then returns to the
coronary veins. The coronary veins then drain to the coronary sinus, which returns blood to the right
atrium.

The conduction system
of the heart coordinates
alternating contraction of
the atria and ventricles.
Autorhythmic cells are

able to fire
spontaneously- they act
as a pacemaker and start
the APs that propagate
via the conduction
system of the heart. The
SA node is a cluster of
autorhythmic cells
located in the wall of the
right atrium. Although all
of the heart's cells have
the ability to generate
electrical signals that trigger cardiac contraction, the sinoatrial node normally initiates it, simply because
it generates impulses slightly faster than the other areas with pacemaker potential. From the SA node,
the potential spreads to the RA and LA and both atria contract. The action potential is then propagated
to the AV node, which is located in the posterior inferior portion of the interatrial septum close to the
ventricles. The AV node transmits the signal to the bundle of His, which is the connection between the
atria and ventricles.
The bundle of his divides into bundle branches within the interventricular septum, and then into the
purkinje fibers, which are large diameter fibers that conduct signals quickly and distribute them over
the ventricular myocardium. This allows the cardiac muscle fibers in the ventricles to contract
simultaneously.
162
Purkinje fibers.
From Histology World. This slide is
courtesy of William L. Todt Ph.D at
Concordia College.MI
8. Explain variations of coronary arteries and common pathologies of heart: cardiac tamponade,
pericardiocentesis, coronary artery disease, ischemia, heart attack, and myocardial infarction.
Please refer to Blue Boxes in M&A: pp. 80 Pericarditis and Pericardial Effusion, Cardiac Tamponade,
Levels of Viscera in Mediastinum; pp. 87 Atrial and Ventricular Septal Defects, Thrombi, Valvular Heart
Disease; pp. 96- 97 Coronary Artery Disease or Coronary Heart Disease: Myocardial Infarction, Coronary
Atherosclerosis, Coronary Bypass Graft, Coronary Angioplasty, Variations of Coronary Arteries, Cardiac
Referred Pain, Injury to Conducting System of Heart.
Green Box pp. 109- 110 Medical Imaging Thorax.
163
Lecture 11: Histology of Blood Vessels
Objectives
1. Recognize the three layers of the blood vessel wall: tunica intima, tunica media and tunica adventitia.
2. Recognize blood vessels vs. other tubular structures, e.g. ducts
3. Distinguish arteries vs. veins, large vs. small vessels: conducting, distributing arteries, arterioles and
capillary vessels
1. Recognize the three layers of the blood vessel wall: tunica intima, tunica media and tunica
adventitia.
Three layers of the blood vessel wall are:
1. Tunica (aka coat) intima aka interna (innermost of the layers) consists of endothelial (simple
squamous) layer and elastic layer (1lastic interna);
2. Tunica media (middle) smooth muscles and fibers;
3. Tunica adventitia (outermost) – connective tissue.
Tunica intima (internal coat) is

the innermost layer and lines
the lumen of the blood
vessels. It consists of simple
squamous epithelium and a thin
layer of loose connective tissue
immediately beneath (aka
elastic lamina). The basement
membrane is often seen as a
squiggly line right under the
simple squamous epithelium.
This simple squamous
epithelium provides a smooth
surface for blood passage. The
tunica intima is continuous from
the endocardium in the heart
through the capillaries.
Gray448.png
Tunica media is made of smooth

muscle cells and elastic
fibers. It is responsible for
164
vasodilation and vasoconstriction of the blood vessels. It is also the target tissue for hormones that
control blood pressure. It also contains some elastic fibers and allows for stretching of the arteries.
http://fau.pearlashes.com/anatomy/Chapter%2032/Chapter%2032.htm
165
http://www.esg.montana.edu/esg/kla/ta/circ1.html
Tunica adventitia is the most superficial of the layers. It is made of dense irregular CT with lots of
collagen fibers running in all directions to provide strength and resistance to stress from different
directions. It protects blood vessels from overstretching and anchors them to other tissues and organs.
2. Recognize blood vessels vs. other tubular structures, e.g. ducts.
Thickness of the blood vessel wall

depends on the size of the vessel and
pressure in the vessel. Smaller blood
vessels have thinner walls. Capillaries
have a single layer of endothelial cells.
(see the image below).
Glandular ducts are different from

blood vessels and easily distinguishable
because they are usually lined by
cuboidal or columnal epithelium.
166
3. Distinguish arteries vs. veins, large vs. small vessels:
conducting, distributing arteries, arterioles, capillary vessels.
Artery wall from Cunningham, D.J. Textbook of Anatomy (New
York, NY: William Wood and Co., 1903) to the left. A-intima, B –
media and C –adventitia.
Compare arteries to veins. Artery has a thicker wall with more

smooth muscle and usually better holds its round shape.
The artery and vein slide above is courtesy of Histology World. www.histology-world.com
Vasa Vasorum consists of small

blood vessels that supply the
exterior of the wall with oxygen
and nutrients. Interior of the
blood vessel gets its supply across
the endothelium. Veins have vasa
vasorum more developed than
arteries.
Outer vena cava with vasa

vasorum (image to the left.)
167
Zoom in the wall of vena cava shows vasa vasorum (image below.) www.histology-world.com
These two slides of vena

cave are the courtesy of
Florida State University.
Arterial wall (to the

left.) Note the
thickness of tunica
adventitia (green),
tunica media (black)
and tunica interna
(blue arrow.)
From Histology
World. This and the
next slides are the
courtesy of William
L. Todt Ph.D at
Concordia College.MI
168
Internal layers of aorta (below.)
Aorta and big arteries are classified as conducting or elastic arteries. They are able to stretch and to
hold high blood pressure and coil back, when pressure drops. There is a thin layer of connective tissue
with occasional fibroblasts and smooth muscle cells between endothelium and internal elastic lamina in
these arteries.
Tunica media of conducting arteries

contains many fenestrated (thin
perforated) membranes of elastin. The
number of these membranes and the
thickness of the elastic arteries increases
with age (in adults x2 of newborn). At
autopsy, artery looks yellow because of
elastin.
169
External layers of aorta, note tunica media and adventitia (below.)
In muscular or distributing
arteries, (image to the left) are
smaller than conducting. Their
tunica intima is thinner than in
conducting arteries. Internal elastic
lamina makes characteristic
undulating surface. Tunica media
has proportionally more smooth
muscular cells and less elastin than
tunica adventitia of conducting
arteries.
From Histology World. This and
the next slides are courtesy of
William L. Todt Ph.D at Concordia
college College, MI
170
Arterioles are the smallest vessels
carrying blood to capillary beds.
Tunica intima contains collagen
and elastin. Tunica media consists
of few layers of smooth muscle
cells (can be just one layer).
Tunica adventitia is also thin,
contains few fibroblasts and
contains both collagen and elastic
fibers.
From:
https://s3.amazonaws.com/meducation/files/high_quality/26202.jpg?AWSAccessKeyId=AKIAJFF4C3XTJL
L3N63Q&Expires=1361054371&Signature=lcyVbeu9e5haFJSzHi2MnbSDYHw%3D
171
In vena cava and large veins (image below), tunica intima includes endothelium, elastic lamina and
elastic and reticular fibers. Tunica media with smooth muscles not well developed in veins comparing to
arteries (and may be absent in small veins). Tunica adventitia contains many elastic and collagen fibers
and well developed vasa vasorum.
Wall of Vena cava. From

Histology World
www.histology-world.com
This and the next slides are
the courtesy of Florida State
University.
172
A cross section of coronary artery narrowed by fibro-lipid plaque. This right coronary artery has more
than 50 percent occlusion in the cross-sectional area.
Movat stain; original magnification, x 6.
Histology slide courtesy of National Heart,
Lung, and Blood Institute (NHLBI) and
National Human Genome Research
Institute.
Two slides above are showing the vein with organizing thrombus. From Histology World. This slide is the
courtesy of William L. Todt Ph.D at Concordia College.MI
Please refer to the following slides for more practice:
173
http://iws.collin.edu/mweis/Images/Histology/2402%20histology/Circulatory%20Histo/labeled%20circ%
20histo/circ_vessels_carotid_histo_tunics_labeled.png
Blue Boxes in M&A pp. 24-25 Anastomoses, Collateral Circulation and Terminal (End) Arteries,
Arteriosclerosis: Ischemia and Infarction & Varicose Veins.
174
http://iws.collin.edu/mweis/Images/Histology/2402%20histology/Circulatory%20Histo/labeled%20circ%
20histo/circ_vessels_av_compare_heading.png
175
Lecture 12: Thorax
Objectives
2. Identify anatomical features of the sternum.
3. Be able to identify and differentiate between cervical, thoracic, lumbar and sacral vertebrae.
5. Compare and contrast the joints of the vertebral column; rib articulations; components of the
intervertebral discs.
6. Identify anatomical features of ribs; differentiate between different types of ribs: true, false and
floating.
8. Discuss the congenital abnormalities of the vertebral column: spina bifida occulta, spina bifida
cystica, meningocele and myelomeningocele.
The thorax is protected by bony thoracic cage and is separated from abdominal cavity by the diaphragm.
The thoracic cage is limited by vertebrae posteriorly, by sternum anteriorly and by ribs laterally.
In the image on the next page please identify: sternum: manubrium, xiphoid process, body of sternum,
sternal angle, superior and inferior thoracic apertures. (see image on the next page).
Vertebra: there are 12 thoracic vertebrae that are separated by intervertebral discs.
Ribs: there are 12 pairs of ribs.
Superior thoracic aperture and inferior thoracic aperture are the outlets of thoracic cage at the top and
bottom correspondingly (see image on the next page).
176
177
2. Identify anatomical features of the sternum:
Sternum: manubrium, body (gladiolus), xyphoid process, sternal angle (angle of Louis),
sternomanubrial joint, claviculomanubrial joint.
3. Be able to identify and differentiate between cervical, thoracic, lumbar, and sacral vertebrae.
Each vertebra has the following structures: body, spine (spinous process), vertebral foramen (spinal
canal), transverse processes, lamina, pedicles, and articular processes (for vertical articulations).
As a rule, inferior vertebra has bigger bodies

and relatively smaller vertebral canal.
Vertebrae are separated by intervertebral
discs composed of fibrous cartilage. Each
disc has annulus fibrosus and nucleus
pulposus. (See image below).
178
179
Cervical vertebrae are characterized by transverse foramina (foramen transversarium) for passage of
vertebral arteries.
180
Thoracic vertebrae are characterized by the presence of articular facets and demifacets for attachment
of the ribs. The head of the rib is attached to the body of the vertebrae. The costal tubercle articulates
with transverse process.
Identify: Atlas (C1): anterior arch, posterior arch, transverse ligament of atlas, foramen for dens of
axis, superior articular surface for articulations with occipital condyles. Axis (C2): dens (odontoid
process, axis), superior articular facet.
From http://thesebonesofmine.wordpress.com/category/atlas-axis-vertebrae/
181
Henry Gray (1825–1861).
Anatomy of the Human
Body. 1918.
http://www.bartleby.com/107/illus306.html
Superior articular facets of the atlas articulate with occipital condyles and make atlanto-occipital joints,
which permit flexion and extension of the head. Atlas also articulates with dens (odontoid process) of
the axis and makes atlanto-axial joint. The dens passes through the foramen formed by anterior arch
and transverse ligament in the atlas. Atlanto-axial joint is a pivot joint that allows for rotation of the
head.
M&A Please see pp. 270-271 Table 4.1 Cervical Vertebrae, p. 272 Table 4.2 Thoracic Vertebrae,
p. 273 Table 4.3 Lumbar Vertebrae, p. 274 Table 4.4 Sacrum and Coccyx
5. Compare and contrast the joints of the vertebral column; rib articulations; components of the
intervertebral discs.
Vertebral bodies are connected by intervertebral discs. The outer layer of the disc, annulus fibrosus, is
made of fibrocartilage and holds two vertebrae together like a ligament. Nucleus pulposus is a gel and
fibers that fill the middle of the disc. Nucleus pulposus provides cushion and resistance to pressure.
Intervertebral discs permit many kinds of movements, but in limited range.
182
6. Identify anatomical features of ribs, differentiate between different types of ribs: true, false and
floating.
There are 12 pairs of ribs: upper seven ( 1 to 7) ribs are true ribs; they are connected to the sternum by
their own strip of cartilage; three false ribs (8, 9 and 10) are connectd to each other by branching
cartilage, which is connected to the cartilage of the seventh rib, floating ribs (11 and 12) do not
connected to the sternum at all and do not have costal cartilage.
183
Facets or demifacets on
the body of the vertebrae
articulate with the head
of the rib, facets on the
transverse process of
thoracic vertebrae
articulate with the costal
tubercle.
Identify: head of the rib,
neck, costal tubercle,
costal angle, facets for
articulation with the
vertebrae, costal groove.
184
Heads of the ribs articulate with the facets and
demifacets on the vertebral bodies. A zygapophysial
joint is a joint between the superior articular process
of one vertebra and the inferior articular process of
the vertebra directly above it.
Costo-vertebral joint: ribs and vertebra. Costo-
chondrial joints: ribs and costal cartilage. Sterno-costal
joints: ribs and sternum. Sterno chondrial joints:
sternum and cartilage.
There are three layers of the intercostal muscles between ribs:
1. external intercostal (fibers

orientation – hands in the
pockets) lift the ribs and expand
the volume of thoracic cage;
2. internal and
3. innermost intercostal (fibers
oriented across the external)
depress the ribs and decrease
the volume of thoracic cage
during forceful exhalation.
Costal groove runs along deep
inferior surface of each rib and
houses intercostal nerves,
arteries and veins.
185
8. Discuss the congenital abnormalities of the vertebral column: spina bifida occulta, spina bifida
cystica, meningocele and myelomeningocele.
Spina bifida occulta (hidden) is characterized by the

absence of the observable opening on the skin of the
back, but the part of the vertebrae is not completely
closed. The split in the vertebrae is so small that the
spinal cord does not protrude. The skin at the site of
the lesion may be normal, or it may have some hairs
growing from it; there may be a dimple in the skin, or
a birthmark. People with this form may have light
problems (e.g. back pain, fatigue) and slight loss of
sensation.
186
Meningocele (in spina bifida cystica) is the least common form;
the outer part of some of the vertebrae is split and the meninges
are pushed out through the opening, appearing as a sac or cyst,
which contains both the meninges and cerebrospinal fluid;
therefore, there is often little disability present. There are usually
no long-term problems. Most likely, the nerves are not badly
damaged and are able to function although problems can arise.
The defect needs to be surgically closed soon after birth.
In spina bifida cystica,

(meningomyelocele) the
meningeal membranes that cover
the spinal cord and part of the
spinal cord protrude through a
cleft, forming a sac or cyst, which
is clearly visible on the skin. The
meningeal membranes that cover
the spinal cord and part of the
spinal cord protrude through a
cleft, forming a sac or cyst, which
is clearly visible on the skin. The
opening is surgically repaired,
shortly after birth. The spinal cord

usually damaged at that level. As a
result, there is always some degree of
paralysis and loss of sensation below the
damaged vertebrae.
Meningomyelocele with myeloshisis is

characterized by damaged meninges,
open cyst and spinal cord clearly visible
and exposed to the environment.
187
Please refer to pp. 306-307 Medical Imaging of the Back
Please refer to Blue boxes in M&A pp. 275-276 Laminectomy, Spina Bifida, Dislocation of Cervical
Vertebrae, Lumbar Spinal Stenosis, p. 286, Herniation of Nucleus Pulposis, Rupture of Transverse
Ligament of Atlas, p. 294, Lumbar Spinal Puncture, Epidural Anesthesia.
Role of Costal Cartilages, Rib Fracture, Flail Chest, Supernumerary Ribs, Median Sternotomy, Sternal
Biopsies, Paralysis of Diaphragm, Dislocation of Ribs (sternocostal and costochondrial), p.61 Intercostal
Nerve Block.
Practice questions:
1. To which part of the vertebral column

does the vertebra presented to the right
belong?
2. What layers are penetrated by the

needle for spinal tap? Spinal anesthesia?
Epidural block?
188
3. Label ALL the parts of the thoracic cage in the images below
189
190
Lecture 13: Lungs
Objectives:
1. Describe the anatomy of the lungs: layers of the pleura, lobes, fissures, lingula, and branching
pattern from trachea to alveoli.
4. Compare and contrast right vs. left lung.
5. Describe pleural recesses and common pathologies such as pleurisy.
6. Define the clinical terms associated with lung pathology: aspiration of foreign bodies, pulmonary
embolism, pleural effusion, pleuritis, pneumothorax, hydro/hemothorax; lung resections.
8. Identify cartilage, components of cartilage, and types of cartilage: hyaline, elastic and fibrocartilage.
1. Describe the anatomy of the lungs: lobes, fissures, lingula, and branching pattern from trachea
to alveoli.
Lungs are the paired vital organs of respiration located in the thoracic cavity. They are separated from
each other by the mediastinum. They have elasticity and the ability to recoil. Lungs are light (lighter than
water).
Each lung is enclosed and protected by a double layered serous membrane called pleura. Outer
superficial layer is the parietal pleura. It lines the wall of the thoracic cavity, the diaphragm and
separates the lungs from the mediastinum. The deeper layer, visceral pleura, covers the lung and firmly
adheres to all surfaces of the lung. The space between the parietal and visceral pleura is the pleural
cavity. Four areas of pleura may be referred to as: 1) cervical pleura, 2) costal pleura, 3) mediastinal
pleura and 4) diaphragmatic pleura.
Each lung has three surfaces: 1) costal surface, 2) mediastinal surface and 3) diaphragmatic surface.
Each lung has an apex, a base, a root and a hilum.
The apex is the most superior part of the lung. The base of the lung is a broad, concave foundation that
rests on the diaphragm. The Root of the lung is formed by the bronchus, the pulmonary artery,
superior and inferior pulmonary veins, bronchial arteries and veins, the pulmonary plexus of nerves
and lymphatic vessels and is covered by mediastinal pleura. The hilum is a triangular depression on the
medial side of the lung, where the root of the lung is attached.
191
The bronchial tree is composed of progressively branching tubes that get smaller distally as they extend
into each lung. Trachea and primary bronchi are supported by cartilages. The bronchial tree begins
where the trachea branches into a right and left primary bronchus. The right primary bronchus is wider
and more vertical than the left primary bronchus and therefore more prone to foreign body aspiration.
Carina is a cartilage situated at the bifurcation point at the lower end of the trachea, at the level of 4th
thoracic vertebrae in line with sternal angle. The epithelial lining over carina is very sensitive and triggers
a cough reflex when disturbed. Deep into the lungs each primary bronchus branches into several
secondary (lobar) bronchi according to the number of lobes in the lung: two in the left and three in the
right. Lobar bronchi branch into multiple segmental (tertiary) bronchi.
192
http://www.medicalacupuncture.org/aama_marf/journal/vol14_2/article1.html
Tertiary bronchi subdivide into numerous smaller branches (approximately 20 orders) called conducting
bronchioles. The smallest order of the conducting airway is the terminal bronchioles. Terminal
bronchioles give rise to several generations of respiratory bronchioles, which provide few alveolar ducts.
The respiratory division consists of respiratory bronchioles, alveolar duct, alveolar sac and alveoli.
This area of the bronchial tree is called the respiratory division because these structures conduct gas
exchange with pulmonary capillaries surrounding them. Gas exchange occurs across the respiratory
bronchioles down to the alveoli; however, it is the alveoli that conduct most of the gas exchange in the
lungs, thus, the alveoli are the functional units
of the lungs.
Primary-> secondary (lobular) -> tertiary
(segmental)-> conducting-> terminal->
respiratory-> alveolar duct-> sac-> alveoli.
During branching, air is warmed to body
temperature and moistened before entering
the alveoli. The lumen of the bronchi is lined
with epithelium containing cilia (hair like
projections from the cells) and mucus
secreting cells. The mucus traps dust and
inhaled particles. Cilia sweep mucus back
toward the pharynx where it is either
swallowed or expectorated.
http://www.wikicell.org/index.php/Pulmonary_Alveoli
193
http://www.siimcenter.org/books/displays/chapter-7-d isplay-volumetric-images
Question: Where are lobes, trachea and bronchi in the images above?
194
During inspiration external intercostal muscles pull ribs laterally and superiorly, the dome of the
diaphragm flattens and descends and the volume of thorax increases. During forceful expiration the
internal intercostal muscles pull ribs inferiorly and medially and abdominal muscles push viscera in.
Note the location of esophageal, aortic and caval passages through the diaphragm.
195
The root of the lung is formed by the bronchus, the pulmonary artery, superior and inferior pulmonary
veins, bronchial arteries and veins, the pulmonary plexus of nerves and lymphatic vessels, and is
covered by mediastinal pleura. The hilum is a triangular depression on the medial side of the lung
where the root of the lung is attached.
Mediastinal Surface of Lungs
4. Compare and contrast right vs. left lungs.

