Clinical anatomy, applied anatomy for students and junior doctors 13th ed h ellis, v mahadevan (wiley 2013)

Clinical Anatomy


To my wife, Wendy, and my late parents
H. E.
To my wife, Neila, and my late parents
V. M.


Clinical Anatomy
Applied Anatomy for Students
and Junior Doctors

HAROLD ELLIS
CBE, MA, DM, MCh, FRCS, FRCP, FRCOG, FACS (Hon)
Clinical Anatomist, Guy’s, King’s and St Thomas’ School of Biomedical Sciences;
Emeritus Professor of Surgery, Charing Cross
and Westminster Medical School, London;
Formerly Examiner in Anatomy, Primary FRCS (Eng)

VISHY MAHADEVAN
MBBS, PhD, FRCSEd, FDSRCSEng (Hon), FRCS
Barbers’ Company Professor of Anatomy & Professor of Surgical Anatomy
The Royal College of Surgeons of England
Lincoln’s Inn Fields
London;
Member of the Court of Examiners, RCS England

THIRTEENTH ED I T I O N

This edition first published 2013 © 1960, 1962, 1966, 1969, 1971, 1977, 1977, 1983, 1992, 1992,
2002, 2006, by Harold Ellis; 2010 by Harold Ellis and Vishy Mahadevan; 2013 by John Wiley
& Sons, Ltd
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Library of Congress Cataloging-in-Publication Data
Ellis, Harold, 1926– author.
  Clinical anatomy : applied anatomy for students and junior doctors /
Harold Ellis, Vishy Mahadevan. – Thirteenth edition.
  p. ; cm.
  Includes bibliographical references and index.
  ISBN 978-1-118-37377-4 (pbk. : alk. paper) – ISBN 978-1-118-37376-7
(ePDF) – ISBN 978-1-118-37375-0 (ePub) – ISBN 978-1-118-37374-3 (Mobi) – ISBN 978-1-11837373-6 – ISBN 978-1-118-37372-9
  I.  Mahadevan, Vishy, author.  II.  Title.
  [DNLM:  1.  Anatomy.  QS 4]
  QM23.2
  612–dc23
   

2013012750
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in
print may not be available in electronic books.
Cover image: The Wellcome Museum of Anatomy and Pathology, Royal College of Surgeons
of England, London
Cover design by Sarah Dickinson
Set in 9/12 pt Palatino by Toppan Best-set Premedia Limited
01  2013


Contents

Preface to the Thirteenth Edition, xiii
Preface to the First Edition, xv
Acknowledgements to the Thirteenth Edition, xvii
Acknowledgements to the First Edition, xix
About the Companion Website, xxi

Part 1: The Thorax
Introduction, 3
Surface anatomy and surface markings, 3
The
The
The
The

trachea, 4
pleura, 4
lungs, 6

heart, 6

The thoracic cage, 7
The
The
The
The
The
The
The

thoracic vertebrae, 7
ribs, 8
costal cartilages, 11
sternum, 11
intercostal spaces, 12
diaphragm, 14
pleurae, 19

The lower respiratory tract, 20
The trachea, 20
The bronchi, 25
The lungs, 25

The mediastinum, 30
The
The
The
The
The

The
The

pericardium, 30
heart, 31
superior mediastinum, 46
thymus, 46
oesophagus, 47
thoracic duct, 50
thoracic sympathetic trunk, 52

On the examination of a chest radiograph, 55
Radiographic appearance of the heart, 56


vi   Contents

Part 2: The Abdomen and Pelvis
Surface anatomy and surface markings, 61
Vertebral levels, 61
Surface markings of individual viscera, 63

The fasciae and muscles of the abdominal wall, 64
Fasciae of the abdominal wall, 64
The muscles of the anterior abdominal wall, 65
The anatomy of abdominal incisions, 67
The inguinal canal, 70