The right Lung is larger, heavier, and wider than the left lung. It has a superior lobe, middle lobe and
inferior lobe. The horizontal fissure separates the superior and middle lobe, oblique fissure separates
middle and inferior lobe. The left lung has only two lobes: superior and inferior, they are separated by
an oblique fissure. Lingula is a thin tongue like process of the superior lobe of the left lung.
Please refer to Yellow Box in M&A pp.67 Surface Anatomy of Pleurae and Lungs.
196
5. Describe pleural recesses, and common pathologies associated with them.
Each lung is enclosed and protected by a double layered serous membrane called pleura. The outer
superficial layer is the parietal pleura. It lines the walls of the thoracic cavity and the diaphragm and
separates the lung from the mediastinum. The deeper layer, visceral pleura, covers the lung and adheres
to all the surfaces of the lung. The space between the parietal and visceral pleura is the pleural cavity.
Lungs do not completely occupy the pulmonary cavities during expiration. The fold of parietal pleura is
called a recess: the costo-diaphragmatic recess is the fold between the diaphragm and thoracic wall.
When inflammation of pleura occurs, the recess can accumulate more fluid. Pleuritis (pleurisy) is an
inflammation of pleura. Pleural effusion is excess fluid that accumulates in the pleura. Excessive
amounts of such fluid can impair breathing by limiting the expansion of the lungs during respiration.
Hemothorax (blood), hydrothorax (serous fluid), chylothorax (lymph) and pyothorax (pus) are types of
pleural effusion.
6. Define the clinical terms associated with lung pathology: aspiration of foreign bodies, pulmonary
embolism, pleural effusion, pleuritis, pneumothorax, hydro/hemothorax; lung resections.
http://www.ceessentials.net/article25.html
Pneumothorax is air in the chest; it occurs when air enters the area around the lung (the pleural space).
In the image above, left is normal, right is pneumothorax (arrows show collapsed lung). Pneumothorax
can be caused by an injury or may happen spontaneously. A collapsed lung (pneumothorax) can occur
when parietal or visceral (or both) pleura is breached and air moves in the pleural cavity and presses
against the lung.
Pleural Rubs are squeaking or grating sounds of the dry pleural layers rubbing together that appears on
inspiration and expiration. It can be a clinical sign of pleuritis (pleurisy), pneumonia or pulmonary
embolism.
197
Pleurisy (pleuritic) is inflammation of the lining of the lung (pleura), which often causes pain when
breathing in. Autoimmune conditions, infections, or a pulmonary embolism may cause pleurisy.
Pleural effusion is fluid builds up in the normally tiny space between the lung and the inside of the chest
wall (the pleural space). If large, pleural effusions can cause problems with breathing.
Lung resections. Lung cancer, emphysema, or tuberculosis may necessitate the surgical removal of
damaged portions of the lung. Surgeons exploit the anatomical subdivision of the lungs into lobes and
segments when excising damaged tissue. Each Lung is divided into lobes. Each lobe is divided into
bronchopulmonary segments, which are supplied by segmental bronchus, tertiary branch of pulmonary
artery and drained by intersegmental pulmonary vein.
Segmentectomy (segmental wedge resection): Removal of one or more segments. Lobectomy: Removal
of the lobe. Pneumonectomy: Removal of entire lung.
Segmentectomy Lobectomy Pneumonectomy
Please refer to the Blue Boxes in pp. 74-76 Pulmonary Collapse, Pneumothorax, Hemothorax,
Hydrothorax, Chylothorax, Pleuritis, Variation in Lobes of Lungs, Thoracentesis, Aspiration of Foreign
Bodies, Injury to Pleurae, Pulmonary Embolism, Bronchoscopy.
198
Trachea and primary bronchi are lined by ciliated pseudostratified columnar epithelium.
http://architecturalstudio.com/admin/tracheal-epithelium
Pseudo stratified ciliated columnar epithelium.
199
A – alveolus, AS - alveolar septa, BT - bronchus terminalis, DA - alveolar duct., M - muscular layer, P -
brunch of pulmonary artery, PB - peribronchial connective tissue
Alveoli are lined by simple squamous (alveolar type I) cells, alveolar type II cells are more round, they
produce surfactant.
200
Normal lung. Note
numerous alveoli filled
with air; bronchioles
covered by ciliated
columnar epithelium.
Trachea and large bronchi are characterized by presence of cartilage in their wall.
CT – connective tissue,
CAR - cartilage
Image is taken on July 2008

by Dr. Yale Rosen, labeled by
Dr. Shabashvili
https://www.flickr.com/photos/pulmonary_pathology/3661495488/in/album-72157619688848759/
Cartilage is one of the specialized connective tissues.
201
8. Identify cartilage, components of cartilage and types of cartilage: hyaline, elastic and fibrocartilage.
The cell population of cartilage is limited to chondrocytes and chondroblasts. Chondroblasts are
immature dividing
chondrocytes. In
cartilage, extracellular
matrix may contain
collagen and elastic fibers.
Ground substance
contains a lot of
hyaluronic acid,
chondroitin- & heparan-
sulfate, chondronectin,
rich in water.
Chondrocytes are located
in small cavities of the
matrix called lacunae.
Cartilage has no blood
supply, no lymphatic
drainage and no nerves. Surface of the cartilage may be covered by the layer of dense connective tissue
proper referred as perichondrium. Perichondrium participates in production and repair of cartilage.
There are two distinct layers of perichondrium, an outer fibrous layer and inner chondrogenic layer. The
fibrous layer contains fibroblasts, which maintain and produce extracellular matrix of perochondrium,
while the inner layer contains undifferentiated cells capable of forming chondroblasts (immature cells of
cartilage), that produce and maintain extracellular matrix of cartilage. Mature chondroblasts become
chondrocytes. If cartilage is
transformed to bone, the
perichondrium becomes the
periosteum. There are three
histologically distinct types of
cartilage: Hyaline cartilage,
Elastic cartilage and
Fibrocartilage.
Hyaline cartilage is
characterized by transparent
ground substance, no visible
fibers. You may see more than
one chondrocyte in lacuna.
Arrows in the to the right
indicate lacunae, * - matrix and
P – perichondrium.
202
Location of hyaline cartilage: articular
surfaces of the bones (facets, condyles,
joints); nose, larynx, trachea, and
bronchi, fetal skeleton, thoracic cage,
models for long bones. Functions:
support (soft skeleton) or friction-free
movement in joints.
Perichondrium is absent on the

articular surface of hyaline cartilage
inside the joints.
The image to the left shows the steps of

appositional growth (growth from the
surface) of the cartilage, when cartilage
cell differentiate from the cells of
Perichondrium. Perichondrium is the
CT capsule covering the cartilage. The
fibroblasts of this capsule differentiate
in the cells shown in the image. Please
identify: P – perichondrium; Cg –
chondrogenic cells; Cb – chondroblasts; C
– chondrocytes.
Dividing chondroblasts in the hyaline

cartilage in this image to the right
demonstrate interstitial growth (growth
from inside), when chondrocytes keep
dividing and deposit more of the
cartilage matrix.
Cap – capsular matrix

Ch - chondrocytes
L –lacunae
P - prichondrium
203
TEM image of
hyaline cartilage
to the left
shows the short
fibers of type II
collagen that
are not visible in
the light
microscope.
Elastic cartilage. Characteristic features: visible moderate amount of Type II collagen and elastic fibers
in the matrix, elastic fibers must be demonstrated by special stains; perichondrium present. Location:
Pinna of the ear, nose, epiglottis. Function: Pliable elastic support (elastic skeleton), easy bends and
folds, regains the shape, when released. Elastic cartilage does not calcify or ossify.
204
205
Fibrocartilage Characteristic features: matrix of fibrocartilage resembles dense connective tissue matrix,
it is filled with densely packed Type I and Type II collagen fibers and fewer cells that hyaline or elastic
cartilage. Location: Intervertebral disks, insertion of tendons, menisci, pubis symphysis. Function: shock
absorption, withstanding shocks, tensile resistance.
Aggregates of rounded
cartilage cells in lacunae
and bundles of collagen
fibers in the
fibrocartilage are shown
in the image to the left.
206
Pneumonia is a term for lung infections in which the lung tissue is inflamed and the alveoli are filled
with fluid and blood cells. It may be caused by bacteria or viruses.
Severe acute respiratory syndrome (SARS) is a severe pneumonia caused by a specific virus first
discovered in Asia in 2002.
Tuberculosis is a lung infection caused by a type of bacteria called tubercle bacilli. The lung tissue fights
the infection by walling off the bacteria in pockets called tubercles. This helps to keep the infection from
spreading, but sometimes the bacteria break free and spread through the lungs, damaging tissues and
decreasing the number of alveoli.
Atelectasis is a condition in which alveoli in one or more areas of the lungs deflated and do not inflate.
Common causes of the atelectasis are cancer, surgery, infection inside the lung, lack of surfactant in
neonates and others. Atelectasis is NOT the same as pneumothorax while both can be referred to as
collapsed lung.
The images below: left – lower lobe atelectasis in the right lung; right – middle lobe atelectasis.
By Hellerhoff - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17766964

By Hellerhoff - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=6619035
Asthma is a disorder in which spasms of the bronchioles occur, making it difficult to breathe. In young
people, it is generally the result of allergic reactions to plant pollens or other substances in the air. Air
pollution can also bring on asthma attacks, especially in older people. Drugs to open the bronchioles can
help to ease the breathing distress.
Bronchiectasis is a condition when the walls of the bronchi thick and inflamed, resulting in the inability
to clear mucus normally. As the result of this diameter of bronchi expand abnormally. Coughing, with
large amounts of mucus, is the main symptom of bronchiectasis. Underlying causes are repeated
infections, genetics and air pollution.
Acute bronchitis is an infection and inflammation of the lung’s large airways (bronchi), usually caused by
a virus or bacteria. Cough is the main symptom of acute bronchitis.
207
Chronic bronchitis is repeated, frequent episodes of productive cough, usually caused by recurring
colds, infections or by chronic smoking.
Chronic obstructive pulmonary disease (COPD) results in difficulty blowing air out, causing shortness of
breath. Smoking is by far the most common cause of this disease.
Pulmonary fibrosis is a form of interstitial lung disease. The interstitium (walls between air sacs)
become scarred, making the lungs stiff and causing shortness of breath.
Pulmonary embolism occurs when an embolus (for example a blood clot from the vein or bone marrow
from the broken bone) obstructs an artery leading to the lung. Sudden shortness of breath is the most
common symptom of a pulmonary embolism.
According to American Lung Association, 480,000 people die every year in the U.S. from tobacco
smoking or secondhand smoking. The image below demonstrates changes that occur in the typical
smoker lung.
Smoker’s lung. Note:

1) Accumulation of carbon particles more noticeable in the lymph nodes, where they are brought by
macrophages,
2) Enlarged and stretched alveoli, because smoking decreases elasticity of the lung and increases the risk
of emphysema,
3) Thick septa due to connective tissue replacing injured tissue
208
Additional cartilage images.
209
Lecture 14: Abdominal cavity; Kidneys
Objectives
1. Describe the structure of the anteriolateral abdominal wall: fascia, muscles, and peritoneum.
2. Compare parietal vs. visceral peritoneum; describe the divisions of abdomonopelvic cavity:
abdominal vs. pelvic, intraperitoneal vs. retroperitoneal organs.
4. Describe recesses and common pathologies, such as peritonitis.
1. Describe the structure of the anteriolateral abdominal wall: fascia, muscles, and peritoneum.
Anteriorly, the abdominopelvic cavity is protected by a muscular layer. There are four muscles that form
the anterior wall of abdomen: rectus abdominis, external oblique, internal oblique and transversus
abdominis.
210
2. Compare parietal vs. visceral peritoneum. Describe divisions of abdomonopelvic cavity: abdominal
vs. pelvic, intraperitoneal vs. retroperitoneal organs.
The peritoneum: a glistening, transparent serous membrane that consists of two continuous layers.
211
Parietal peritoneum is the lining of the internal surface of the abdominopelvic wall (shown as a
dark blue line in the image above). Visceral peritoneum covers viscera such as the stomach and
intestines (gray line).
Peritoneal cavity is a
potential space between the
parietal and the visceral
layers of peritoneum. There
are no organs in the
peritoneal cavity. The
peritoneal cavity is
completely closed in males; in
females it communicates with
the exterior of the body
through the uterine tubes,
uterine cavity, and vagina.
Peritoneal fluid lubricates the
peritoneal surfaces, enabling
the viscera to move over each
other. Peritoneal fluid may
contain leukocytes.
Peritoneum also makes folds that attach viscera to each

other and the posterior wall of abdominal cavity: dorsal
mesentery and lesser omentum. Greater omentum is a
fold of peritoneum that contains adipose tissue. Clinical
significance of mesentery and omentums will be
discussed in later lectures, along with the blood supply of
abdominal organs.
Not all the organs in the abdominal cavity are covered by

peritoneum. The picture to the right shows blue parietal
peritoneum, which separates bladder and ampulla of
rectum from the peritoneal cavity. The bladder and
ampulla of rectum are not covered by peritoneum at all,
therefore they are retroperitoneal (extraperitoneal)
organs.
212
Abdominopelvic organs that are
covered by peritoneum are
referred to as intraperitoneal.
Retroperitoneal (extraperitoneal)
organs are mostly located in the
space between peritoneum and
posterior abdominal wall. These
organs may be partially covered by
the parietal peritoneum on one
surface.
Retroperitoneal organs are shown

in the picture below.
Mnemonic for retroperitoneal
organs is “sad pucker.”
S - supra adrenal glands

A - aorta and IVC
D – duodenum(2,3,4 quarters)
P - pancreas (except tail)

U - ureters
C - colon (except transverse)
K- kidneys
E - esophagus
R - rectum
213
Both mesentery and omentum are folds of peritoneum that help to keep abdominal viscera in place.
Mesentery is the fold of peritoneum, a serous membrane that contains the blood vessels and nerves
supplying the intestine. A good way to imagine the shape of the mesentery and the bowel is to look at a
set of drapes hanging in front of a window. The drapes (mesentery) are a sheet of cloth that is folded
back and forth. At the bottom, drapes usually have a kind of wrapper, where the cloth is folded over
onto itself and sewn. In a sense, this folded over part makes a hollow tube or sleeve. The bowel is the
hollow tube sitting in this sleeve at the edge of the curtain (mesentery). The arteries and veins that
attach to the intestine come up to it in the drape material. The mesentery rises up from the back body
wall where the arteries emanate from the aorta. The root of mesentery is about 15 cm long and extends
from left side of L2 to right sacroiliac joint. Because the mesentery is floppy, the guts can be easily
moved around. The mesentery that holds the large intestine (colon) is referred as mesocolon.
Transverse mesocolon divides the abdominal cavity to supracolic compartment (liver, stomach, spleen)
and infracolic (intestines) compartment.
https://upload.wikimedia.org/wikipedia/commons/d/d8/Mesentery.jpg
214
Greater omentum is vascularized fat flap covering intestines first seen on opening of the abdomen. It is
draping from the stomach and over the intestines. Lesser omentum connects liver to stomach and
duodenum, it consists of two ligaments: hepatogastric and hepatoduodenal.
The greater omentum is sometimes referred to as the “Policeman of the Abdomen,” due to its ability to
fill voids if something is removed or in the wrong place. It scars down, sealing holes, bringing blood flow
and immune function.
215
3. Describe recesses and common pathologies such as peritonitis.
Peritonitis is an inflammation
of the peritoneum. It is a
medical emergency and
potentially fatal condition.
The image to the left shows
the abdominal cavity with
peritonitis. Note the yellow
pus spread around the
intestines in the inferior part
of abdomen. Compare to the
transparent and glistening
peritoneum that is covering
liver superiorly.
Ascites (aka
hydroperitoneum) is
accumulation of the fluid in
the peritoneal cavity.
Common risk factors for
developing ascites are
inflammations, cancer, as well
as, liver, digestive and heart
problems.
http://www.pathologyoutlines.com/topic/smallbowelmeconiumperitonitis.html
Peritoneal recesses (aka gutters) are the potential spaces formed by peritoneum draping over organs.
Recesses are clinically significant because the infection and excess fluid can spread over them. Blood,
pus or other fluids released from viscera anywhere in the recess may run along the gutter and collect in
sites quite remote from the organ of origin.
The biggest peritoneal recesses are the left and right paracolic gutters and hepatorenal recess. There
are other, smaller recesses.
216
Right paracolic recess (image to
the right).
Left and right paracolic gutters

are spaces between the colon
and lateral abdominal wall.
Hepatorenal recess (aka

subhepatic recess, aka pouch of
Morison) is between the liver
and the right kidney.
Please identify the major organs of

abdominal cavity in the image to the left.
Think of intraperitoneal versus retroperitoneal

organs; recesses and gutters.
217
Kidneys
Objectives

2. Identify the major blood vessels associated with each kidney and trace the path of blood
flow through a kidney.
3. Describe the structure of a nephron and outline the processes involved in the formation of
urine.
4. Discuss the clinical associations related to kidney pathology and congenital malformations
of kidneys: kidney stones, bladder cancer, ectopic kidney, bifid ureter, bifid kidney pelvis,
horseshoe kidney, and renal transplantation.

Kidneys make less than 0.5% of the total body mass but they receive the largest share of resting
cardiac output which is 20 to 25%.
They are bean-shaped organs about five inches long, two to three inches wide, and one inch thick.
They are located in the middle of the back near the lower ribs. Kidneys produce urine, which is
excreted from the body. Kidneys also regulate water content of the blood and tissue and help
maintain the balance of some key electrolytes such as sodium, chlorine and potassium.
http://structuralevolution.org/blog/wp-content/uploads/2009/08/kidneys.gif
218
Normally, kidneys are located between the level of the 12th thoracic and 3rd lumbar vertebra, lateral
to the vertebral body. The right kidney is usually slightly lower than the left. The kidneys hang in
their layered
capsules
attached to the
posterior wall.
They can
normally move
about 3cm up
and down,
depending on
the position of
the body and the
diaphragm. Only
the anterior
surface of the
kidneys is
covered by
parietal
peritoneum.
Kidneys are
retroperitoneal.
Inferior view http://home.comcast.net/~wnor/peritoneum.htm

1 and 2 - parietal peritoneum, 7,8 and 9 – visceral peritoneum. K - kidney
Each kidney has an anterior and posterior surface, and a superior and inferior pole; they also have
concave (medial) and convex (lateral) margins. The concave margin has the renal hilus, where ureters
and blood vessels are entering
and exiting the kidney. There are
three layers of membranes
surrounding the kidney: the
deepest is the renal capsule
made of a thin transparent
smooth layer of dense irregular
connective tissue immediately
attached to the kidney. The
renal capsule helps to maintain
the kidney’s shape. Adipose
capsule surrounds the renal
capsule. It protects, cushions
and isolates the kidney, it also
helps to hold the kidney in place.
219
The outermost layer is the renal fascia, which is also made of dense irregular connective tissue that
anchors the kidney to the surrounding structure.
Internal Anatomy of the kidney

Parenchyma, the functional portion of the
kidney, has two distinct regions: outer
cortex and inner medulla. Medulla may
consist of 8 to 18 pyramids. Renal column is
the space between the pyramids.
Several minor calices combine to form a
major calyx. Major calices combine to make
renal pelvis that starts at the crossing of
medial margin. Base of renal pyramids is
facing towards the cortex. The apex of
pyramid (renal papilla) is facing toward the
hilus. Renal hilus contains renal arteries,
renal veins and renal pelvis.
2. Identify the major blood vessels associated with each kidney

and trace the path of blood flow through a kidney.
Renal artery divided into the

segmental arteries, which are divided into interlobar arteries, which are divided into arcuate
arteries and then interlobular arteries, which are then divided into afferent arterioles, which are
divided into glomerular capillaries, from which blood is collected into efferent arterioles and
220
peritubular capillaries, from which blood is collected by interlobular veins, from which blood is
collected by arcuate veins, from which blood is collected by interlobar veins, from which blood is
collected by segmental veins, from which blood is collected by renal vein that drains to inferior
vena cava (IVC).
Right gonadal vein (testicular or ovarian) drains directly into (IVC). Left gonadal vein drains into left
renal vein first (not to vena cava directly), which then drains into IVC.
3. Describe the structure of a nephron and outline the processes involved in the formation of urine.
Nephron is the functional base unit of the kidney.
Each nephron has two parts: renal corpuscle and
renal tubule. Histology of the nephron will be
discussed in more detail in the next chapter.
The nephron has three distinct parts that perform
three consecutive functional steps: 1.Glomerular
filtration (filtration of solutes and water from
glomerulus to Bowman’s capsule),
2. Tubular reabsorption (reabsorption of solutes
and water from loop of Henle back to blood flow)
and 3.Tubular secretion (excretion of urine via
collecting ducts).
http://vzajic.tripod.com/8thchapter.html
Copyright 1998 by Fogra
221
Glomerulus is a tuft of capillaries where filtration occurs. Glomerular capillaries allow for filtration of
large volumes of fluid.
Normally, only
glucose, small ions
and water pass
through the filter
during filtration step.
The presence of
blood cells and
protein in the urine is
the sign of a kidney
problem.
Bowman's capsule surrounds the glomerulus and collects filtrate (primary urine).
Fluid is filtered from the glomerulus to the Bowman’s capsule by blood pressure. Note that the
diameter of the afferent arteriole is bigger than of the efferent areteiole.
222
In the proximal convoluted tubule, the loop of Henle and the distal convoluted tubule volume of fluid is
adjusted and urine is concentrated. Collecting ducts collect and drain urine.
Path of urine drainage: renal tubule

collecting duct  papillary duct 
minor calyx  major calyx  renal pelvis
 ureter  urinary bladderurethra.
There are more than a million nephrons in
each normal adult human kidney.
Nephrons regulate water and soluble
matter (electrolytes, glucose) in the body
by first filtering the blood. Then, the
kidney reabsorbs the necessary fluid and
molecules while secreting other,
unneeded molecules. The number of
nephrons declines with age, to about 50%
at age 60; this decline causes the
glomerular filtration rate (GFR) to drop to
50% of the value of a young person.
http://excretory11u.tripod.com/id19.html
Loss of nephrons can lead to drug overdose in older populations.
Cortical nephrons have glomeruli in the superficial renal cortex. Their short loops of Henle penetrate
only into the superficial renal medulla.
223
Medullary nephrons have glomeruli deep in the renal cortex. Their long loops of Henle extend
throughout the renal medulla all the way up to renal papilla. Vasa recta (strait vessel) supply the tubular
portion of the juxstamedullary nephron in renal medulla and peritubular capillaries supply the tubular
portion of cortical nephron in the renal cortex. Slow blood flow in peritubular capillary and vasa recta
makes them a likely site of obstruction by thrombi, with subsequent ischemia which can lead to renal
necrosis.
4. Discuss the clinical associations related to kidney pathology and congenital malformations of
kidney: kidney stones, bladder cancer, ectopic kidney, bifid ureter, bifid kidney pelvis, horseshoe
kidney, renal transplantation, and kidney stones.
Please refer to the Blue Boxes in M&A p.174, Perinephric Abscess, Renal Transplantation, Renal and
Ureteric Calculi, Congenital Abnormalities of Kidneys and Ureters.
224
Congenital Malformations of the Kidney:
Bifid Renal Pelvis, Pyelogram.
Bifid Duplicated Ureters.
Duplication of collecting systems is often

associated with fetal ureterocele, which is
a balloon like formation of the area where
the ureter enters the bladder. (copyright
2007 Children’s Memorial Hospital).
225
Retrocaval Ureter.
The retrocaval ureter wraps around and
behind the vena cava. It can cause a
problem, if the ureter became obstructed.
Retrocaval ureter is a rare congenital
abnormality. Though the abnormality is
congenital, it usually does not present until
the third or fourth decades of life. Ureter
crosses behind the inferior vena cava at the
level of the third lumbar vertebra and has a
fish hook shaped (S shaped) deformity of the
ureter at the point of obstruction.
Common presentations are right lumbar
pain, dull aching or intermittent renal colic,
recurrent urinary tract infections and
hematuria. It also may be associated with a
high incidence of calculi (kidney stones) due
to stasis.
Horseshoe kidney is a congenital abnormality due to the fusion of the inferior poles of the kidneys.
226
Ectopic kidney refers to a kidney located in an abnormal place. Kidneys that fail to ascend to their
normal position are known as ectopic pelvic kidneys (image below). Accidents, tumors, enlarged organs,
extreme diets and weight lifting can cause kidney displacement.
Image to the left is computed tomography (reconstruction) showing displacement of the left kidney into
the thoracic cavity due to diaphragmatic hernia.
http://www.ispub.com/journal/the_int
ernet_journal_of_pediatrics_and_neon
atology/volume_8_number_1_10.html
227
Kidney stones.
A stone can cause pain, hematuria and

promote urinary tract infection. Stones less
than 6 mm in diameter most likely will pass
on their own, with diuretics and muscle
relaxants. Some stones can block urine flow
and cause hydronephrosis and damage the
kidneys. Kidney stones can be made up of
calcium oxalate, calcium phosphate,
struvite, uric acid or cystine. The most
common type of stone contains calcium.
Calcium is a normal part of a healthy diet.
Calcium that is not used by the bones and
muscles goes to the kidneys. In most
people, the kidneys flush out the extra
calcium with the rest of the urine.
http://cme.medscape.com/viewarticle/703
272
People who have calcium stones keep the calcium in their kidneys. The calcium that stays behind joins
with other waste products to form a stone.
Treatment of Kidney stones:
1.) Open surgery,
2.) Percutaneous surgery, when a needle and
guide wire are used to access to the kidney
and the upper urinary tract through small-
diameter percutaneous access tracts.
3.) Uretroscopic surgery, when tiny endoscope
and tiny surgical tools are used to get to the
stone without breaking the skin. Now it is
replacing many invasive open urologic
procedures.
4.) Lithotripsy high energy shock waves to
break the stones that then flashed out by
natural flow of urine.
228
Cancer of the urinary bladder is the fourth most common malignancy among men, and the eighth most
frequent among women. An average of 260,000 new cases of urinary bladder cancer is diagnosed
worldwide every year. Approximately 90% of these cancers are “Transitional Cell Carcinoma” (TCC) type,
originating in the epithelial cells (the internal lining) of the bladder wall. When the tumor is limited to
this layer, it is called “superficial” urinary bladder cancer. This superficial type of cancer tends to recur
despite surgery and/or treatment; in most cases, the tumor tends to recur as superficial cancer. A tumor
that penetrates more deeply into the muscular layer of the urinary bladder is called “invasive” urinary
bladder cancer.
Polycystic Kidney Disease

The images below show the autopsy of an infant with polycystic kidneys. This infant was the product of
a gestation estimated at 36 weeks by dates and ultrasound. The mother is a 38-year-old Caucasian
woman. On prenatal ultrasound, the infants was found to have enlarged echogenic kidneys with loss of
the corticomedullary margins, consistent with polycystic kidney disease. Additionally, the ultrasound
demonstrated severe oligohydramnios. After counseling, the parents elected to carry the child to term.
The mother underwent spontaneous rupture of membranes with a forceps assisted vaginal delivery. The
Apgar scores of the baby was 1. The infant was immediately transferred to the neonatal intensive care
unit where a renal ultrasound revealed enlarged echogenic kidneys. The patient was placed on
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ventilator support and subsequently developed a right pneumothorax, which was treated with the
placement of a right chest tube. Despite treatment with fluids, the infant failed to produce urine. After
discussion with the family a decision was made to withdraw support measures and the patient died.
http://www.bing.com/images/search?q=abdominal+cavity&view=detail&id=983246C0CB8956A8AE7CFF
C11E5D00DCF6D88CB3&first=1&FORM=IDFRIR
Two different genes can cause a similar condition. The autosomal dominant form causes problems in
middle aged people, usually no symptoms until later in life. The patients with autosomal recessive gene
usually die in infancy or early childhood.
Kidney cancer
In the autopsy of the cancerous kidney
to the left note the difference between
normal and abnormal tissue, cortex,
medulla, pelvis, renal capsule, adipose
capsule and renal fascia.
Please learn the terms of common

inflammations: cystitis - bladder,
uretritis –ureters, pyelitis – renal
pelvis.
230
Lecture 15: Kidney Histology
1. List and describe functions of the kidney.

2. Identify and describe the structural and functional components of the nephron: glomerulus,
vascular vs. urinary poles, podocytes, pedicels and filtration slits; proximal convoluted tubule,
distal convoluted tubule, collecting tubule, macula densa, and JG cells.
3. Identify and describe the epithelia and specialized cells characteristic for parts of a nephron.
4. Identify cortex vs. medulla.
5. Identify histological features of the bladder and urethra.
1. List and describe functions of the kidney.
The main function of the kidney is to produce urine. Kidney plays role in: 1) excretion of wastes; 2)
regulation of electrolytes (Na, K, Cl, glucose and amino acids); 3) acid-base balance; 4) the body’s fluid
volume; 5) the osmolarity of urine. When you lose a lot of fluid, e.g. sweating during exercise, you
urinary output decrease and the osmolarity of urine is increase.
The kidneys also produce and secrete hormones and hormone-like substances that play a role in
multiple body functions: they secrete erythropoietin that is a stimulant of RBC production; medullipin I
that is a precursor of a potent vasodilator; renin that stimulates the angiotensin cascade and causes
vasoconstriction. The kidney also plays a role in the activation of vitamin D.
231
2. Identify and describe the structural and functional components of the nephron: glomerulus,
vascular vs. urinary poles, podocytes, pedicels and filtration slits; proximal convoluted tubule, distal
convoluted tubule, collecting tubule, macula densa, and JG cells. A. Hemisected kidney illustrating
morphology and circulation.Note: capsule, cortex, medulla, renal artery, renal vein, interlobar,
interlobular and arcuate arteries, renal pyramids, renal columns, major and minor calyx, renal pelvis,
and ureter.
B. Arrangement of and juxtamedullary cortical

nephrons. Note their location in reference to
capsule, cortex and medulla. Find the loop of
Henle and collecting ducts.
C. The uriniferous tubule and
its vascular supply and
drainage. The juxtamedullary
nephron extends much deeper
into the medulla than does the
cortical nephron. Note the parts
of a nephron and their location in
the kidney: glomerulus,
Bowman’s proximal and distal
convoluted tubules, loop of
Henle, arcuate artery and vein,
and the collecting duct. Find the
peritubular capillary.
232
3. Identify and describe the epithelia and specialized cells characteristic for parts of a nephron.
Note that the apical end of each cell in the cuboidal epithelium of the proximal convoluted tubule has a
brush border of microvilli. This
provides an increased surface area
to accommodate the membrane
channels that are responsible for
absorption of small molecules from
the filtrate in the tubular lumen into
the cell. This brush border is seldom
visible under a light microscope.
Proximal tubule cells tend to have
indistinct apical ends, in contrast to
the more definite apical border of
cuboidal epithelium lining distal
tubules and collecting ducts. The
lumen in distal tubules is more open
and clear. Presence of glomeruli
indicates that the tissue was taken
from the cortex.
Identify proximal and distal convoluted tubules in the image above and below.
P- Proximal CT, d –distal CT; peritubular capillaries are lined by endothelium.
233
EM: Podocytes and basement membrane of glomerulus (below)
Electron micrograph of pedicels (P) and diaphragms bridging

the filtration slits of a glomerulus in a rat (×86,700). BS,
Bowman's space; CL, capillary lumen. Note the laminae rara
externa (short arrow) and the filtration slit diaphragm (long
arrow). (From Brenner BM, Rector FC: The Kidney, 4th ed,
Vol 1. Philadelphia, WB Saunders, 1991.)
Compare the EM images to the labeled cartoon picture

presented below. Identify the same structures: filtration
slits, pedicels, basements membrane, fenestrated
endothelium in both.
234
Scanning electron micrograph of the rat renal
cortex displaying a renal corpuscle with its
glomerulus (g) (×543). The renal corpuscle
below it does not have its glomerulus, so the
urinary pole (arrow) is evident. c, capillaries; d,
distal convoluted tubule; p, proximal
convoluted tubule; v, blood vessels. (From
Leeson TS, Leeson CR, Paparo AA: Text/Atlas
of Histology. Philadelphia, WB Saunders,
1988.)
A decrease in GFR (Glomerular Filtration Rate)

causes slower filtrate movement through the
proximal tubule and thus more time for
reabsorption and, consequently, a lower NaCl
concentration by the time the filtrate reaches the
macula densa. Decrease in NaCl absorption in the macula densa causes secretion of renin by JG cells.
Renin stimulates the production of angiotensin I (AGT I) from angitensinogen, AGT is then converted to
AGT II, which causes blood vessels to constrict, resulting in increased blood pressure. Angiotensin II also
stimulates the secretion of the hormone aldosterone from the adrenal cortex. Aldosterone causes the
235
tubules of the kidneys to increase the reabsorption of sodium and water into the blood. This increases
the volume of fluid in the body which also increases blood pressure.
4. Identify cortex vs. medulla. Cortex: M –macula densa, S – Bowman’s space, P –parietal layer of
Bowman’s capsule.
The JG cells also secrete renin in
response to sympathetic
stimulation or decrease in renal
perfusion pressure detected
directly by the granular cells (low
BP).
If the renin-angiotensin-
aldosterone system is too active,
blood pressure will be too high.
There are many drugs that
interrupt different steps in this
system to lower blood pressure.
236
http://expokerja.com/1/kidney-histology.html
The medulla of the kidney

displays simple cuboidal
epithelium of the
uriniferous tubules (CT), as
well as the simple
squamous epithelium of
the thin limb of Henle's
loop (HL) and the
endothelial cells (E) of the
vasa recta. Note that the
connective tissue
components are sparse and
consist mostly of vascular
elements (×270).
237
A thin segment of the loop of
Henle is lined by squamous
epithelial cells.
A thick segment of loop of Henle is

lined by cuboidal epithelial cells
having eosinophilic cytoplasm and
no apparent cell boundaries.
A collecting duct is lined by

cuboidal epithelial cells with
relatively clear cytoplasm and
distinct cell boundaries.
238
5. Identify histological features of the bladder and urethra.
The wall of Urinary bladder: M –

smooth muscles, CT connective
tissue, E –epithelium (transitional).
Transitional epithelium is lined by

connective tissue LP (lamina propria).
239
In the male reproductive and urinary system penile urethra is lined by stratified columnar epithelium.
Note that the apical (superficial) layer consists of columnar cells and basal (deeper) layer, which is
attached to basal lamina, is made of cuboidal cells.
The female urethra is lined by transitional epithelium, which is closely surrounded by smooth muscle (no
penile tissues around).
240
Lecture 16: Liver & Pancreas
Objectives
1. Describe the location and structural features of the liver.

2. Identify hepatic triad, lobes, ligaments, and bare area of the liver.
3. Explain the hepatic portal circulation: identify the hepatic artery, portal vein, and hepatic
vein. Trace the path of blood flow through the liver.
4. Describe the location and features of the gall bladder, pancreas, and spleen.
5. Explain the path of bile and pancreatic juice trough the ducts from the liver to the
duodenum.
6. Outline the blood supply of the upper abdomen: identify the branches of the celiac artery
(trunk): left gastric, common hepatic, splenic, superior and inferior pancreaticoduodenal
arteries.
7. Discuss the clinical correlations of the pancreas, spleen, liver, and gall bladder pathology:
liver rupture, spleen rupture, jaundice, cirrhosis, gall stones, cholecystitis, pancreatitis, liver
cancer, and pancreatic cancer. Know the risk factors.
1. Describe the location and structural features of the liver.

The Liver is the largest internal organ and the largest gland of the body (1500g). It is located in the right
upper quadrant of the abdominal cavity and is mostly covered by ribs. The liver produces bile, stores
glycogen, is involved in several metabolic processes, and it detoxifies blood. The liver has a
diaphragmatic surface and a visceral surface.
The subphrenic recess is between the superior anterior surface of the liver and the diaphragm. The
hepatorenal recess is between the liver and the right kidney.
241
2. Identify hepatic triad, lobes, ligaments, and bare area of the liver.
The liver is attached to the surrounding structures by ligaments:
Falciform ligament (sickle-shaped) is a fold of parietal peritoneum, which extends from the
undersurface of the diaphragm to the posterior surface of the right rectus abdominis fascia. At the
inferior end it continues as the Round ligament (ligamentum teres), which is a remnant of the umbilical
vein and is inserted in the abdominal wall around the umbilicus.
The coronary ligament is a fold of peritoneum, which lies in the coronary plane. The Coronary ligament
is missing at an area between left and right lobe, where the liver is not covered by parietal peritoneum
and it is in close contact with the diaphragm. This area is called the bare area of the liver.
The Right Triangular Ligament is a small triangular ligament that attaches the right lobe of the liver to
the diaphragm. The Left Triangular Ligament is a small triangular ligament that attaches the left lobe of
the liver to the diaphragm.
Based on superficial features (Right and Left Sagittal

Fissures, Falciform Ligament, and Porta Hepatis) the
liver is divided into four anatomical lobes: right, left,
caudate and quadrate.
1. Right lobe, 2. Left lobe, 3. Quadrate lobe, 4. Round

ligament, 5. Falciform ligament, 6. Caudate lobe, 7.
Inferior vena cava, 8.Common bile duct, 9.Hepatic
artery, 10. Portal vein, 11. Cystic duct, 12. Hepatic
duct, 13. Gallbladder. (inferior view)
242
Based on blood supply and bile drainage, (see blood supply of the liver), the liver is divided into
functional liver lobes: right and left portal lobes. These are more equal in size and are further divided
into eight segments.
The Porta Hepatis is a transverse fissure in the middle visceral (inferior) surface of the liver. It receives
the portal triad: portal vein, hepatic artery and common hepatic duct.
243
3. Explain hepatic portal circulation: identify the hepatic artery, hepatic portal vein and hepatic vein,
trace the path of the blood flow through the liver.
Liver receives blood from two

sources: 1) Hepatic artery
(oxygenated blood) brings about 20-
25% of blood supply; 2) Portal vein
brings 75-80% of blood entering the
liver. It brings deoxygenated
nutrient rich blood from the
digestive tract. At the porta hepatis
the hepatic artery and portal vein
divide into left and right branches,
which are further dividing into
segmental branches, and then lobar
branches. In the lobules arterial
blood and venous blood is mixed in
specialized capillaries of the liver
called sinusoids. The basic
functional unit of the liver, the
lobule, consists of specialized epithelial cells called hepatocytes.
Hepatocytes are square shaped basic cells of the liver. They are involved in cholesterol and steroid
synthesis, bile
production, and
detoxification of
blood (drugs,
steroids,
insecticides,
conversion of
ammonia to urea).
The bile is drained
by tiny bile ducts-
bile canaliculi.
Hepatocytes also
secrete important
proteins such us
serum albumin,
fibrinogen and
prothrombin.
244
Sinusoids are lined
by endothelial cells.
Endothelial cells are
separated from the
hepatocytes by the
Space of Disse
(interstitial space),
involved in the
drainage of lymph.
Kupffer cells are
phagocytes
(macrophages); they
destroy RBC, worn
out leukocytes,
bacteria and foreign
matter in the
sinusoids.
Above: Scanning electron micrograph of liver sinusoid with fenestrated endothelial cells. Image created
by Prof. Robin Fraser, University of Otago, New Zealand and released into the public domain on 2006-
05-22 as quoted below. Date: Mon, 22 http://en.wikipedia.org/wiki/File:Sinusoid.jpeg
From the liver sinusoids, blood drains to the

central vein. Central veins drain into the
hepatic vein, which drains into the inferior vena
cava.
245
4. Describe the location and features of the gall bladder, pancreas, and spleen.
Gallbladder Spleen
Pancreas
The gallbladder is located inferiorly to the liver. It stores and concentrates bile.
The pancreas sits in the epigastric and left hypochondriac regions. The head of the pancreas is located
in the concavity of duodenum. The head is the most anterior and right part of the pancreas. The body
of the pancreas is stretched to the left posteriorly to the stomach. The tail is the leftmost part of the
pancreas. It makes contact with the spleen and the left kidney.
The pancreas has both digestive and endocrine functions. It is producing pancreatic juice which is
drained into the duodenum along with the bile. Pancreatic juice is a cocktail of enzymes that help to
break down the carbohydrates, fats and proteins in the small intestine. Endocrine hormones produced
by the pancreas include insulin, glucagon and somatostatin.
The spleen is a purple gray organ located in the left upper quadrant of the abdominal cavity close to the
tail of the pancreas and left kidney. It stores the body’s blood reserve in case of bleeding. It destroys red
blood cells and recycles iron. It is a part of the immune system and plays an important role in WBC
production (and RBC recycling). People born without a spleen or those who have lost their spleen are
prone to infectious diseases.
246
5. Explain the path of bile and pancreatic juice trough the ducts from the liver to duodenum.
Bile is synthesized by the hepatocytes and

stored in the gallbladder. The Left and Right
Hepatic Ducts (from left and right lobes
respectively) form the Common Hepatic Duct.
The gallbladder drains into the Cystic Duct. The