Peritoneal cavity, 72
Intraperitoneal fossae, 76

The subphrenic spaces, 76

The gastrointestinal tract, 77
The stomach, 77
The duodenum, 82
Small intestine, 85
Large intestine, 86
The appendix, 87
The rectum, 89
Arterial supply of the intestine, 94
The portal system of veins, 95
Lymph drainage of the intestine, 96
The structure of the alimentary canal, 97
The development of the intestine and its congenital
abnormalities, 98

The gastrointestinal adnexae: liver, gall bladder and its
ducts, pancreas and spleen, 101
The
The
The
The
The

liver, 101
biliary system, 106
gall bladder, 107
pancreas, 110
spleen, 112

The urinary tract, 114
The kidneys, 114
The ureter, 118
The embryology and congenital abnormalities of the kidney
and ureter, 119
The bladder, 121
The urethra, 124


Contents   vii

The male genital organs, 125
The prostate, 125
The scrotum, 128
Testis and epididymis, 129
Vas deferens (ductus deferens), 133
The seminal vesicles, 134

The bony and ligamentous pelvis, 134
The os innominatum, 134
The sacrum, 135
The coccyx, 136
The functions of the pelvis, 136
Joints and ligamentous connections of the pelvis, 137
Differences between the male and female pelvis, 137
Obstetrical pelvic measurements, 138
Variations of the pelvic shape, 139
Sacral (caudal) anaesthesia, 142

The muscles of the pelvic floor and perineum, 143

The anterior (urogenital) perineum, 144
The posterior (anal) perineum, 146

The female genital organs, 147
The vulva, 147
The vagina, 148
The uterus, 150
The Fallopian tubes, 154
The ovary, 156
The endopelvic fascia and the pelvic ligaments, 157
Vaginal examination, 158
Embryology of the Fallopian tubes, uterus and vagina, 159

The posterior abdominal wall, 161
The suprarenal glands, 162
Abdominal aorta, 163
Inferior vena cava, 164
Lumbar sympathetic chain, 166

Computed axial tomography, 167

Part 3: The Upper Limb
Surface anatomy and surface markings of
the upper limb, 171
Bones and joints, 171
Muscles and tendons, 172


viii   Contents

Vessels, 172
Nerves, 176

The bones and joints of the upper limb, 177
The
The
The
The
The
The
The
The
The

scapula, 177
clavicle, 177
humerus, 179
radius and ulna, 180
bones of the hand, 183
shoulder joint, 185
elbow joint, 190
wrist joint, 193
joints of the hand, 194

Three important zones of the upper limb: the axilla,
the cubital fossa and the carpal tunnel, 197
The axilla, 197
The cubital fossa, 197
The carpal tunnel, 199

The arteries of the upper limb, 199
The
The
The
The

axillary artery, 199
brachial artery, 200
radial artery, 200
ulnar artery, 201

The brachial plexus, 201
The segmental cutaneous supply of the upper limb, 203

The course and distribution of the principal nerves of
the upper limb, 205
The
The
The
The
The

axillary nerve, 205
radial nerve, 205
musculocutaneous nerve, 206
ulnar nerve, 207
median nerve, 208

Compartments of the upper limb, 209
Compartments in the segments of the upper limb, 209

Compartment syndrome, 210

The female breast, 210
Structure, 210
Blood supply, 211
Lymphatic drainage, 211
Development, 213


Contents   ix

The anatomy of upper limb deformities, 214
The spaces of the hand, 218
The superficial pulp space of the fingers, 218
The ulnar and radial bursae and the synovial tendon sheaths
of the fingers, 219

Part 4: The Lower Limb
The surface anatomy and surface markings of
the lower limb, 225
Bones and joints, 225
Bursae of the lower limb, 226
Mensuration in the lower limb, 226
Muscles and tendons, 229
Vessels, 230
Nerves, 233

The bones and joints of the lower limb, 235
The os innominatum, 235
The femur, 235

The patella, 240
The tibia, 242
The fibula, 244
A note on growing ends and nutrient foramina in the long bones, 244
The bones of the foot, 245
The hip joint, 245
The knee joint, 250
The tibiofibular joints, 253
The ankle joint, 253
The joints of the foot, 256
The arches of the foot, 256
The anatomy of walking, 258