Cystic Duct and the Common Hepatic Duct form
the Common Bile Duct. The Common bile duct
and the Pancreatic Duct drain into the
Hepatopancreatic Ampulla (Ampulla of Vater).
which is separated from the duodenum by the
Sphincter of Oddi. From the side of the
duodenum the entrance of the hepatopancreatic
duct/ampulla is called the Major Duodenal
Papilla. The fluids will drain into the duodenum
at the Major Duodenal Papilla.
247
6. Outline the blood supply of the upper abdomen: identify the branches of the celiac artery (trunk):
left gastric, common hepatic, splenic, superior and inferior pancreaticoduodenal arteries.
After passing through the diaphragm thoracic (descending) aorta becomes abdominal aorta.
Besides the renal arteries the aorta gives three major branches: celiac trunk (aka celiac artery),
superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). Then the aorta
bifurcates to the left and right common iliac arteries.
Celiac Trunk: To the left - Left gastric artery (supplies lower esophagus and lesser curvature of
the stomach), and Splenic artery (supplies spleen and gives branches to the greater curvature of
the stomach and pancreas).
To the right - Common hepatic artery, braches to Hepatic artery proper (to the liver, gallbladder
and cystic duct); and the Gastroduodenal artery. The Gastroduodenal artery branches into the
Posterior and Anterior superior pancreaticoduodenal arteries (to the pancreas and the
duodenum). The Posterior inferior pancreaticoduodenal artery comes from the Superior
mesenteric artery.
248
7. Discuss the clinical correlations of the pancreas, spleen, liver, and gall bladder pathology: liver
rupture, spleen rupture, jaundice, cirrhosis, gall stones, cholecystitis, pancreatitis, liver cancer, and
pancreatic cancer. Know the risk factors.
Refer to the Blue Boxes on p. 158 Rupture of Spleen and Splenomegaly, Rupture of Pancreas, Pancreatic
Cancer; p. 166, Liver Biopsy, Rupture of the Liver, Cirrhosis of the Liver, Hepatic Lobectomies and
Segmentectomy, Gallstones, Cholecystectomy, p. 118, Portal Hypertension.
249
Cholecystitis is an
inflammation of the
gallbladder that can
be caused by a
blockage of the
cystic duct by a
gallstone. Gallstones
are solid deposits of
bile that can form in
the gallbladder.
Gallstones can grow
as large as a golf ball,
yet most of them are
smaller. Gallstones
may not cause any
symptoms at all or
may require surgical
removal of
gallbladder. Pain
(biliary colic) usually starts above umbilicus and then shifts to right hypochondriac region at the junction
between 9th costal cartilage and lateral border of rectus abdominis. Pain may also refer to the ribs at the
right side, to the right scapula, or between the shoulder blades. An Acute cholecystitis attack may last
from a few minutes to hours. Chronic or prolonged cholecystitis may lead to jaundice. Anatomical
differences such as extensive production of bilirubin or cholesterol increases the chances of gallstone
formation. Risk factors: The four “f’s”: fat, fertile, female, forties; also Native Americans and their
descendants, pregnancy, low fiber and /or high cholesterol diet, diabetes, some anti cholesterol drugs,
and estrogen containing pills. Gallstones are usually removed with the entire gallbladder in a surgical
procedure known as a cholecystectomy.
Cirrhosis of the liver occurs as a

complication of other chronic liver
diseases or conditions.
Hepatocytes are replaced by
fibrous tissue. Risk factors: Liver
diseases like hepatitis B,
alcoholism, chronic poisoning
(tetracycline or other), insulin
resistance, high fat diet.
250
Symptoms of liver disease: enlarged or shrunken liver, jaundice, ascites (accumulation of fluid in
peritoneal cavity), weight loss, itching and eczema.
Please identify the

vital organs of the
abdominal cavity in
the picture to the left.
Use NetAnatomy for

the reference.
Liver biopsy: for diagnostic purposes, the hepatic tissue may be obtained by needle biopsy through the
10th intercostal space. Kupffer cell activation is responsible for early ethanol-induced liver injury,
common in chronic alcoholics. Chronic alcoholism and liver injury deal with a two hit system. The second
hit is characterized by an activation of the receptors on the Kupffer cell. This activates the transcription
of pro-inflammatory cytokines TNFα (tumor necrosis factor alpha) and production of superoxides (a pro-
oxidant). TNFα will then enter the stellate cell in the liver, leading to collagen synthesis and fibrosis
within Space of Disse. As a consequence the sinusoid lumen becomes smaller. Fibrosis will eventually
cause cirrhosis, or loss of function of the liver.
251
A complication of liver cirrhosis is portal hypertension. The cause of portal hypertension is the
obstruction of blood flow through the liver sinusoids. Varicose veins develop in the anastomoses
between the portal vein and the systemic circulation. These varices/venous aneurisms may become so
dilated and damaged that they rupture and cause profound bleeding. Portal hypertension may be
relieved by a portacaval shunt (anastomoses)- which is an artificial communication between portal vein
and IVC (inferior vena cava).
Caput medusae: (varicose veins around umbilicus) is a sign of portal hypertension
252
http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/step40b.htm
Liver rupture often occurs as a result of trauma. Brocken ribs can also cause liver rupture. Complications
of liver rupture include profound bleeding in the peritoneal cavity and pain.
Liver can regenerate, can remove sections and still function, and can be transplanted.
Splenic rupture: The spleen is the most frequently ruptured organ. It is covered by a thin capsule, has a
relatively superficial location and is often lacerated by bone fragments from broken ribs 9-12; or it can
burst due to a sudden increase of internal abdominal pressure. Complication is severe bleeding, that
may lead to shock and death. The partial removal of the spleen is difficult, while possible; splenectomy is
often done. Splenomegaly (an enlarged spleen, up to 10 times) can be caused by leukemia.
Rupture of the pancreas may be caused by a sudden increase of internal abdominal pressure or trauma.
Complication is leakage of pancreatic juice, which may cause digestion of adjacent organs and is very
painful.
Pancreatic cancer is one of the most deadly cancers. Pancreas shares its blood supply with most of the
vital abdominal organs and has an extensive and close drainage of lymph to the deep abdominal nodes.
Due to its deep location there are usually no presenting symptoms until it has already spread.
Metastasis occurs quickly and profoundly. Risk Factors: Smoking, obesity, diet high in fat and processed
or smoked meats, and genetics. Possible signs and complications are obstruction of the bile duct,
jaundice, severe back pain, obstruction of the IVC or portal vein.
Hepatic cancer also often presents in advanced stage. Risk Factors: Hepatitis B or C, alcohol abuse,
cirrhosis, hemochromatosis, smoking, some toxins (aflatoxin, vinyl chloride), fatty liver. Complications
can include jaundice, ascites, muscle wasting, blockage of portal vein with resulting portal hypertension
and varices, and enlarged liver.
253
Pancreatitis is a disease in which the pancreas becomes inflamed. Symptoms of acute pancreatitis:
Upper abdominal pain that radiates into the back (may be aggravated by eating, especially foods high in
fat), swollen and tender abdomen, nausea and vomiting, fever, and increased heart rate. Symptoms of
chronic pancreatitis similar to those of acute pancreatitis: constant pain in the upper abdomen that
radiates to the back, weight loss caused by poor absorption (malabsorption) of food. This malabsorption
happens because the gland is not releasing enough enzymes to break down food. Also, diabetes may
develop if the insulin-producing cells of the pancreas are damaged. In most cases, acute pancreatitis is
caused by gallstones or heavy alcohol use. Other causes include medications, infections, trauma,
metabolic disorders, surgery, and in 30% cause is unknown. Chronic pancreatitis can be caused by long-
time alcohol use, gallstones, hereditary disorders of the pancreas, cystic fibrosis, high triglycerides,
certain medicines, and in 25% cause unknown.
Please identify the vital organs of the abdominal cavity in the picture to the left. Use Net Anatomy as the
reference.
Please refer to Medical imaging of the Abdomen at M7A pp. 190-194.
254
Complete the picture above. Identify intraperitoneal and retroperitoneal organs.
Please label.
255
Lecture 17: Histology of Glands: Liver and Pancreas
Objectives
1. Describe and explain glands’ structure and function: differentiate between endocrine and
exocrine glands, mucous and serous glands, between unicellular, multicellular simple and
compound glands, acinar, alveolar and tubular glands.
3. Be able to identify cells and histological features that are characteristic for liver: hepatocytes,
Kupffer cells, space of Disse, sinusoids, canaliculi, triads, hepatic plates, lobules: classic, portal
and hepatic acinus.
5. Be able to identify cells and histological features which are characteristic for pancreas: acini,
ducts, septa, islets of Langerhans.
1. Describe and explain glands’ structure and function: differentiate between endocrine and exocrine
glands, mucous and serous glands, between unicellular, multicellular simple and compound glands,
acinar, alveolar and tubular glands.
Glands are structures (organs) formed mostly by epithelial tissue. Their function is production and
release of the secretions;
e.g., digestive enzyme,
mucus, milk or hormone.
Exocrine glands usually
have secretory portion
and ducts. They deliver
their products to the
external or internal
surface of the body.
Endocrine glands secrete
their products in the
interstitial fluid and into
the blood flow.
256
Serous secretion is a rather thin
opalescent fluid composed of water
and proteins, such as the digestive
enzyme amylase. Serous gland cells
(see image of pancreas to the left)
usually have relatively uniformly
stained cytoplasm, sometimes multiple
small secretory granules can be visible
in LM.
Mucous glands produce a protein called

mucin, which with water forms mucus, a
thick, clear, and somewhat slimy
substance.
Mucus is usually light stained
(transparent) in LM.
Goblet cells are unicellular mucous

glands. They are a typical component of
the mucous membranes which are the
typical covering of the respiratory and
digestive tracts. Image to the right is a
light micrograph of goblet cells (GC) in
the epithelial lining of a monkey ileum.
257
Electron mocrograph of mucous
membrane. Identify: mucous granules
(MG), Golgi apparatus (arrows), nuclei.
McMannus' Periodic
acid schiff's (PAS) stain
is often used as an
addition to regular
stains (H & E) to reveal
glycoproteins. It
stained the mucin
purple in the goblet
cells in the image to the
right. Identify:
basement membrane,
goblet cells, nuclei, and
the connective tissue of
the lamina propria.
258
In the images of multicellular glands, secretory cells that produce secretions and ducts that collect and
evacuate this secretions
are usually identifiable.
Small ducts are lined by
simple cuboidal
epithelium, larger ducts
can be lined by columnar
epithelium or stratified
epithelia.
Secretory cells may form tubes, acini and alveoli. Acini are characterized by a narrow lumen (smaller
than the cell size) and the pyramidal shape of the cells. Alveoli (mammary gland) are characterized by a
large lumen (much bigger than the cell size) and cuboidal cells. In tubular glands and ducts are more or
less comparable with the size of the lining cells.
Note the difference in the acinar gland above and the alveolar gland below.
259
Multicellular glands may be described as simple or compound. Simple multicellular glands have a single
non-branching duct or just one degree of branches.
Compound glands
have several levels of
branches. Large
compound glands such
as the liver or the
pancreas are divided
to sections called
lobes, which in turn
are divided into
smaller sections called
lobules. Secretion
from the small
branches is collected
by the lobular
(interlobular) duct,
which drains into the
bigger lobar
(interlobar) duct.
260
As ducts become bigger the ducts’ lining can change from low simple cuboidal to tall cuboidal, to
columnar, to stratified cuboidal or even stratified columnar (see image below). Some biochemical or ion-
exchange activity can be present in the ducts, where the product is modified and finished.
Lobes and lobules are separated by partitions made of connective tissue and referred to as septa. Ducts,
nerves and blood vessels usually run within the septa.

The liver can be roughly described as a compound tubular gland that produce bile. The most abundant
functional cells of the liver are the bile producing cells referred to as hepatocytes. They compose almost
75% of the weight of the liver. They are polygonal in shape and about 20 to 30 mkm in diameter; most
of the hepatocytes have one nucleus while up to 25% may have two. Besides bile production,
hepatocytes actively synthesize various proteins (including, but not limited to, blood albumin and
fibrinogen), and they detoxify blood coming from intestines via the portal vein.
261
3. Be able to identify cells and histological features that are characteristic for liver: hepatocytes,
Kupffer cells, space of Disse, sinusoids, canaliculi, triades, hepatic plates, lobules: classic, portal and
hepatic acinus .
Hepatocytes help to maintain the

level of blood glucose and store
glycogen and lipids. They usually do
not store proteins and glycoproteins
but constantly release them into the
blood stream. Hepatocytes have
extensive lysosome and peroxisome
population for degradation of their
own dead organelles, as well as the
excess fatty acids, purines,
hemoglobin, and various drugs and
toxins coming from the blood.
Hepatocytes are closely packed to

form irregular one to two cells thick
plates, drained by a tiny bile duct.
The smallest bile ducts (about 1
mkm in diameter) between two hepatocytes are called bile canaliculi (sing. canaliculus).
The capillary size

blood vessels, called
sinusoids, run
between the plates
of hepatocytes.
Sinusoids are lined by
fenestrated
squamous
endothelial cells that
normally do not
allow passage of cells
but do allow the
passage of fluid to
the tiny extracellular
space between the
endothelial cell and
the hepatocyte
known as the
perisinusoidal space or space of Disse.
262
Blood running through the sinusoids comes from branches of the portal vein (nutrients rich) and the
hepatic artery (oxygen rich) which are coming to the liver via the portal triad (hepatic artery, portal vein
and bile duct). Histologically, branches of portal triad appear as three tubular structures running within
the connective tissue of septa between the lobules. From the sinusoids, blood drains into the central
vein located in the center of the lobule. From the central veins, blood eventually drains to hepatic veins
and the inferior vena cava.
Please refer to the image below to identify: liver plates, sinusoids, lobules, branches of portal triad,
central vein and bile ducts. Think of the direction and volume of the fluids flowing through the liver.
Classic lobule is a histologically

identifiable lobule seen in the
image to the left. It has natural
borders made of the connective
tissue of the septa and usually has
a central vein in the middle. While
from the physiological perspective,
the functional unit of the liver is
the portal lobule, which is the part
of the liver that drains bile to the
same small duct.
263
Identify the portal triad, the
central vein, the liver plates and
the sinusoids in images above
and below.
Note, portal lobule may include

parts of few neighboring
classical lobules and the
classical lobule may include
parts of few portal lobules.
The liver acinus or

hepatic acinus is the
third way to describe
the functional unit of
the liver. The acinus
is the part of the liver
between the two
closest triads and the
two closest central
veins. An acinus is
smaller than portal
lobule.
The part of hepatic
acinus presented on
the left. Please note
the difference in
thickness of hepatic plates and sinusoids as you move from portal triade to central vien.
http://www.zeably.com/Hepatic_lobule
264
Please note the histological differences between the components of the portal triad in the image below:
the bile duct is easy to
identify by cuboidal epithelial
lining; the arterioles usually
appear more round and have
few layers of smooth muscles
around them; the portal vein
is usually the largest in
diameter and has a more
irregular shape. Also note the
hepatocytes with one or two
nuclei and the sinusoids lined
by endothelium.
http://myhomepage.ferris.ed
u/~griffida/anatomy%20onlin
e/h_atlas/bluehisto/gi3/liver
%20triad%2040x.html
Kupffer cells, which are resident macrophages of the liver, are often seen in the sinusoids. They pick up
debris and
particles found in
the sinusoids. The
image to the left
shows the liver
after carbon
particles were
introduced to the
sinusoids (Si) for
demonstration
purposes. Kupffer
cells (K) look black
because of these
carbon particles
they collected.
265
Star-shaped stellate cells (aka Ito cells) can be found in the
space of Disse. Normally, they store fat and vitamin A,
produce collagen type III fibers and release growth factor
required for regeneration of the liver. Hepatocytes are able
to undergo mitosis. However, mitotic figures are not
observed frequently because the hepatocytes have an
average life span of 5 months. The liver is able to regenerate
after up to 75% of it was surgically removed or damaged by
toxins.
High power electron micrograph of the border of a hepatic

sinusoid showing two hepatocytes, with their plasma
membranes facing a sinusoid containing erythrocytes. The
sinusoid is lined by fenestrated endothelial cells; the nucleus
of an endothelial cell is seen in the center of the field. The
endothelium lacks a basal lamina and is separated from
hepatocytes by the space of Disse, into

which hepatocyte microvilli project.
(By permission from Young B, Heath
JW 2000 Wheater's Functional
Histology. Edinburgh: Churchill
Livingstone.)
When the liver is damaged by alcohol or toxins the stellate cells will proliferate; they activate NK cells
and increase the production of collagen. A massive death of hepatocytes and their replacement with
connective tissue is the cause of liver scarring, known as cirrhosis.
266
The pancreas has both exocrine and endocrine parts that are histologically different.
The exocrine portion of the pancreas produces the pancreatic juice - the liquid secretion that contains
the mixture of enzymes and their precursors: trypsinogen, chymotrypsinogen, elastase,
carboxypeptidase, pancreatic lipase, a-amylase and nucleases. Pancreatic juice has a high concentration
of bicarbonate ions and is alkaline. It neutralizes the acidic gastric acid and optimizes the work of the
enzymes in duodenum.
The endocrine portion of a healthy pancreas consists of more than a million of highly vascularized
compact clusters of epithelial cells known as the pancreatic islets or islets of Langerhans. Islets produce
hormones mostly insulin, glucagon and somatostatin. The hormones are released directly to interstitial
fluid and to the blood circulation.
267
5. Be able to identify cells and histological features which are characteristic for pancreas: acini, ducts,
septa, islets of Langerhans.
Pancreatic juice is produced by secretory cells packed in the pancreatic acini (SA in the image below).
The cytoplasm of these acinar cells looks grainy in light microscope due to the presence of secretory
zymogen granules. CC is the centraoacinar cell - relatively small and pale stained cells that line the
acinar lumen. Se – septum, connective tissue separating pancreatic lobules.
268
From the acinar lumen
pancreatic juice is drained into
the branching network of ducts,
which eventually drain into the
duodenum via the ampulla of
Vater through the sphincter of
Oddi.
http://ocw.tufts.edu/Content/15/imagegallery/342521/342532/342567
Identify Acini and ducts of the exocrine pancreas in the images above.
269
Islets are about 100-200 mkm in diameter and consist of a few hundreds cells. Islet cells are usually
smaller and lighter stained than
acinar cells. There are no ducts in
the islets, hormones are released
into the interstitial (extracellular)
fluid and the fenestrated capillaries.
Then the hormones are transported
to other organs via the blood flow.
The islets of Langerhans are

populated by a few types of
hormone producing cells. The most
abundant types are the alpha (A)
cells and the beta (B) cells which
produce hormones that regulate the
level of glucose in the blood.
A-cells are mostly located in the

periphery of the islets and B-cells
are mostly centrally located. B-cells
are stimulated by a high glucose
level in the blood. They release
insulin which helps to transport
glucose from the blood flow to the
tissues. Increased glucose level also inhibits A-cells which produce glucagon. A low glucose level
stimulates glucagon release. Sympathetic activation stimulates glucagon release and inhibits insulin.
Parasympathetic activation stimulates both A and B cells.
The third type of cells are delta or D-cells that

secrete somatostatin. Somatostatin inhibits
growth factors. Besides D-cells in the pancreas,
somatostatin is produced by some cells of the
stomach and intestines.
270
Cirrhotic liver is characterized by a

decreased number of hepatocytes
and sinusoids and the replacement of
healthy liver tissue with connective
tissue (see image below). Cirrhosis
causes the slowing of blood flow
through the liver, portal
hypertension, obstruction of biliary
tracts, jaundice, tremors and
occasionally psychosis due to chronic
poisoning.
http://www.microscopyu.com/static
gallery/pathology/cirrhosisofliver20x
03.html
Cirrhotic liver (from extremeliversupport.com).
271
Type-one (juvenile) diabetes is caused by
insufficient insulin production due to
autoimmune destruction of B-cells by
antibodies.
Diabetic pancreas (images to

the right and below) is
characterized by the loss of
the islets and a replacement
of healthy pancreatic tissue
by fibrous connective tissue.
http://faculty.tcc.edu/mmitchell/histo/pa
nc3.htm
272
Lecture 18: GI Tract
Objectives
1. Describe the structure and function of the digestive tract and the role of each digestive organ in
digestion and absorption.
2. Describe the anatomical features of the esophagus.
4. Discuss the clinical significance of the esophagus.
6. Describe the histological features of the stomach
8. Describe the blood supply of the stomach.
9. Explain the significance of each portion of the small and the large intestine in the digestion and
absorption of nutrients: duodenum, jejunum, ileum and colon.
10. Diagram the blood supply of the lower abdomen; identify the branches of the superior and inferior
mesenteric arteries.
1. Describe the structure and function of the digestive tract and the role of each digestive organ in
digestion and absorption.
The major functions of the digestive tract are: digestion of food (breaking big molecules to smaller
ones); absorption of nutrients, water and vitamins; transport of wastes out of the body. The digestive
tract also acts as a selective and protective barrier that protects the rest of the body from poisons and
infectious agents coming in with food as well as from being digested by acid and the enzymes of the
digestive juice.
Roughly the digestive tract can be described as a hollow tube for digestion of the food. While the food is
passing through this tube it is ground, mashed, mixed with digestive juices, broken into molecules,
which in turn are broken into smaller ones. The purpose of all these complicated steps is to extract
energy stored in the food and use this energy to make ATP or other energy equivalents.
As food is passing through the digestive tract, each organ performs a specific function: esophagus is
passing a mixture of ground food and saliva to the stomach; in the stomach the food is mixed with acidic
stomach juice and passed to the small intestine, where most of the food absorption occurs. Small
intestine consists of three parts: in the duodenum: bile, enzymes of pancreatic juice and alkaline secrete
of Brunner’s glands are added, and the new mixture is passed to the jejunum; in the jejunum extensive
absorption of water and nutrients occurs and in the ileum absorption continues. The ileum also plays on
important role in the immune response and in passing food to the large intestine, where the remaining
water is absorbed and fecal masses are formed. The latter are evacuated from the body via the rectum
and anal canal.
The GI tract is a hollow tube where the lumen varies in diameter, and the wall is composed of four
layers. The thickness and specific content of which is also slightly different from organ to organ.
The four layers making the wall of the digestive tract are:
1. mucosa – the epithelial lining of the lumen with underlying lamina propria – the layer of loose
connective tissue and muscularis mucosae (aka interna) – the thin layer of smooth muscle cells,
273
2. submucosa – the layer of dense irregular connective tissue supporting mucosa and carrying blood v.;
3. muscularis externa (aka propria)– the thick layer of smooth muscle cells, (with smooth muscle fibers
arranged circular in inner layer and arranged longitudinal in outer layer) that helps to propel the food
along the digestive tract;
4. either serosa or adventitia represents the outermost layer of connective tissue. In some parts of the
alimentary canal this outermost layer is a serous membrane, which is the same as the visceral
peritoneum, in this case it is referred to as serosa. In the retroperitoneal parts of alimentary canal this
outermost layer of dense CT is referred to as adventitia.
Besides the
four principal
layers
described
above each
organ of
alimentary
canal may
contain specific
glands,
lymphoid
organs, neural
plexuses and
blood vessels.
2. Describe anatomical features of esophagus.

The esophagus is a muscular tube that extends from the pharynx to the gastroesophageal (GE) junction.
In an adult it is about 25 cm (10 inches) in length. The esophagus conducts food and fluids from pharynx
to stomach. The esophagus is limited by sphincters at both ends: the upper esophageal sphincter (UES)
is the upper portion of esophagus that contains skeletal muscles and is involved in a very complex
deglutition reflex (swallow), which is controlled by CN IX, X and XII and involves 22 muscles. Normally,
UES is closed and only relaxes to pass the coming bolus (the compacted portion of the mashed food).
When the bolus stretches the pharynx tactile receptors trigger the peristalsis. Peristalsis is a wave of
radially symmetrical relaxation and contraction of the smooth muscles that propagates and pushes the
contents along the tube of the GI tract. The bolus moves from the pharynx to the esophagus by
pharyngeal peristalsis and then down to esophagus by esophageal peristalsis.
274
The main function of UES is to prevent the backflow of the food from esophagus to pharynx, it is also
involved in eructation (aka belching, burping) - release of the gas trapped in the stomach and esophagus
that usually comes with the characteristic sound and sometimes odor.
The gastro-esophageal sphincter (aka low esophageal sphincter, LES) consists of smooth muscle and
prevents reflux of gastric contents into esophagus. Normally, it relaxes only when bolus reaches the
gastroesophageal junction and food accumulates at the lower end of esophagus.
The esophagus is lined by nonkeratinized stratified squamous epithelium that normally appears as a
silky off-white velvety surface.
In this image, compare
the light lining of the
esophagus (to the left)
with the dark lining of
the stomach (to the
right).
Esophageal lamina
propria contains
mucous glands
(cardiac esophageal)
and lymph nodes at
the beginning and at
the end of the
esophagus.
Esophageal muscularis mucosa is very thin and in most parts of the esophagus consists of only one
longitudinal layer of smooth fibers. This layer becomes thicker as it comes closer to the LES.
Esophageal submucosa contains scattered small tubule-acinar glands (esophageal glands proper) that
are populated by two types of cells: mucous cells produce mucus and serous cells produce pepsinogen
and lysozymes. Lysozymes are glycosyl hydrolases that damage bacterial walls and protect against
infections. Esophagus and duodenum are the only two regions of GI tract that have glands in the
submucosa. While in esophagus the submucosal glands are not as abundant as glands in duodenum.
Esophageal muscularis externa consists of both smooth and skeletal muscles. The upper part of
esophagus contains only skeletal fibers, the lower part of esophagus contains only smooth fibers and
middle of esophagus contains both. These fibers make the internal circular and external longitudinal
layers.
The small portion of esophagus inside the abdominal cavity is covered by serosa, superior to the
diaphragm the esophagus is covered by adventitia.
275
Above is a light micrograph of the esophagus (×17). Note that the lumen is lined by a relatively thick
stratified squamous epithelium (E) that forms a well-developed rete apparatus (papilla + ridges) with the
underlying lamina propria (LP). The muscularis mucosa and esophageal glands are almost unnoticeable
at this magnification. The submucosa (S) is surrounded by a thick muscularis externa, composed of inner
circular (IC) and outer longitudinal (OL) muscle layers.
Please note the submucosal esophageal glands proper and the muscularis mucosae in the image above.
276
http://cybermediaservicesdigitalmag.com/biospectrumasia/labeled-esophagus-slide
4. Discuss the clinical significance of esophagus.
The two most common clinical problems with LES

are achalasia and GERD. Achalasia is a failure of
relaxation of LES, which may occur due to
neurological disorders. In severe cases of
achalasia food can remain in the esophagus for
days; the esophagus can be significantly stretched
and enlarged in diameter. Most common
symptoms of achalasia are regurgitation (back
flow of the food to the mouth), dysphagia
(difficulty swallowing), heavy feeling and pain in
the chest after a meal and loss of appetite.
Inflammation of the esophagus, weight loss,
aspiration of food can present subsequent
problems. To confirm the diagnosis of achalasia
the X-ray study called esophagram is performed.
In this study, patient consumes “artificial food”
containing barium and a video or series of X-ray
shots is taken. The esophagram of a patient with
achalasia is presented to the left. Note, ribs, diaphragm, heart shadow and enlarged esophagus partially
filled with barium.
277
Gastro-esophageal reflux disease (GERD)
occurs if the lower esophageal sphincter is
incompetent (stays open even when food is
not passing through it). GERD is causing spill
of acidic contents of the stomach back to the
esophagus and can cause esophageal damage
(Barrett’s esophagus). Most common
symptom of GERD is heartburn; other
symptoms may include nausea after meal,
regurgitation, coughing, difficulty swallowing,
hiccups and sore throat. Most common
diagnostic method is endoscopy also known
as esophagogastroduodenoscopy (EGD).
http://gastrointestinalatlas.com/English/Esophagus/Endoscopic_Gastroplicature_/endoscopic_gastroplicature_.html
In EGD, thin tube with a small video camera and light is inserted in the digestive tract via the throat. The
lining of the esophagus, stomach and duodenum is visually examined and photographs and biopsies can
be taken if necessary. The tissue samples taken during biopsy are further examined in the microscope
to determine the degree of damage. Most common complication of GERD is Barrett’s esophagus,
esophageal ulcer and esophageal cancer.

Stomach is the thickest part of the GI tract and it also has the thickest wall. Stomach is a j-shaped
muscular sack located in the left
upper quadrant of the abdominal
cavity immediately under the
diaphragm. The stomach can
stretch to accommodate and store
consumed food; in most people the
volume of the stomach after a meal
is about 1-1.5 liter, while in some
people it can hold up to 2 gallons
and extends as far as the pelvis.
In the stomach food is broken down

and mixed with stomach juice by
mechanical movements of the
stomach walls, it is also chemically digested by hydrochloric acid and enzymes produced by the stomach
mucosa. Chemical digestion of proteins begins in the stomach. In the stomach boluses are turned into a
soupy mixture called chyme.
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The stomach has two
borders (curvatures):
medial border is lesser
curvature (concave),
lateral border is
greater curvature
(convex). When the
stomach is empty, the
mucosa of the internal
surface of the stomach
makes the rough
irregular longitudinal
folds called rugae,
when the stomach is
full the walls become
smooth and stretched.
There are four parts of the stomach:

cardia is the part closest to esophagus;
fundus is the top of the stomach closest to the diaphragm;
body of the stomach is the biggest middle part;
pylorus is the last part before the connection to the duodenum. The pylorus is subdivided into the
pyloric antrum, where stomach turns to the right and the pyloric canal, where stomach becomes
narrower. The pyloric canal ends with pyloric (gastroduodenal) sphincter that separates stomach from
the duodenum.
Mucosa of the stomach has a variable population of cells that produce different secretions, (the
population of these cells will be discussed in more details in histology section). Parietal cells, or oxyntic
cells produce hydrochloric acid, pH of stomach juice can be as low as 0.8. Another important product of
parietal cells is intrinsic factor that is essential for absorption of vitamin B12. Chief cells produce
pepsinogen, the zymogen that is converted to pepsin when mixed with acid, pepsin breaks down
peptide bonds in proteins.
After the contents of the stomach are processed and chyme is produced, the pyloric sphincter allows
passage of small portions (about 3ml) of the chyme to the duodenum with each peristaltic wave. Small
portions of chyme can be easily neutralized by the alkaline secretions of Brunner’s glands in the
duodenum. It usually takes about 2 -6 hours to convert food into chyme.
6. Describe the histological features of the stomach.
Stomach has coarse rugae, the thick folds of mucosa and submucosa; these rugae permit expansion of
the stomach as it fills. Internal surface of the stomach is lined by simple columnar epithelium with goblet
cells.
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Small invaginations of
epithelium into
mucosa are called
gastric pits or
foveolae.
Gastric glands that
empty into gastric pits
are deeper in mucosa.
Regenerative cells
(mostly concentrated
at isthmus) are
undifferentiated cells
that can potentially
differentiate into
surface mucous cells
or the glandular cells
of a gastric pit. Parietal (oxyntic) cells (mostly at the neck of the pit) make HCl and gastric intrinsic
factor (IF), which is necessary for vitamin B12 absorption. Chief cells (zymogenic cells) (at the base of
gastric pit) make pepsinogen and gastric lipase. Entero-endocrine cells are present in most of the GI
tract including the pancreas and liver. In the stomach entero-endocrine cells make gastrin and
histamine. G cells (in antrum) make gastrin that through a cascade of reactions stimulates HCl release by
parietal cells.
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A is a light micrograph of
the mucosa of the fundus
stomach (×132). The
mucosa is composed of
the simple columnar
epithelium (E), the
connective tissue lamina
propria (LP), and the
muscularis mucosae
(MM). A little section of
the submucosa (S) is
evident at the bottom left
hand corner of the light
micrograph. B is a light
micrograph of fundic
glands (×270). Note that
the glands are very tightly
packed, and much of the
connective tissue is compressed
into thin spaces occupied by
capillaries. Note: chief cell (C);
mucous neck cell (M); parietal cell
(P).
Light micrograph of the pyloric

stomach (×132). Note that the
gastric pits are much deeper here
than in the cardiac or fundic
regions of the stomach. P, gastric
pits; LP, lamina propria; MM,
muscularis mucosae.
There are some histological

differences between the parts of
the stomach: cardiac region,
pylorus, antrum, fundus and
body, these differences are not
discussed in this course. You are required to identify stomach and recognize the differences between
stomach, esophagus and intestines.
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The failure of the pyloric sphincter to relax is called pylorospasm, retention of the contents in the
stomach leads to significant discomfort, regurgitations and even vomiting. Pylorospasm is caused by
imperfect neuromuscular regulation of the pyloric sphincter and is usually transient. It is more common
in children than in adults.
Congenital pyloric stenosis is abnormal development of the pyloric sphincter, which is permanent and
does not allow passage of the food at all. It usually presents as a non-bilious projectile vomiting within
the first week of life and requires surgical repair.
Inflammation of stomach mucosa is referred to as gastritis. There are two types of chronic gastritis:
Type A gastritis is autoimmune in nature and usually involves inflammation of mucosa in the fundus and
body of the stomach. Autoimmune destruction of parietal cells producing HCl and intrinsic factor causes
low stomach juice acidity and B12 avitaminosis. Type B gastritis involves the antrum and pylorus and is
caused by Helicobacter pylori (H. pylori) infection. These bacteria are able to survive the high acidity of
the stomach.
8. Describe blood supply of the stomach.

The stomach receives its blood supply mostly from the three branches of the celiac trunk.
https://www.slideshare.net/fahadshafi/arterialsupplyoftheabdomen-aorta
The left gastric artery runs through the lesser omentum and supplies cardia and lesser curvature of the
stomach. It anastomoses with right gastric artery, which is a branch of hepatic artery proper. Left
gastro-omental (gastro-epiploic) artery is a terminal branch of the splenic artery that supplies the
greater curvature of the stomach. It runs through greater the omentum. Right gastro-omental artery is
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a terminal branch of the gastroduodenal artery (branch of the common hepatic a.). Right gastro-omental
artery anastomoses with left gastro-omental artery on greater curvature of the stomach. Each vein that
drains the area supplied by the artery usually has the same name as the artery.
9. Explain the significance of each portion of the small and the large intestine in the digestion and
absorption of nutrients: duodenum, jejunum, ileum and colon.
The first part of the small

intestine is the duodenum.
Duodenum is ten to twelve
inches long mostly
retroperitoneal C-shaped
piece of small intestine. It
consists of four parts: 1)
superior, 2) descending:
where bile enters the
intestine through the
sphincter of Oddi, 3)
horizontal and 4) ascending.
Last 3 parts have no
mesentery and are
immobile as they are
retroperitoneal. Submucosa
of duodenum contains
Brunner’s glands; main
function of these glands is
to produce a mucus-rich alkaline secretion that contains bicarbonate to neutralize acid coming from the
stomach. Duodenum ends with the sharp bend known as the duodenojejunal flexure.
Jejunum constitutes next eight feet of small intestine. Jejunum is often empty; it is thicker, more
vascular and redder in a live person than duodenum or ileum. It mostly lies in the umbilical region, has
highest activity of brush border enzymes (isomaltase, alpha-dextrinase, etc.). Jejunum is responsible for
absorption of many molecules, which requires a large surface area. The surface area is increased by the
presence of many villi and plicae circularis. Plicae circularis are permanent large, tall and closely spaced
circular folds running around the lumen of small intestine, they are also referred to as intestinal valves.
Ileum is the last and longest (12 feet) part of the small intestine. It is mostly located in the hypogastric
and inguinal region. The ileum also has plicae circularis, but they are shorter and less abundant than in
the jejunum.
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Abdominal arteries supplying both jejunum and ileum emanate arterial arcades, which make an
anastomosing meshwork within mesentery. Vasa recta (straight vessels) run from these arcades to the
small intestine. The
pattern of arterial
arcades and vasa recta
supplying jejunum and
ileum is different; ileum
has more mesenteric fat
and arterial arcades, but
shorter vasa recta than
jejunum (the image to
the left).
Ileum is also characterized by the

presence of Peyer’s patches,
which are the clusters of
lymphatic nodules seen on the
side of the ileum opposite to
mesentery.
Absorption of B 12 occurs in the

ileum. Patients who had this part
of the intestine removed suffer
from B12 deficit and need
injections of B12.
Small intestine ends at the Ileocecal sphincter (valve) the thickened muscularis of the ileum that
extends in the cecum and is seen as a doughnut on the cecal side. It is normally closed and allows
prolonged mixing and absorption of the food in the small intestine. Opening of the ileocecal valve is
normally stimulated by full stomach via gastroileal reflex. In other words, as food fills the stomach, it
stimulates peristalsis and the increased peristalsis leads to opening of the Ileocecal sphincter allowing
the passage of food residues from the small intestine to the large intestine.
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Large Intestine: Large intestine is about 2.5 inches in diameter and a 5 foot long part of the alimentary
canal. It includes the cecum with the appendix, ascending colon, transverse colon, descending colon,
sigmoid colon, rectum and anal canal. Most of the nutrients and water are absorbed in small intestine.
Large intestine absorbs remaining water, compacts feces and houses symbiotic bacteria.
The cecum is a blind pouch in the right lower abdominal quadrant. The vermiform appendix is a
small (1 to 3 inches long) blind tubule that opens into the cecum. The appendix plays some role in
immune system development, while the complete removal of appendix does not affect the health of the
person.
The ascending colon goes superiorly on the right side of abdominal cavity and makes a sharp
(approximately 90o) turn at the hepatic flexure (right colic) near the right lobe of the liver and becomes
the transverse colon.
The transverse colon goes horizontally across the abdomen and turns inferiorly at the splenic
(left colic) flexure and becomes the descending colon that goes down along the left side of the
abdominal cavity. The sigmoid colon begins at the left iliac crest, projects medially to midline and
terminates at the rectum that extends inferiorly.
The last three centimeter of the colon is the anal canal. The anal canal has two sphincters:
internal (smooth muscle) involuntary and external (skeletal) voluntary.
Large hemorrhoidal veins form a plexus around the anal canal. These veins can easily become
permanently distended and protrude in the anal canal forming hemorrhoids.
Muscularis of large intestine is different from other parts of alimentary canal; instead of a longitudinal
external layer, muscularis of the large intestine forms teniae coli - three separate longitudinal ribbons of
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smooth muscle on the outside of the ascending, transverse, descending and sigmoid colons. Because the
taenia coli are shorter than the intestine, the colon becomes sacculated between the taenia, forming
haustra. Haustra are the small pouches caused by the sacculations, which give the colon its segmented
appearance. Epiploic appendages are small pouches of the peritoneum filled with fat and are situated
along the colon and upper part of the rectum.
Please refer to Blue Boxes p. 135 Peritoneum and Surgical Procedures, Peritonitis and Ascites, Peritoneal
Adhesions and Adhesiostomy, Abdominal Paracentesis, Functions of Greater Omentum, Spread of
Fluids; pp. 152-154 Hiatal Hernia, Carcinoma of Stomach and Gastrectomy, Gastric Ulcers, Peptic Ulcers,
H. Pylory and Vagotomy, Duodenal Ulcers, Diverticulosis, Appendicitis, Appendectomy, Colitis,
Colectomy and Ileostomy, Colonoscopy.
pp. 190-194 Medical Imaging of Abdomen.
10. Diagram the blood supply of the lower abdomen; identify the branches of the superior and inferior
mesenteric arteries.
It is easier to understand abdominal blood supply from embryological point of view. Embryonic gut
includes:1) foregut supplied by the celiac artery (trunk): (esophagus, stomach, duodenum, liver,
gallbladder, pancreas, spleen); 2) midgut supplied by superior mesenteric artery: (starts at lower
duodenum and has two loops: a. cranial limb of midgut loop forms the jejunum, ileum, b. Caudal limb
forms Ileum, Cecum, Appendix, Ascending & Transverse colon (first 2/3); 3) Hindgut supplied by the
Inferior Mesenteric Artery: a. Cranial end starts at the Distal 1/3 of transverse colon, descending and
sigmoid colon, b. Caudal end: cloacae, rectum, anal canal, urogenital bladder.
Duodenum receives blood supply from two sources: proximal part of duodenum including second
(descending) part that receives bile and pancreatic juice from ampulla of Vater, receives blood from
celiac trunk via gastrodudenal and superior pancreaticoduodenal arteries. Distal part, starting from the
sphincter of Oddi and down receives blood from inferior pancreaticoduodenal arteries that receive
blood from superior mesenteric artery (SMA). Superior and inferior pancreaticoduodenal arteries form
anastomoses between celiac trunk and SMA that allows collateral circulation if needed. Duodenal veins
drain to the portal vein directly or via the splenic and superior mesenteric veins.
Jejunum, Ileum and proximal colon including proximal 2/3 of transverse colon receive blood from SMA
that runs within mesentery and gives arterial arcades and vasa recta. Branches of SMA are named after
the guts that they supply or direction of flow: jejunal, Ileal, ileocolic, right colic, middle colic (see image
on the next page). Blood from these intestines drains into the corresponding veins: superior mesenteric
vein (SMV) and eventually to portal vein.
Arterial supply of distal transverse, descending sigmoid colon and rectum artery comes from inferior
mesenteric artery (IMA), which gives left colic, sigmoid, superior rectal and marginal arteries. Marginal
artery also receives a significant supply from middle colic and forms the anastomosis between SMA and
IMA. Inferior mesenteric vein (IMV) returns blood from descending and sigmoid colon to portal vein.
286
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Lecture 19: Bone Histology
Objectives:
3. Understand clinical significance of articular cartilage.
5. Identify types of bone tissue (compact vs spongy) and components of bone: lacunae, lamella,
periosteum, osteon, trabeculae.
8. Understand clinical significance of Vitamin C and D deficiency, osteoporosis, osteomalacia.
Connective tissues have relatively few cells and some fibers scattered in the extracellular matrix. The
extracellular matrix of connective tissue consists of ground substance and fibers. Connective tissues
can be classified based on the density and constitution of ground substance, type and abundance of the
fibers and the population of cells. Fibroblasts are the principal cells of connective tissue. They produce
the extracellular fibers, as well as produce and maintain complex carbohydrates of the ground
substance. Active fibroblasts have abundant RER and prominent Golgi complex.
There are few different types of highly specialized cells of connective tissues: Myofibroblasts are
modified fibroblast that possess characteristic of fibroblasts and smooth muscle. They cannot be
distinguished from fibroblasts in light microscope. In EM, actin, myosin, and dense bodies can be seen in
myoblasts. They are abundant in areas of wound healing (wound contraction). Pericytes are specialized
cells of connective tissue that surround endothelial cells of capillaries and small venules. They possess
characteristics of both endothelial and smooth muscle cells (they contain actin, myosin, and
tropomyosin). Both pericytes and endothelial cells contribute in production of basal lamina.
Specialized cells that produce cartilage are referred as Chondroblasts or Chondrocytes. Osteocytes,
osteoblasts, osteoprogenitor cells and osteoclasts are specialized cells of bone that will be discussed
later in this handout. Red Blood Cells and different types of White Blood Cells are also highly
differentiated types of connective tissue cells. Adipose cells that are responsible for synthesis, storage
and release of fat (triglycerides) is another example of fully differentiated cells that derived from
undifferentiated fibroblast-like mesenchymal cell.
The cell population of cartilage is limited to chondrocytes and chondroblasts. Chondrocytes are located
in small cavities of the matrix called lacunae.
288
There are three histologically distinct types of cartilage: Hyaline cartilage, Elastic cartilage and
Fibrocartilage.
Characteristic features of
hyaline cartilage: fibers are
not visible in the light
microscope.
Elastic cartilage.
Characteristic features:
visible moderate amount of
elastic fibers in the matrix.
289
Fibrocartilage
Characteristic
features: collagen
fibers are densely
packed in ground
substance, resemble
with dense
connective tissue.
Chondrocytes in
fibrocartilage
assemble in groups
and less abundant
than in other types of
cartilage.
Aggregates of rounded cartilage cells in

lacunae and bundles of collagen fibers in
the fibrocartilage are shown in the image
to the left.
290
The image to the left shows the steps of appositional growth (growth from the surface) of the cartilage,
when cartilage cell differentiate from the cells of Perichondrium. Image to the right shows interstitial
growth by division of chondrocytes in the lacunae.
Please identify cartilage in the image below. What type is it?
291
3. Understand clinical significance of the articular cartilage.
Articular cartilage is a special hyaline cartilage that covers the surfaces of the bones that glide against
each other inside synovial (movable) joints. Articular cartilage is not covered by perichondrium. Please
identify the parts of synovial joints in the image below: periosteum, synovial membrane, articular
(synovial) cavity, articular cartilage, marrow cavity, compact bone, spongy bone.
http://www.med.nyu.edu/medicine/labs/abramsonlab/basic-arth-research.html
Osteoarthritis (OA) is a loss of articular cartilage that makes movement of the joint extremely painful.
OA risk factors are diabetes, gout, trauma and autoimmune disorders.
292
Bones play a number of important roles in the body: they provide structural support, protect soft
internal organs, act as fulcrums and levers assisting in movements of the body, store minerals (mostly
calcium and phosphorus) and fat, and regulate blood
calcium levels. Bone marrow is a hematopoietic tissue.
Bone extracellular matrix is rich in collagen (90% of matrix)
and calcium and phosphorus as hydroxyapatite crystals.
Bones appear as the result of ossification (turning into
bone) of other connective tissues: cartilage (endochondral
ossification, cartilaginous bones) or connective tissue
proper (dermal bones). In Gross Anatomy bones are
classified based on shape as you can see in the examples
given in image below: a – long bone; b – short bone; c –
flat bone; d – irregular bone and e – sesamoid bone.
Long and short bones are derived from cartilage models.
They have marrow cavities inside them. Flat bones are
result from skin ossification, there is no marrow cavity
inside them. Irregular bones have mixed origin. Sesamoid
bones appear inside the tendons, where the tendons are
frequently stressed and become rough.
5. Identify types of bone tissue (compact vs spongy), and components of bone: lacunae, lamella,
periosteoum, osteon, trabeculae.
There are two types of mature bone tissue: dense
(compact) bone and spongy (cancellous) bone. Compact
bone usually covers the surface (shown by arrows in the
image below) and spongy bone fills the inside. Spongy
(cancellous) bone consists of numerous interconnecting
bony trabeculae separated by a labyrinth of
interconnecting marrow spaces. Bone Marrow sits in
marrow cavity or in spaces between trabeculae of
spongy bone. Red (active) bone marrow is a mixture of
developing and differentiating bone cells and blood
cells at different degree of maturity. Yellow (inactive)
bone marrow is mainly fat and reticular fibers; it
occupies marrow cavity. While there is no active
hematopoiesis in yellow marrow it can be converted
back to red when in a situation of extreme blood loss or
pre-mature destruction of blood cells (hemolysis). In
adults bone marrow is mostly found in flat bones and
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epiphyses (ends) of long bones. Bone marrow for biopsy or transplant is usually harvested from sternum
or iliac crest.
Long bones are derived from cartilage models and keep growing till maturity. Primary ossification of the
long bone starts at the diaphysis (shaft -
primary site of ossification). When the
cartilage becomes too large, the middle of
the cartilage does not get enough nutrients
and oxygen and becomes calcified. Then the
blood vessels grow into the calcified center
and ossification begins. There is a difference
between calcification and ossification:
calcification means deposition of calcium
salts in the tissue, while ossification means
formation of the bone – specialized
connective tissue; in other words, bone has
very specific and complex tissue structure
compared to just a deposition of calcium
salts. Epiphyses are next (secondary) sites of
ossification. The zone between epiphysis
and diaphysis is called metaphysis;
metaphysis remains a cartilage and keeps
growing from the middle while the borders
of these growth zones are ossifying.
Ossification of metaphysis is usually
completed by age 18-25 when it becomes an
epiphyseal plate (aka anatomical neck). The
articular surfaces of long bones remain
covered by cartilage for lifetime.
Medullary cavity contains red and/or yellow bone marrow.
Periosteum is a layer of connective tissue proper, which is a part of the deep fascia that covers bone and
connects it to muscles, joints and other bones. Periosteum has two layers: outer fibrous layer and inner
cambial zone. Fibroblasts in this zone can turn into osteoblasts (immature bone cells).
Osteocytes are mature osteoblasts that are responsible for the production and maintenance of bone
matrix, and they reside in lacunae. Osteoblasts become osteocytes when they are trapped in the bone
matrix that they themselves produce.
Osteoclasts (bone eaters) are big cells responsible for resorption and remodeling of bone. They
originate from the fusion of monocytes (type of WBC) and typically have multiple (up to 50) nuclei.
Osteoclasts are usually seen sitting in the resorption pits (aka Howship’s lacunae) that they make on the
internal surfaces of the bone by releasing acidic phosphatases that make bone soft and prone to
resorption.
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There are two types of bone tissue: compact and spongy.
Mature compact bone is composed of structural units called osteons (Haversian systems)
Osteons consist of: Haversian canal (HC; aka osteonic canal; aka central canal) containing blood vessels
and nerves; concentric lamellae of bone matrix surrounding an osteonic canal; lacunae with osteocytes
located between lamellae; canaliculi connecting lacunae to each other and to Harvesian canal.
Harvesian canals are usually oriented along the axis of the long bone. Volkmann’s canals also contain
blood vessels, but they are oriented more perpendicular to the axis of the long bone; they connect
Haversian canals to each other, to the marrow cavity, and to the periosteum.
Interstitial lamellae are remnants of previous concentric lamellae, they are found between osteons.
Endosteum is the incomplete layer of osteoprogenitor cells and connective tissue fibers that can be
found in marrow cavity, Harvesian canals, Volkmann’s canals, or spongy bone.
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L – lamellae; Os – osteon, Oc –osteocyte.
296
Woven (primary) bone is
immature bone that is
characterized by chaotic
orientation of collagen fibers
and absence of lamellae. It is
abundant in the fetus and
young children. In adults
woven bone may be found at
insertion of tendons and
bony alveoli around teeth.
Image (left): WB – woven
bone, BV- blood vessel, En –
endosteum, CT – connective
tissue, Ocl –osteoclast, Ob –
osteoblast, UO -osteoid.
297
In the image of woven bone below: OBI – osteoblasts; B – bone matrix.
Spongy bone is secondary bone which is characterized by the regular orientation of collagen and the
presence of lamellae in trabeculae.
298
The cells of the

bone originate from
fibroblasts of
periosteum or from
the osteoprogenitor
cells of the red bone
marrow. The
immature bone cells
are called
osteoblasts, they
are producing
matrix but they are
not completely
surrounded by it, so
their lacunae are
not completed.
Once they are
settled in the
lacunae they become oscteocytes.
In the image to the

left
En – endosteum
(incomplete layer of
osteoprogenotor
cells and
osteoblasts);
LB – lamellae of the
bone;
BM –bone marrow;
FC – capillary;
Arrows – lacunae
with osteocytes.
299
Osteoclasts are the big
multinucleated cells
responsible for bone
resorption, they
release collagenase
and other enzymes in
the bone matrix and
dissolve it. This way
they withdraw
minerals, mostly
calcium, from the
bone and play vital
role in balance of
calcium in the body.
Osteoclasts are often
dig the depressions in
the bone surface which are called resorption bays, pits or Howships’ lacunae. Octeoclasts take origin
from monocyte phagocytes that are fused together.
During periods of bone growth and during adult life there is constant internal remodeling of bone,
destruction of old osteons and formation of new ones occurs. On average the skeleton is replaced every
300
5 years. Bone growth and remodeling is controlled by many factors: An increase in PTH (parathyroid
hormone) level increases osteoclast activity; promotes bone resorption and causes an increase in
calcium in the blood. Calcitonin (a hormone secreted by parafollicular cells of thyroid) promotes
osteoblastic activity. Somatotropin stimulates growth in general by stimulating the growth of
epiphyseal cartilage and bone and causes a decrease in calcium in blood counterbalancing effect of PTH.
Growth Hormone in children and teens stimulates osteoblasts’ proliferation and accumulation of bone
mass.
Bone fracture healing (see

image to the right) goes as a
succession of specialized
connective tissues replacing
each other. Blood clot is
replaced by osteoid (soft
callus) cartilage like immature
bone tissue produced by
osteoblasts, then osteoid is
replaced by spongy bone (hard
callus), which is finally
replaced by compact bone.
There is a variety of clinical
conditions related to improper
growth or maintenance of
bone.
8. Understand clinical significance of Vitamin C and D deficiency, osteoporosis and osteomalacia.

Clinically, there are numbers of genetic disorders related to defects in collagen production. Collagen
production can be also affected by nutrition, vitamin deficiencies, hormonal status and autoimmune
disorders.
Vitamin C deficiency or Scurvy. Vitamin C (Ascorbic acid) is required for activity of prolyl-hydroxylase,
which is responsible for hydroxylation of proline in collagens. Vitamin C deficiency interferes with
assembly of the procollagen triple-helix, resulting in degradation of the collagen. Scurvy was well known
in cold countries, prisons, armies, and to sailors and polar explorers. Symptoms of scurvy include gradual
weakening, pale skin, sunken eyes, tender bleeding gums, muscle pain, loss of teeth, internal bleeding,
and the opening of wounds such as sword cuts that had healed many years before. Exhaustion, fainting,
diarrhea, and lung and kidney trouble followed. Treatment of scurvy is Vitamin C in high doses. The
following products are rich in vitamin C: fresh citruses, onion, cabbage, raw fish or meat. Vitamin C is
destroyed by heat, pasteurization, and contact with air and copper.
301
Vitamin D deficiency affects
bones because intestinal
mucosa cannot absorb calcium
without Vitamin D. In children
deficient in Vitamin D, defect in
ossification of epiphyseal
cartilages results in poorly
calcified bone matrix known as
rickets. Symptoms of rickets
include crooked legs, big head
and big stomach.
Osteomalacia is a term used to describe softening of the

bone in adults after growth is completed. The bone has
normal amount of collagen but low calcium. Causes of
osteomalacia are lack of vitamin D, sunlight, malabsorption
of vitamins in intestines or hormonal imbalances.
Symptoms of osteomalacia in adults are bone fractures
without significant injury, muscle weakness, pain and
spasms, bone pain, joint pain, and fatigue.
Osteoporosis which is most common in women after

menopause is referred to as primary type 1 or
postmenopausal osteoporosis. Women normally lose 7%
/of their bone mass every ten years after age 40. Men lose
about 3% of the bone mass in the same period. Regular
exercise and proper nutrition helps to prevent
osteoporosis.
http://www.escuelapedia.com/osteoporosis
Exercise and fitness promotes healthy bones. Skeletal muscles pull against the bone causing bone to
retain more minerals and grow bigger at the site of muscle attachment. Bones of athletes have more
prominent bone markings than the bones of “couch potatoes.”
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Lecture 20: Upper Limb Bones and Nerves
Objectives

3. Identify and compare and contrast the joints of the upper limb, their types and the types of
movements permitted in the upper limb.
5. Describe the path of six terminal branches of the brachial plexus: axillary, radial, ulnar, median,

Bones of the upper girdle and extremity:
Upper girdle: clavicle and scapula. Upper
extremity: humerus, ulna, radius, carpals
(8 bones), metacarpals, phalanges.
303
304
Clavicle is an S-shaped bone
that extends from the
sternum to the scapula above
the first rib. Lateral
(acromial) end of the clavicle
articulates with the scapula,
medial (sternal) end
articulates with the clavicular
notch on the manubrium of
the sternum. Clavicle
connects the upper extremity to the axial skeleton. Most common site of the clavicular fracture is in the
middle, between two curves.
The scapula is
triangular bone located
posteriorly to the
thoracic cage. It does
not directly articulate
with thoracic cage, but
the acromion process
of the scapula
articulates with the
clavicle. Please
identify:
Scapula: Acromion process, Coracoid

process, Spine, Medial border, Lateral
border, Superior border, Glenoid
cavity (fossa), Supraspinal fossa,
Infraspinal fossa, Subscapular fossa,
Supraglenoid tubercle, Infraglenoid
tubercle.
305
Humerus is the long bone that
articulates with glenoid cavity of
scapula at the glenohumeral
joint. It has large range of
mobility allowing flexion,
extention, rotation, abduction
and adduction of the arm.
Please identify: Humerus: Head,

Shaft, Anatomical neck, Surgical
neck, Greater Tubercle, Lesser
tubercle, Intertubercular
groove, Deltoid tuberosity,
Radial groove, Medial and
Lateral epicondyles, Capitulum,
Trochlea, Olecranon fossa,
Coronoid fossa.
Ulna and radius make the elbow joint with the humerus.
Humero-ulnar joint only allows flexion and extension of the
forearm. Humero-radial joint also allows pronation and
supination of the hand.
306
.
Ulna: Head, shaft, Styloid process,

Olecranon process, Coronoid
process, Trochlear notch
Radius: Head, Shaft, Radial

tuberosity, Styloid process, Dorsal
(Lister’s) tubercle.
Carpal bones: Scaphoid and 7 others.

Metacarpals: I, II, III, IV and V. Phalangies:
Proximal, Medial (intermediate) and Distal.
3. Identify, compare, and contrast the joints of the upper limb, their types and the types of
movements permitted in the upper limb.
Sternoclavicular (gliding, plane), Acromioclavicular (gliding), glenohumeral (ball and socket).

Humeroradial joint (limited ball and socket). Humeroulnar (hinge). Proximal and Distal Radioulnar
joints (pivot). Radiocarpal joint and Intercarpal joints (wrist) are the number of gliding and joints,
Carpometacarpal joints, Metacarpophalangeal, Proximal and Distal Interphalangeal joints (condylar
and hinge).
Please refer to Table 1.3 pp. 16 in M&A for Types of Joints.
307
http://www.daviddarling.info/encyclopedia/B/brachial_plexus.html
Roots of the brachial plexus originate from spinal nerves C5 (in some cadavers from C4) to T1.
Roots are fused together to form trunks: C5 to C6 make up upper trunk; C7 makes middle trunk; C8 and
T1 compose lower trunk.
Each trunk divides to anterior and posterior division. Divisions fuse together to make cords:
Lateral cord is composed of anterior divisions of upper and middle trunk,
Posterior cord is composed of all three posterior divisions of upper, middle and mower trunks,
Medial cord continues the anterior division of lower trunk.
Branches originate from different parts of the plexus. The branches that originate from the cords
sometimes referred as terminal branches.
308
http://en.wikipedia.org/wiki/Brachial_plexus
5. Describe the path of six branches of the brachial plexus: axillary, radial, ulnar, median,
Axillary nerve (C5 and C6) rises

from posterior cord. It passes
through the axilla and branches in
deltoid muscle. It provides motor
innervations of deltoid muscle and
teres minor (rotator cuff muscle).
It brings cutaneous sensation from
the patch of skin below deltoid.
Axillary nerve injury often occurs

due to anterior shoulder
dislocation or fracture of the
surgical neck of humerus. Clinical
sign of Axillary nerve damage is
inability to abduct humerus
against resistance.
309
Radial nerve-(C5-8 and T1) arises from the posterior cord and is
the largest branch of the brachial plexus. It passes through the
axilla, wraps around the humerus and runs posterior and lateral
along the upper extremity to the thumb.
The radial nerve innervates the posterior compartment of arm

and forearm. Radial nerve sometimes is referred as Great
extensor nerve provides motor innervations to the BEST
(Brachioradialis, Extensors of wrist and fingers, Supinator, and
Triceps). It brings sensations from dorsal thumb and radial 2
fingers.
Radial nerve can be damaged if on crutches for prolonged time.
Clinical sign of the radial nerve injury is “Wrist drop.”
Median nerve (C5-8 and T1) originate from medial and lateral cords. Runs anterior to the humerus, does
not innervate upper arm. It passes between two heads of the Pronator teres muscle in the forearm:
medial epicondyle of humerus and medial side of coronoid process of ulna. It provides motor
innervations to wrist flexors, finger flexors and thenar muscles that move the thumb. It brings sensation
from lateral palm, thumb and the radial two fingers and a half of the third finger.
Clinical sign of median nerve damage is Thenar Atrophy:
310
Thenar Muscles: 1.Abductor pollicis brevis 2. Opponens pollicis 3. Flexor pollicis brevis 4. Adductor
pollicis.
Carpal tunnel syndrome is median nerve entrapment (compression). There is a narrow passageway
formed anteriorly by the flexor retinaculum and posteriorly by the tendons of the hand flexors and
carpal bones.
Commonly believed causes are key boarding, cutting hair, playing piano and other excessive exercises.
311
Real cause is edema due to trauma, infection,
inflammation, rheumatoid arthritis, heredity and
other conditions causing fluid retention.
Ulnar nerve (C8 and T1, in some people contains few fibers of C7) originates from the medial cord and
passes medial to the humerus, between the medial epicondyle of humerus and the olecranon process of
ulna. It provides motor innervations to the hypothenar muscles and deep muscles of the hand. Ulnar
nerve brings sensations from the medial palm digiti minimi and ½ of the ring finger.
Hypothenar Muscles: 1. Abductor digiti minimi, 2. Opponens digiti minimi and 3. Flexor digiti minimi
(discuss later).
Clinical sign of ulnar nerve damage is Claw hand:
The patient will demonstrate MCP

(metacarpophalangeal joint) hyperextention and PIP (proximal interphalangeal) flexion due to an
imbalance of the muscles. The patient will also have a weak grip and flexion of medial fingers.
312
Musculocutaneous nerve (C5, C6 and C7) rises from lateral cord and runs anterior and lateral to the
humerus. It provides motor innervation to biceps brachii,
coracobrachialis and brachialis muscles. It brings sensations from
the skin of the lateral forearm. Weakness of the elbow flexors is
a sign of musculocataneous nerve trauma.
Explain how the location of the humerus fractures shown in the

picture to the right relate to the specific nerve damage. Terms:
Comminuted fracture occurs when bone is broken into pieces.
Avulsed (piece, usually process) is broken off.
Fractures of Humerus:
Blue box p. 405. Relate the types of
humeral fracture to the nerve
damage: Surgical neck fracture –
axillary. Transverse and comminuted
fractures of the shaft –radial.
Transverse supracondylar fracture –
median. Avulsed fracture of medial
epicondyle –ulnar.
313
Long thoracic nerve originates immediately from the roots on the spinal nerves C5, C6 and C7. It passes
posteriorly to brachial plexus and descends along the lateral thoracic wall. It provides motor
innervations of the serratus anterior muscle. Due to relatively superficial location traumatic injuries may
occur in contact sports, mastectomy, lymph nodes removal and other thoracic surgeries.
Clinical sign of LTN damage is Winged scapula seeing in the image to the right. People are unable to
abduct the arm above horizontal due to the dead lock between the greater tubercle of humerus and
acromion, unless the serratus anterior rotates the scapula and moves glenoid cavity upward.
See Blue Boxes in M&A pp. 404-406, Fracture of the Clavicle, Fractures of Ulna and Radius, Fractures of
the Hand, p. 416 Paralysis of Serratus Anterior; p. 419 Injury to Axillary Nerve; pp. 430- 431 Brachial
Plexus Injuries; p. 437 Injury to Radial Nerve, p.460-462 Carpal Tunnel Syndrome, Trauma to Medial
Nerve, Ulnar Nerve Injury, Radial Nerve Injury.
Please review Terms of Movement: M&A Fig. 1.4 pp. 6-7; Types of Joints Table 1.1 and Types of
Synovial Joints Table 1.2. pp. 15- 16.
314
Lecture 21 and 22: Upper Limb Muscles
Objectives
1. Identify the muscles of the upper limb and groups where they belong.
2. List origin, insertion, action and innervations of the upper limb muscles.
3. Explain the pattern of motor innervation to the forearm; discuss the various common
injuries and clinical signs of damage to the upper limb nerves.
4. Explain the clinical signs of upper limb nerve damage and clinical tests for nerve integrity
and functionality.
1. Identify the muscles that move the upper limb and groups where they belong.
Muscles that fix and move the scapula are inserted on the scapula: Trapezius (spinal
accessory nerve (CN XI), Serratus anterior (long thoracic), and Pectoralis minor.
Muscles that move the humerus are inserted on the humerus: Deltoid, Latissimus dorsi,
Pectoralis major, Coracobrachialis, Teres major, rotator cuff muscles: Infraspinatus,
Supraspinatus, Subscapulartis and Teres minor.
Flexors of the forearm: Brachialis, Brachoradialis, Biceps bracii.
Extensors of the forearm: Triceps brachii and Anconeus.
Pronators and supinator are moving the radius.
Extrinsic muscles of the hand are the muscles of forearm that move the digits they include
three layers of anterior compartment (flexors) and two layers of posterior compartment
(extensors) that will be described in more details later in this lecture.
Intrinsic muscles of the hand are located in hand and move digits: thenar, hypothenar,
interossei and lumbricals.
2. List origin, insertion, action and

innervations of the upper limb
muscles.
Please go to Table 6.1. and Fig.

6.14, p 414-415 for the reference
to the origin, insertion, innervation
and action of the following
muscles: Pectoralis major,
Pectoralis minor, Serratus
anterior.
315
Please refer to Table 6.2. p.417 for the origin, insertion, innervation and action of the following
muscles: Latissimus dorsi and Trapesius.
Please refer to Table 6.3 and Figures 6.16, 6.17 p. 418 to learn the origin, insertion, innervation
and action of the following scapulohumeral muscles: Deltoid, Supraspinatus, Infraspinatus,
Subscapularis, Teres major and Teres minor.
Supraspinatus, Infraspinatus, Teres minor and Subscapularis (mnemonics SITS) constitute the
rotator cuff muscles that make a cuff around the glenohumetal joint.
Supraspinatus abducts humerus to 15 degrees. Deltoid and supraspinatus are synergists.
Deltoid Supraspinatus
316
Subscapularis Infraspinatus
Teres Minor Teres major
Please refer to Table 6.6 and Figures 6.25 to 6.28 p. 432- 435 to learn the origin,
insertion, innervation and action of the following muscles of the arm: Coracobrachialis,
Biceps brachii, Brachialis, Triceps brachii, Anconeus.
Coracobrachialis
317
Biceps bracii Brachialis
Triceps brachii Anconeus

Anterior muscles of the forearm
make three layers: superficial,
intermediate and deep. Please refer
to Table 6.7 p. 440-441 to learn
origin, insertion, innervation and
action of the following muscles of
the anterior compartment of the
forearm:
318
Superficial layer: Pronator teres (M) (image above), Flexor carpii
radialis(M), Palmaris longus(M), Flexor carpii ulnaris (U) (o-
medial epicondyle).
Intermediate layer: Flexor digitorum superficialis (M) (o-medial

epicondyle, i- mid phalanges).
Deep layer: Flexor digitorum profundus(U to distal phalanges of

4 & 5 and M to df of 2&3), Flexor pollicis longus (M), Pronator
quadratus (M) (o-bones of the forearm).
319
Please refer to Table 6.8 p. 443-445 to learn the origin, insertion, innervation and action of the
following muscles of the posterior compartment of the forearm:
Superficial layer (R): Brachioradialis, Extensor carpii radialis longus, Extensor carpii
radialis brevis, Extensor digitorum, Extensor digiti minimi, Extensor carpii ulnaris (o-
lateral epicondyle).
Deep layer: Supinator (o-lateral epicondyle and ulna), Abductor pollicis longus,
Extensor pollicis longus, Extensor pollicis brevis, Extensor indicis.
320
Supinator Brachioradialis Pronators teres and quadratus
Antagonists are the muscles that perform opposite actions. Supinator and pronator
teres are the example of antagonists: they both inserted in the middle radius and rotate
radius to the opposite directions at proximal and distal radio-ulnar joints. Synergists are
the muscles that assist each other in their action. Pronator quadratus is a synergist of P.
teres: they both pronate the forearm (rotate radius medially).
Please refer to Table 6.11 and Fig. 6.42 and 6.44 to learn the origin, insertion,
innervation and action of the following intrinsic muscles of the hand:
Thenar muscles: Abductor pollicis brevis (M), Opponens pollicis (M), Flexor pollicis(M),
Adductor pollicis (U)
(A OF A mnemonics)
Abductor Opponens
321
Flexor Adductor
Hypothenar muscles (U): Opponens digiti minimi, Flexor digiti minimi, Abductor digiti
minimi. (OF A)
Opponens Flexor Abductor
322
Intrinsic muscles of the hand: Lumbricals (1&2 -M; 3&4- U), Dorsal interossei (U), Palmar
interossei (U).
Lumbricals Dorsal interossei Palmar interossei
323
3. Explain the pattern of motor innervation to the forearm; discuss the various common
injuries and clinical signs of damage to the upper limb nerves.
Muscles innervated by radial nerve (posterior compartments): triceps brachii, anconeus,

brachioradialis, supinator, extensors carpii radialis longus and brevis, extensor carpii ulnaris,
extensor digitorum, extensor digiti minimi, abductor pollicis longus, extensors pollicis longus
and brevis, extensor indicis.
Muscles innervated by axillary nerve: deltoid and teres minor.
Muscles innervated by median nerve (lateral half of anterior compartment): pronator teres,
flexor carpii radialis, palmaris longus, flexor digitorum superficialis (PIP and MCP), lateral two
digits (II and III) of flexor digitorum profundus (DIP), flexor pollicis longus, pronator
quadratus, Thenar muscles except adductor pollicis, lumbricals 1 and 2.
Muscles innervated by ulnar nerve (medial half of anterior compartment and most of the
intrinsic muscles): flexor carpii ulnaris, and ulnar half (IV and V) of flexor digitorum profundus
(DIP), Hypothenar muscles, adductor pollicis, dorsal interossei, palmar inteossei, lumbricals 3
and 4.
Muscles innervated by musculocutaneous nerve: coracobrachialis, biceps brachii and

brachialis.
Muscle innervated by long thoracic nerve is serratus anterior.
Please refer to the Blue Boxes pp. 419 Injury to Axillary Nerve, Rotator Cuff Injuries and
Supraspinatous; p. 436 Injury to Musculocutaneous Nerve, p.437, Injury to Radial Nerve, Ulnar
nerve, p.436, Rupture of Tendon of Long Head of Biceps; p. Muscle Testing of Flexor Digitorum
Superficialis and Flexor Digitorum Profundus, p. 460, Carpal Tunnel Syndrome, Trauma to
Median Nerve; p. 461 Ulnar Nerve Injury , Radial Nerve Injury.
4. Explain the clinical signs of upper limb nerve damage and clinical tests for nerve
integrity/functionality.
Long thoracic nerve: Paralysis of Serratus Anterior Winged scapula
Axillary nerve: injury to Axillary Nerve, deltoid change of shoulder counter if wasted, difficulty
to abduct the arm above 15 degrees
Radial Nerve: weak extensions, wrist drop, finger drop.
324
Signs and symptoms: decreased ability to extend the arm at the elbow, decreased ability to
supinate the forearm, difficulty to extend the wrist or fingers (extensor muscle weakness),
atrophy (muscle loss) in the forearm; Wrist or finger drop, wasting of the dorsal side of
forearm.
Median nerve: Carpal Tunnel Syndrome: pain in the wrist or hand that wakes the patient up at
night, changes of sensation in the thumb and pointer (index), middle, and part of the ring
fingers, such as: tingling, burning, numbness, decreased sensation, loss of sensation, dropping
things, difficulty grasping objects and pinching; wasting of thenar muscles.Benediction hand
presents due to median nerve damage when patient is asked to make a fist; inability to flex I, II
and III fingers,
Ulnar Nerve: Signs and symptoms: changes of sensation in the little finger and ring finger, such
as: tingling, burning, numbness, decreased sensation, loss of sensation, weak grip, and an
inability to hold the paper between fingers, weak abduction and adduction of the fingers.
Ulnar Claw hand: inability to flex fingers IV and V, and hyperextension of MCP, wasting of
medial lumbricals, interossei, hypothenar muscles and adductor pollicis brevis.
325
Image to the right: Left ulnar
nerve damage: wasting of
interossei and “claw” appearance
of the ring finger and little finger
due to unopposed action of
extensors digitorum and flexor
digitorum superficialis.
Musculocutaneous nerve: weak flexion and supination of forearm.
Practice:
326
Identify damaged nerves based on the images above.
Fracture of clavicle. Blue Box pp. 404. Explain: Why does the fractured clavicle appear shorter?
Fractures of ulna and radius. Fractures of the hand. Blue Box pp. 406.
Colles’ fracture (the comminuted transverse fracture of distal radius) is most common wrist
fracture. Explain: Why the scaphoid fracture causes avascular necrosis and degenerative joint
disease?
Anatomical Snuff box or Radial Fossa: A triangular hollow/deepening seen on the radial aspect
(the thumb side) of the dorsum of the wrist when the thumb is extended fully. The reason that
it is called the snuff box is that Snuff (Powdered tobacco) could be put there and then inhaled.
Please identify: Styloid process of radius, Scaphoid and radial artery. Avascular necrosis of the
Scaphoid leads to the degenerative joint disease of the wrist.
Please review Green Boxes pp. 492- 494 in M&A Medical Imaging of Upper Limb.
327
Lecture 23: Lower Limb I (Bones and Nerves)
Objectives

3. Identify, compare and contrast joints of the lower limb, their types and the types of movements
permitted in the lower limb.
4. Describe the path of the nerves supplying lower limb: femoral, obturator, sciatic, tibial, common
fibular (peroneal), superficial and deep fibular (peroneal), superior and inferior gluteal.

Bones and markings of the lower girdle and extremity: Pelvic bone (os coxa), femur, patella, tibia,
fibula, tarsal bones (7 including calcaneus and talus), metatarsals, phalanges.
Pelvic girdle: The two hip bones (left and right) make
up the pelvic girdle. The pelvic girdle is greater in
strength and lesser in mobility as compared to
shoulder girdle which offers more mobility but less
strength. Hip (pelvic) bones articulate with the
sacrums, which is a part of vertebral column, at the
sacroiliac joints (next page).
328
Pelvic bone is made from the fusion of three bones, which completely fuse at puberty: Ilium, Ischium,
pubis.
IIeum: Anterior superior iliac spine (ASIS), Anterior inferior iliac spine, Posterior superior iliac spine
(PSIS), Posterior inferior iliac spine. Greater sciatic notch (allows the passage of the Sciatic nerve to
posterior
compartment of the
thigh).
Obturator foramen
(largest foramen, for
obturator nerve). It is
closed by the
obturator membrane.
Obturator nerve
innervates the medial
compartment of the
thigh.
Pubis; Pubic
symphysis is a joint
where 2 pubic bones
unite anteriorly.
Ischium: Lesser sciatic
notch, ischial
tuberosity, ischial spine.
Pelvic bones articulate: with each other at pubis symphysis,

with sacrum at sacroiliac joint and with the femur at the hip
joint (acetabulum).
Male pelvis is better adapted to locomotion than the female
pelvis, which is more shallow and broader than the male
pelvis. The female inlet is larger and oval in shape, while the
male sacral promontory projects further (i.e. the male inlet is
more heart-shaped) Female sacrum is shorter, wider, more
curved posteriorly, and has a less pronounced promontory.
The angle between the inferior pubic rami is about 70
degrees in men, but 90-100 degrees in women. Accordingly,
the angle is called pubic angle in men and pubic arch in
women. Additionally, the bones forming the angle/arch are
more concave in females but straight in males. (See the images on the following page).
329
The distance between the ischial bones is larger in females. The ischial spines and tuberosities are
heavier and project farther into the pelvic cavity in males. The greater sciatic notch is wider in females,
and the iliac crests are lower and further apart in females. The acetabula are wider apart in females than
in males. In males, the acetabulum faces more laterally, while it faces more anteriorly in females.
Consequently, when men walk, the leg can move forwards and backwards in a single plane. In women,
the leg must swing forward and inward, from where the pivoting head of the femur moves the leg back
in another plane. This change in the angle of the femoral head gives the female gait its characteristic (i.e.
swinging of hips).
Female pelvis (left) compare to male pelvis (right).
330
Femur: Femur is largest and heaviest
long bone in the body. Head of the
Femur: covered with articulate cartilage;
has a depression in its articular surface,
the fovea capitis femoris, to which the
ligamentum capitis femoris is attached
(to acetabulum). Neck is a common site
for fractures. Neck fractures are more
common in elderly women due to
weakness as a result of osteoporosis.
Proximal end: Greater Trochanter,
Lesser Trochanter: Linea aspera.
Distal End: Medial epicondyle and
Lateral epicondyle. Medial femoral
condyle and Lateral femoral condyle
articulate with tibia.
Patella
Patella is a sesamoid bone that

protects the knee joint; it
develops in the tendon of the
Quadriceps Femoris. Patellar
ligament attaches to the tibial
tuberosity.
331
Tibia and Fibula
Tibia articulates with the femur, fibula and talus.

Fibula articulates with the tibia and talus.
Proximal tibia: tibial tuberosity.
Distal tibia: medial malleolus.
Fibula: lateral malleolus.
Tarsal bones.
Talus articulates with medial malleolus of tibia, lateral malleolus of fibula, calcaneus (posteriorly) and
other tarsal bones (anteriorly).
Calcaneus (heel bone) provides posterior support to lower limb.
332
The x-ray presents the avulsion fracture of calcaneus
and the tear of calcaneal tendon. Please identify also
Talus, Fibula, Tibia, tarsal and metatarsal bones.
3. Identify, compare and contrast joints of the lower

limb, their types and the types of movements
permitted in the lower limb.
Hip joint is a synovial joint. Acetabulum and the

femoral head have surfaces covered with hyaline
cartilage. The joint is strengthened by ligaments and
the fibrous joint capsule, which is attached to the rim
of the acetabulum at the proximal end and to the
femoral neck at the distal

end. It is a ball and socket
type of joint, which allows
for various movements:
flexion, extension,
hyperextension, abduction,
adduction, rotation and
circumduction. The range of
these movements is smaller
than in the gleno-humeral
joint. Blue Box p.374
Fractures of Femoral Neck,
Surgical Hip Replacement,
Dislocation of Hip Joint.
333
The knee joint is also a synovial joint; it allows a wide range flexion and extension and a very
limited range of rotation, when the knee is flexed, due to the gliding movements in the femoro-
tibial articulations between
lateral and medial femoral
and tibial condyles. There is
also the femoropatellar
articulation, between femur
and patella. The knee joint is
strengthened by ligaments:
patellar, tibial collateral,
fibular collateral, anterior
cruciate and posterior
cruciate; and menisci:
medial and lateral. When
the knee is completely
extended with the foot on
the ground the femur rotates
medially on tibia and knee “locks,” a locked knee makes a solid column better adapted to
bearing the body weight. Blue Boxes pp. 382-384 Patellar Dislocation, Popliteal Cysts, Knee Joint
Injuries, Arthroscopy of Knee Joint, Knee Replacement, Bursitis in Knee Region.
The ankle joint is a set of multiple joints, most important is talocrural articulation (between
talus and tibia,
plantar flexion,
dorsiflexion), this is a
hinge type joint
between the
superior part of the
talus, the inferior
surface and medial
malleolus of the
tibia, and the lateral
malleolus of the
fibula. Body weight is
transferred from
tibia to talus. The
joint capsule is
supported by
ligaments, most
often sprained are: anterior and posterior talofibular ligaments and calcaneaofibular.
Blue Boxes p. 388 Ankle Sprains, Pott Fracture- Dislocation of Ankle.
334
4. Describe the path of the nerves supplying lower limb: femural, obturator, sciatic, tibial, common
fibular (peroneal), superficial and deep fibular, superior and inferior gluteal nerves.
The femoral nerve originates from the lumbar

plexus (L2-L4), runs anteriorly to pelvic bone,
under inguinal ligament, gives branches to
iliacus and pectineus muscles and branches in
the anterior compartment of the thigh
(extensors). The obturator nerve also originates
from the lumbar plexus (L2-L4, L3 is largest) and
runs along the psoas muscle, passing through
the pelvis and exits the pelvis via obturator
foramen. It supplies the medial muscles of the
thigh (adductors), Note, the obturator internus
muscle is an abductor and supplied by a
different nerve (obturator internus nerve, L5-
S1). The sciatic nerve (ischiadic or ischiatic) is
the longest and widest nerve in human body. It
originates from the lumbar and sacral plexus
(L4 –S3). It
leaves the
pelvis via
the sciatic
notch and runs down along the posterior side of the femur, here it
branches to the tibial and common peroneal (fibular) nerves. The
sciatic nerve gives off branches to the muscles of the posterior
thigh (flexors) and adductor magnus. The tibial nerve passes
through the popliteal fossa and runs down posteriorly and medially
to the tibia (toward medial malleolus). It supplies the posterior
muscles of the leg (plantar flexors). The common peroneal (fibular,
external popliteal, lateral popliteal) runs through the popliteal fossa
to the head of the fibula; it innervates the peroneus muscles
(longus and brevis, and divides to superficial peroneal (fibular) and
deep peroneal (fibular). The superficial peroneal nerve runs
laterally to the fibula and supplies the lateral peroneal muscles
(eversion and plantar flexion). The deep peroneal nerve runs
anteriorly to the tibia and supplies the anterior muscles of the leg
(dorsiflexors and extensors). The Superior Gluteal nerve originates
from the sacral plexus, supplies the tensor fascia lata, gluteus
medius and minimus (abduction at the hip joint). The inferior
Gluteal nerve originates from the sacral plexus and supplies the
gluteus maximus (extension of the thigh).
335
Lecture 25. Lower Limb Muscles.
Objectives
2. List the origin, insertion, action and innervations of the lower limb muscles.
3. Explain the common injuries, pathologies and clinical signs of damage to the lower limb:
compartment syndrome, fasciitis, hip joint fractures repair and replacements, patelofemoral syndrome,
unhappy triad (p.338), heel spur, plantar fasciitis, problems in femoral triangle, etc.
4. Discuss the clinical signs and tests to evaluate the lower limb nerve integrity and functionality.
Gluteal region consists of two layers: superficial layer has glutei maximus, medius and minimus, deep
has obturator internus, piriformis, quadratus femoris, superior and inferior gemeli.
Gluteus maximus (inferior gluteal nerve, o – posterior ilium, sacrum and coccyx, i – gluteal tuberosity
between the linea aspera and the greater trochanter) extends thigh, rotates it laterally and stabilizes
thigh, when rising from sitting position. Gluteus medius and minimus (superior gluteal nerve, o – Ilium, i
– greater trochanter) abducts and medially rotates thigh.
336
The iliopsoas muscles (image to the left) share the
insertion, lesser trochanter, and action flexion of the
hip and stabilization and support of the trunk.
Iliacus (femoral nerve, o – iliac crest).
Psoas (lumbar nerves, o – T12-L5).
Muscles of the thigh are separated by the deep

fascia into 4 compartments: anterior, posterior,
medial and lateral.
The adductors of the thigh belong to medial

compartment and mostly controlled by obturator
nerve. The adductor longus, adductor brevis,
adductor magnus and gracilis adduct and also flex
the thigh.
The obturator externus

originates on the obturator
membrane and margins of the
foramen, inserted in the
trochanteric fossa, rotates
thigh laterally. Pectineus
muscle is also an adductor, but
most often innervated by
femoral nerve (in some
cadavers by obturator).
337
The anterior muscles of the thigh
(femoral nerve): quadriceps femoris is
inserted in the patella, and via patellar
ligament in the tibial tuberosity, extends
the knee, has 4 heads, rectus femoris
(also flexes the hip, removed in the
image to the left), vastus medialis,
vastus lateralis, vastus intermedius
(deep to rectus). Articularis genu is
located deep to the vastus intermedius,
it originates on the anterior lower third
of the femur and inserts into the synovial
membrane of the suprapatelar bursa,
when the knee extends it pulls the bursa
up to prevent impingement (collision)
between the patella and femur.
Sartorius (taylor’s muscle) flexes both
the hip and knee. (Table 5.1 and Fig.
5.10).
Posterior thigh muscles (flexors, sciatic

nerve, origin ischial tuberosity):
Biceps femoris inserts in the head of fibula (long (T) and short (CP) head, also rotates leg laterally),
Semitendinosus (superficial) and Semimembranosus (deep) are inserted in the proximal medial tibia,
they rotate tibia medially, when leg is flexed (T).
338
Lateral thigh muscles. Tensor fascia lata abducts
and medially rotates the thigh (superior gluteal
nerve). Fascia lata. Iliotibial tract
Muscles of the Leg: There are only three

compartments in the leg: anterior, posterior
and lateral.
Anterior compartment: deep fibular

(peroneal) nerve, main action dorsiflexion
of the ankle and extension of toes. Tibialis
anterior (origin – lateral condyle of the tibia,
insertion medial and inferior tarsals, 1st
metatarsal), dorsiflexes and inverts the foot.
Extensor hallusis (origin – anterior fibula,
insertion - distal phalanx of hallus), extends
great toe, dorsiflexes ankle. Extensor
digitorum longus (origin – lateral condyle of
tibia, insertion – phalanges of the lateral
four digits) extends the toes and dorsiflexes
the ankle. Fibularis (peroneus) tertius (deep
fibular nerve) dorsiflexes ankle and everts
foot.
Lateral compartment (superficial peroneal nerve): Fibularis longus originates at proximal 2/3 of fibula,
Fibularis brevis distal 2/3 of fibula, insertion is 1st and 5th metatarsals; it everts and plantarflexes the
foot.
339
Posterior compartment (tibial nerve (T):
Gastrocnemius lateral and medial head
originates on the condyles of the femur, Soleus
originates from the posterior fibula and tibia,
Plantaris originates from the posterior distal
femur and all of them are inserted in the
calcaneus via calcaneal (Achilles) tendon.
Deep muscles of posterior compartment (T).
340
Lateral compartment (to the left).
2. List the origin, insertion, action and innervations of the lower limb
muscles.
For more details about origin, insertion, action and innervation, please
refer to Tables 5.1, 5.2, 5.4, 5.5, 5.6, 5.7, 5.8 and 5.9.
3. Explain the common injuries, pathologies and clinical signs of damage to the lower limb:
compartment syndrome, fasciitis, hip joint fractures repair and replacements, patelofemoral
syndrome, unhappy triad (p.338), heel spur, plantar fasciitis, etc.
4. Discuss the clinical signs and tests to
evaluate the lower limb nerve integrity and
functionality.
Bone fractures. Femur fracture (Blue Box
pp. 318). Symptoms: pain, inability to stand
and bear weight, shortened length of the
limb, swelling of the thigh, groin, swelling of
the leg or ankle less common, but possible
symptom. Most common

fracture is at the neck of femur. X-ray shows hip
replacement.
341
Tibia and fibula fractures (Blue Box p.319). Tibia is most often fractured at the narrowest place
between inferior and middle third. Compound fractures and diagonal fractures are pretty common.
Fibula is often broken just above

malleolus, (if person slips with
extremely inverted foot). “Pott’s
fracture” is presented in the X-ray
image.
342
Foot fractures (Blue Box pp.327). Metatarsals (dancer fracture, right image); Calcaneal fractures (left
image), jumping or falling from a height (e.g. ladder)

and landing on the heel.
Calcaneal (Achilles) tendon. (Blue Box p.361 Calcaneal Tendon Reflex, Inflammation and Rupture of
Calcaneal Tendon). Due to the large force applied to it the
calcaneal tendon is often a subject of minor tears of
collagen fibers, which lead to inflammation of calcaneal
tendon and tendinitis that causes pain (9-18% of running
sports injuries). People with chronic tendinitis are at greater
risk of the rupture of the calcaneal tendon. People who have
a ruptured calcaneal tendon are unable to plantarflex the
foot.
Compartment Syndrome and Fasciotomy (Blue Box p.

328). Boundaries of the muscle compartments are strong.
Compartments are surrounded by fascia and closed at the
joints’ proximal and distal ends. Inflammation, edema,
accumulation of blood and other fluid may increase the
pressure inside the compartment. Compression of the blood
vessels may lead to ischemia and permanent damage to the
muscle. Compression of the nerves may cause the paralysis
of the muscles within compartment and distally to it. Loss of the pulses and low temperature of the
distal tissues is the sign of compartment syndrome. To relieve the pressure a fasciotomy (incision of
fascia) is performed.
343
Strength of quadriceps can be tested by asking the person to extend the knee against resistance.
Strength of hamstrings is tested by person’s ability to flex the knee against resistance.
Patelofemoral syndrome (chondromalacia patellae, runner’s knee, Blue Box pp. 333) is an irregularity
of the internal surface of the patella. It is a common problem in athletes: runners, basketball players,
dancers related to the repeated stress and pressure on the knee. It is more common in females and
overweight people (images below).
Knee joint injuries (Blue Box pp. 393). Injuries to the knee joint often involve ligaments sprains and
menisci tears. When the leg is completely extended and the foot is on the ground the TCL and FCL are
stretched. They are preventing medial & lateral dislocation of the knee. If force is applied from the side
such as in contact sports, these ligaments are likely to be torn. A blow from the lateral side often leads
to the tear of medial meniscus, because it is firmly attached to TCL. The injury, which involves TCL, ACL
and medial meniscus, was historically called “unhappy triad,” “ O’ Donoghue’s triad,” “terrible triad” or
“blown knee,” resent statistical studies show that the lateral meniscus gets torn even more often than
the medial, because it gets trapped and smashed between the femur and the tibia.
344
The Femoral Triangle (triandle of Scarpa) (Blue Box pp. 345 Femoral Hernia) is limited by the inguinal
ligament that runs from the pubic tubercle on the superior posterior surface of pubic bone to the ASIS,
Sartorius muscle and adductor longus. (Mnemonics SAIL –Sartorius, Adductor longus, Inguinal
Ligament). Floor of the triangle is made by iliacus, psoas and pectineus. The triangle contains the
femoral nerve, femoral artery, femoral vein and lymph nodes. (Mnemonics NAVaL – Nerve, Artery, Vein
and Lymph). Femoral hernia occurs when abdominal viscera protrude under the inguinal ligament into
the femoral canal, strangulation of a femoral hernia and poor blood supply can lead to inflammation and
degeneration of the tissues.
The femoral pulse can be palpated inferiorly to the middle of inguinal ligament. The femoral artery
often can be cannulated at this point, e.g. for blood gas testing, radiography, left cardiac angiography.
The femoral vein is located just medial to the femoral artery and can be used for right cardiac
angiography. (Blue Box pp. 338 Femoral Pulse and Cannulation of Femoral Artery, Cannulation of
Femoral Vein).
Injury to sciatic nerve and intragluteal injections.

(Blue Box pp. 345) Compression of sciatic nerve by
vertebra, muscles, stab wounds of sciatic nerve may
cause paralysis of the muscles of the posterior
compartment of the thigh and any compartment of
the leg. Intramuscular injections in the buttock are
only safe in the superior lateral quadrant.
Complications of improper injection may include
injury to sciatic nerve, hematomas and abscess.
Injury to common fibular nerve leads to flaccid
paralysis of all muscles in the lateral and anterior compartment. Characteristic sign is a “footdrop”, foot
is plantarflexed and inverted, limb appears too long (image to the left).
345
Ankle Sprains may produce stretching of the superficial fibular nerve, which may cause numbness,
tingling and pain at the lateral side of the foot and ankle. (Blue Box pp. 388)
Injury to the Tibial Nerve is rare because of its deep position. It may be damaged by posterior
dislocation of the knee or a deep laceration in the popleteal fossa. Severity of the tibial nerve leads to an
inability to plantarflex and flex the toes.
Fibula is one of the common sources of bone grafts. Vascularized pieces of bone from fibula usually
grow pretty well, when transplanted to different places in the same person to replace missing bone as a
result of trauma, disease or congenital defect. Removal of even relatively large parts of the fibular shaft
usually does not affect person’s ability to walk. Bone grafts may also be taken from iliac crest (ASIS),
tibial tuberosity, malleoli, ribs, mandible and other available sources.
Transplantation of the Gracilis (Blue Box pp. 333). Since gracilis is a relatively weak muscle, its removal
does not badly affect the function of the leg. Whole or part of gracilis with blood vessel and nerves can
be transplanted for replacement of other muscles: e.g. sphincters, muscles of the arm.
M&A pp. 394- 395 Medical Imaging of Lower Limb.
346
Lecture 25: Reproductive Tract Anatomy
Objectives
1. Outline the anatomy of the female reproductive tract. Be able to describe each components
functional significance.
4. Explain common pathologies of the female reproductive tract including: chlamydia,
gonorrhea, pelvic inflammatory disease, infections of the female genital tract, ectopic
pregnancy, infertility, and leiomyoma uteri.
5. Describe the anatomy of the male reproductive tract. Be able to describe each components
functional significance.
6. Explain common pathologies of the male reproductive tract including: chlamydia,
gonorrhea, Reiter’s syndrome, benign prostatic hyperplasia, and hydrocele.
1. Outline the anatomy of the female reproductive tract. Be able to describe each
components functional significance.
The female reproductive system includes the ovaries, fallopian tubes, uterus, and vagina. These
organs are involved with the production of hormones and of the human gametes (ovum)
involved in fertilization/conception. In addition they assist with the transport of ovum and
sperm during fertilization and help in the development and protection of the fetus during
gestation.
http://humananatomychart.info
Vagina is a musculomembranous tube. The superior end of the vagina surrounds the cervix of
the uterus. The inferior end consists of the vaginal orifice. The vagina is usually collapsed, with
its anterior and posterior walls contacting one another. The vagina has several functions. It
forms the inferior part of the birth canal. It serves as a canal for menstrual fluid. It receives the
penis and ejaculate during sexual intercourse. It communicates anteriorly and superiorly with
347
the cervical canal which extends from the isthmus of the uterus to the external os (opening) of
the cervix.
Uterus
https://commons.wikimedia.org/wiki/File:Illu_cervix.jpg
Thick- walled, pear-shaped hollow muscular organ. The uterine body lies on the bladder and its
cervix is located between the bladder and the rectum. Typically the uterus is anteverted- tipped
anterosuperiorly relative to the axis of the vagina. \
The uterus has two main parts: the body and the cervix.
The body consists of the superior two thirds of the uterus. It includes the fundus which is the
most superior part of the uterus and has a rounded shape. The elongated constricted region of
the body is called the isthmus. The uterine horns or cornua are the superolateral regions
where the uterine (fallopian) tubes enter.
The wall of the body is made of three

layers: perimetrium, myometrium,
and endometrium. The perimetrium is
an outer serous layer which consists of
peritoneum supported by a thin layer
of connective tissue. The myometrium
is the thick muscular layer. It consists
of smooth muscle. The endometrium
is the inner mucous coat. It differs in
structure during different stages of
the menstrual cycle. It is also where
the blastocyst will implant if
https://commons.wikimedia.org/wiki/File:Uterine_anatomy..jpg conception occurs.
348
The cylindrical, narrow inferior part of the uterus is called the cervix. It has a supravaginal part
between the isthmus and the vagina, and a vaginal part that protrudes into the vagina and
surrounds the external os (or opening) of the uterus. The cervix is mostly fibrous, with a small
amount of smooth muscle and elastin.
There is a double layer of peritoneum that extends from the sides of the uterus to the lateral
walls and floor of the pelvis, called the broad ligament of the uterus. It helps to keep the uterus
centered in the pelvis and contains the ovaries, fallopian tubes, and related structures. The part
of the broad ligament by which the ovary is suspended is known as the mesovarium. The part
of the broad ligament forming the mesentery of the fallopian tube is called the mesosalpinx.
https://en.wikibooks.org/wiki/Human_Physiology/The_female_reproductive_system
Uterine (Fallopian) Tubes

Extend laterally from the uterine horns and open into the peritoneal cavity near the ovaries.
They lie in the mesosalpinx in the free edges of the broad ligament. Each tube has four parts.
The infundibulum is the funnel-shaped distal end that opens into the peritoneal cavity. Its
fimbriae (finger-like projections) spread over the medial surface of the ovary. The ampulla
begins at the medial end of the infundibulum. It is the widest and longest part of the fallopian
tube. The isthmus enters the uterine horn. The fallopian tube opens through the uterine
ostium into the uterine cavity at the uterine horn.
349
http://figures.boundless-cdn.com/34012/full/3nje8cntcwkthxxc1wug.png
Ovaries
Pair of small glands whitish in color. They are typically located near the attachment of the broad
ligament to the lateral pelvic walls; suspended from both by peritoneal folds, the mesovarium
from the posterosuperior aspect of the broad ligament and the suspensory ligament of the
ovary from the pelvic wall. The
suspensory ligament carries the
ovarian vessels and nerves. The
ovaries are located on the left and
right sides of the pelvis lateral to
the uterus in a region called the
ovarian fossa. It can usually be
found beneath the external iliac
artery and in front of the ureter
and internal iliac artery. The
ovaries are attached to the uterus
by a fibrous cord called the ovarian
ligament (runs within the
mesoovarium).
The outermost layer of the ovary is called the germinal epithelium. The ovarian cortex consists
of ovarian follicles, which contain the ovum, and stroma in between them. The innermost layer
of the ovary is called the ovarian medulla; it is composed of connective tissue, blood vessels,
lymphatics, and nerves.
350
https://upload.wikimedia.org/wikipedia/commons/5/57/Gray1163.png
The ovaries produce the female sex hormones- estrogen and progesterone; as well as the
female gamete, the ova (egg). Usually, ovulation occurs in one of the two ovaries releasing a
fertilizable egg each menstrual cycle. Because the ovary is suspended in the peritoneal cavity
and its surface is not covered by peritoneum, the oocyte expelled at ovulation passes into the
peritoneal cavity but is usually trapped by the fimbriae of the fallopian tube and carried to the
ampulla.
4. Explain common pathologies of the female reproductive tract including: chlamydia,

gonorrhea, pelvic inflammatory disease, infections of the female genital tract, ectopic
pregnancy, infertility, and leiomyoma uteri.
Chlamydia- Chlamydia is the most commonly reported Sexually Transmitted Disease in the United
States. It is caused by a bacteria called Chlamydia Trachomatis. It is spread through unprotected anal,
vaginal, or oral sex or through vertical transmission (mother to baby). Most infections are
asymptomatic. Although women can also get cervicitis (inflammation of the cervix). This can lead to
spotting (light vaginal bleeding) and mucopurulent discharge. An uncomplicated infection is treated with
antibiotics.
Occasionally the infection can become complicated and lead to pelvic inflammatory disease (PID). This
occurs when the bacteria ascends and spreads from the vagina or cervix to the endometrium, fallopian
tubes, and ovaries. This usually presents with lower abdominal pain, discharge, and fever; and on
examination the patient will have cervical motion tenderness and uterine or adnexal tenderness on
palpation. Rarely this infection can be clinically silent- causing no symptoms or signs on exam. PID can
lead to scarring of the fallopian tubes which can result in ectopic pregnancy and/or infertility for the
patient.
Gonorrhea- It is caused by a bacteria called Neisseria gonorrhoeae. It is spread through unprotected
anal, vaginal, or oral sex or through vertical transmission (mother to baby). About 50% of women are
asymptomatic. Women can also get cervicitis which causes mucopurulent or purulent cervical discharge,
intermenstrual bleeding, and lower abdominal pain. An uncomplicated infection is treated with
antibiotics. Like chlamydia, gonorrhea can occasionally ascend and spread to the upper pelvic organs
causing pelvic inflammatory disease (PID).
351
Infections of the Female Genital Tract- Because the female genital tract communicates with
the peritoneal cavity through the openings of the fallopian tubes; infections of the vagina,
uterus, and fallopian tubes may result in peritonitis. Also inflammation of the tubes, salpingitis,
may result from infections that spread from the peritoneal cavity. Blockage of the fallopian
tubes, often due to infection, is a major cause of infertility and ectopic pregnancy.
Ectopic Pregnancy- A blastocyst may implant in the mucosa of the fallopian tube, most
commonly in the ampulla, this is known as an ectopic tubal pregnancy. Tubal rupture and
severe hemorrhage can threaten the mother’s life. The embryo cannot survive. Risk factors
include: prior pelvic inflammatory disease, previous tubal surgery, previous ectopic pregnancy,
ovulation induction and in vitro fertilization, and smoking. Possible symptoms include uterine
bleeding and lower abdominal pain.
Leiomyoma uteri- Leiomyoma uteri, also known as fibroids or uterine myomata, are benign
smooth-muscle tumors of the uterus. They are the most common pelvic tumors of women,
occurring in 20-30% of reproductive age women. Risk factors for myomas: obesity, nulliparity,
early menarche, and a history of infertility. Uterine myomas are classified as being submucosal
(just beneath the endometrium), intramural (in the muscular wall of the uterus), or subserosal
(beneath the serosa).
Most fibroids are asymptomatic. However they can cause abnormal uterine bleeding, pelvic
pain and/or pressure, and urinary frequency or urgency can occur if the fibroid compresses the
bladder. In most cases diagnosis can be made based on physical examination and pelvic
ultrasound. Treatment is based on clinical presentation and ranges from expectant
management to medicinal treatment to surgery.
Image: 1) Subserosal 2) Intramural 3) Submucosal

https://upload.wikimedia.org/wikipedia/commons/d/df/Fibroid.jpg
Intraoperative picture of fibroid uterus,

https://commons.wikimedia.org/wiki/File:Uterine_fibroids.jpg
352
5. Describe the anatomy of the male reproductive tract. Be able to describe each
components functional significance.
Male Pelvic Genital Organs. The male internal genital organs include the testes, epididymides,
vas (ductus) deferentes, seminal glands (vesicles), ejaculatory ducts, prostate, and bulbo-
urethral glands.
https://figures.boundless.com/19742/large/figure-43-03-01.png
Testes
Ovoid in shape. The testes are suspended in the scrotum by the spermatic cords. They produce
sperms and hormones, mainly testosterone.
Epididymis
Elongated structure on the posterior surface of the testes.
Vas (Ductus) Deferens

It is the continuation of the duct of the epididymis. It begins in the tail of the epididymis at the
inferior pole of the testis and ascends to pass through the inguinal canal and then passes along
the lateral wall of the pelvis to join the duct of the seminal gland to form the ejaculatory duct.
Seminal Glands
Each seminal gland is an elongated structure that lies between the bladder and the rectum.
They secrete a thick alkaline fluid that mixes with sperm as they pass into the ejaculatory ducts
and urethra. It is the major ingredient of semen making up 65-75%.
353
Ejaculatory Ducts
The duct of the seminal gland and the vas deferens join to form a slender tube called the
ejaculatory duct. The ejaculatory ducts join and open within the prostate. Prostatic secretions
join the seminal fluid in the prostatic urethra after the termination of the ejaculatory ducts.
Prostate
It is walnut-size and surrounds the prostatic urethra. The glandular part makes up
approximately two thirds of the prostate. One third is fibromuscular. It also has a dense fibrous
capsule. This is surrounded by the visceral layer of the pelvic fascia, forming a fibrous prostatic
sheath. Prostatic fluid provides about 15-30% of the volume of semen.
Bulbo-Urethral Glands
Two pea-sized glands that lie posterolateral to the intermediate part of the urethra. Produce
mucus-like secretions which enter the urethra during sexual arousal. These secretions
contribute less than 1% to semen.
6. Explain common pathologies of the male reproductive tract including: chlamydia,

gonorrhea, Reiter’s syndrome, benign prostatic hyperplasia, and hydrocele.
Chlamydia- Chlamydia is the most commonly reported Sexually Transmitted Disease in the United
States. It is caused by a bacteria called Chlamydia Trachomatis. It is spread through unprotected anal,
vaginal, or oral sex or through vertical transmission (mother to baby). Uncomplicated infections are
treated with antibiotics.
Most infections are asymptomatic. Although males can get urethritis which causes burning with
urination and urethral discharge (mucopurulent, mucoid, clear); or epididymitis leading to fever,
tenderness, swelling and scrotal pain. A rare complication is Reiter’s Syndrome: a post-inflammatory
autoimmune disease which causes conjunctivitis, urethritis, and oligoarthritis about 3-6 weeks after
genital infection.
Gonorrhea- It is caused by a bacteria called Neisseria gonorrhoeae. It is spread through unprotected

anal, vaginal, or oral sex or through vertical transmission (mother to baby). In men gonorrhea is usually
symptomatic. It causes urethritis leading to purulent or mucopurulent urethral discharge (“drip” of pus),
and burning with urination. Rarely epididymitis can occur causing testicular pain and swelling, and
epididymal tenderness.
Benign prostatic hyperplasia (BPH) is a noncancerous hyperplasia of prostatic stromal and epithelial
cells, resulting in enlargement of the prostate and the formation of nodules. The nodules can narrow the
urethra resulting in an increased resistance to flow of urine from the bladder. Symptoms include the
need to urinate frequently, waking at night to urinate, urgency, urinary hesitancy, dysuria, and
involuntary urination.
354
https://upload.wikimedia.org/wikipedia/commons/thumb/c/cd/Benign_Prostatic_Hyperplasia_nci-vol-7137-300.jpg/800px-
Benign_Prostatic_Hyperplasia_nci-vol-7137-300.jpg
Hydrocele- A fluid-filled sac surrounding a testicle that causes swelling in the scrotum. It is usually
painless, however there may be discomfort from the heaviness of the swollen scrotum. Can be
congenital or due to injury or inflammation/infection. Often resolves on its own, if persists or gets large
enough to cause discomfort or disfigurement may need to be removed surgically.
355
Table of Contents for the Handout
Lecture Topics Pages
1 Intro to Micro and Micro Anatomy 9

Cell 10
2 Epithelial Tissues 23
Connective Tissue 26
3 Neural Histology 37
4 Introduction to Gross Anatomy 54
Skull 58
5 Muscle Tissue 69
6 Head and Neck Muscles 85
Reflexes 96
7 Cranial Nerves 101
8 Spinal Cord Pathways 118
Cortex 126
9 ANS 130
CSF 137
10 Mediastinum 145
Heart 150
11 Histology of Blood Vessels 164
12 Thorax 176
13 Lungs 191
14 Abdominal Cavity 210
Kidneys 218
15 Histology of Kidney 231
16 Liver and Pancreas 241
17 Histology of Glands 256
18 GI Tract 273
19 Bone and Cartilage 288
20 Upper Limb I (Bones and Nerves) 303
21 Upper Limb II and III (Muscles) 315
22 - 23 Lower Limb I (Bones and Nerves) 328
24 Lower Limb II (Muscles) 336
25 Reproductive Tract 347
356

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Anatomy August 2017

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Course: Anatomy and Histology

Instructor: Elfa Shabashvili, Ph.D.

Visual Histology and additional MERP videos available via Mediasite.

Anatomy and Physiology Revealed, 3. (available in the library)

Lecture 1: Introduction to Macro and Microanatomy; Cell

Introduction to Macro- and Microanatomy

Lecture 2: Epithelial and Connective Tissue

Lecture 3: Neural Histology

1. Explain the function of neural tissue.

Lecture 4: Introduction to Gross Anatomy; Skull

Lecture 5: Muscle Tissue

Lecture 6: Head and Neck Muscles, Reflexes

Lecture 7: Cranial Nerves

Lecture 8: Spinal Cord Pathways: Cortex.

Part II: Thorax and Abdomen

Lecture 10: Mediastinum; Heart

1. Describe the external and internal anatomy of the heart.

Lecture 11: Histology of Blood Vessels

Lecture 12: Thorax

1. Describe Thoracic Skeleton: sternum, vertebra and ribs.

Lecture 13: Lungs

Lecture 14: Abdominal Cavity; Kidneys

Lecture 15: Histology of Kidney

1. List and describe the functions of the kidney.

Lecture 16: Liver and Pancreas

Lecture 17: Histology of Glands

Lecture 18: GI Tract

Lecture 19: Bone Histology

Lectures 20: Upper Limb I (Bones and Nerves)

1. List the bones of the upper girdle and extremity.

Lectures 23: Lower Limb I (Bones and Nerves)

Lecture 24: Lower Limb II (Muscles)

Lecture 25: Reproductive Tract Anatomy

Lecture 1: Introduction to Macro and Microanatomy; Cell

2. Understand the principles of noninvasive diagnostic techniques.

3. Recognize the subjects of Histology, Cytology and Cell Biology.

4. Recognize the levels of human body organization.

1. Understand the nature of the tissues and principles of Cell Theory.

Multipotent cells of different types of

2. Describe the structure of the typical prokaryotic and eukaryotic cell.

The human body is made of approximately 1014

LM (above) and EM (below) shows nucleoli.

CONTENTS OF CYTOPLASM CHARACTERISTICS OF CYTOPLASMIC COMPONENTS

Epithelia are classified based on:

In the image to the left:

Most of the cells of the CT

3) Reticular fibers (type III collagen) are wavy

There are few types of Connective Tissue proper:

Dense Connective Tissue (DCT)

less ground substance than LCT.

Dense Regular Connective Tissue (image

(2) Elastic type of regular

The adipose tissue commonly

1. Explain the function of neural tissue.

Neural cell (neuron) has a body

New signal is generated at the axon

3. Discuss the location and function

Body of the neuron is the large

Neural tissue contains neurons

Confocal micrograph courtesy of Dr. Lotocki.

Ependimal cells are found at the

5. Understand functional types of

Multipolar neurons have many dendrites and one axon. They

Peripheral nerve (high magnification), C = capillary,