Three important zones of the lower limb: the femoral
triangle, adductor canal and popliteal fossa, 259
The femoral triangle, 259
The adductor canal (of Hunter) or subsartorial canal, 263
The popliteal fossa, 264

The arteries of the lower limb, 266
Femoral artery, 266
Popliteal artery, 267
Posterior tibial artery, 268
Anterior tibial artery, 269

The veins of the lower limb, 269


x   Contents

The course and distribution of the principal nerves of
the lower limb, 272
The lumbar plexus, 272
The sacral plexus, 273
The sciatic nerve, 276
The tibial nerve, 277
The common peroneal (fibular) nerve, 278
Segmental cutaneous supply of the lower limb, 279

Compartments of the lower limb, 279
Compartments in the segments of the lower limb, 281
Compartment syndrome, 282

Part 5: The Head and Neck
The surface anatomy of the neck, 285
Introduction, 285
The fascial compartments of the neck, 287
Tissue planes and fascial layers in the anterior part of neck, 287

The thyroid gland, 290
The parathyroid glands, 294
The palate, 296
The development of the face, lips and palate with special reference to their
congenital deformities, 297

The tongue and floor of the mouth, 299
The tongue, 299
The floor of the mouth, 303

The pharynx, 304

The
The
The
The
The

nasopharynx, 304
oropharynx, 306
palatine tonsils, 306
laryngopharynx, 308
mechanism of deglutition, 310

The larynx, 312
The salivary glands, 318
The parotid gland, 318
The submandibular gland, 320
The sublingual gland, 321

The major arteries of the head and neck, 322
The common carotid arteries, 322
The external carotid artery, 322


Contents   xi

The internal carotid artery, 324
The subclavian arteries, 327

The veins of the head and neck, 329
The

The
The
The

cerebral venous system, 329
venous sinuses of the dura, 329
internal jugular vein, 332
subclavian vein, 333

The lymph nodes of the neck, 335
The cervical sympathetic trunk, 337
The branchial system and its derivatives, 339
Branchial cyst and fistula, 339

The surface anatomy and surface markings of the head, 341
The scalp, 342
The skull, 343
Floor of the cranial cavity, 346
Development, 347

The paranasal sinuses (accessory nasal sinuses), 349
The
The
The
The

frontal sinuses, 350
maxillary sinus (antrum of Highmore), 350
ethmoid sinuses, 352
sphenoidal sinuses, 353

The mandible, 353
The temporomandibular joint, 354
The teeth, 355

The vertebral column, 356
The
The
The
The
The
The

cervical vertebrae, 357
thoracic vertebrae, 359
lumbar vertebrae, 359
sacrum, 360
coccyx, 360
intervertebral joints, 360

Part 6: The Nervous System
Introduction, 365
The brain, 365
The brainstem, 365
The cerebellum, 368


xii   Contents

The

The
The
The
The

diencephalon, 370
pituitary gland (hypophysis cerebri), 372
cerebral hemispheres, 374
membranes of the brain and spinal cord (the meninges), 385
ventricular system and the cerebrospinal fluid circulation, 386

The spinal cord, 390
Age differences, 393
The membranes of the cord (the meninges), 394

The cranial nerves, 397
The
The
The
The
The
The
The
The
The
The
The
The

olfactory nerve (I), 398

optic nerve (II) and the visual pathway, 398
oculomotor nerve (III), 401
trochlear nerve (IV), 403
trigeminal nerves (V), 403
abducent nerve (VI), 409
facial nerve (VII), 409
auditory (vestibulocochlear) nerve (VIII), 412
glossopharyngeal nerve (IX), 412
vagus nerve (X), 413
accessory nerve (XI), 415
hypoglossal nerve (XII), 416

The special senses, 417
The nose, 417
The ear, 419
The eye and associated structures, 423

The autonomic nervous system, 428
The sympathetic system, 431
The sympathetic trunk, 432
The parasympathetic system, 436

Glossary of eponyms, 439
Index, 445


Preface to the Thirteenth Edition

As a teacher of medical students and surgical trainees, I know that much
of clinical examination and diagnosis depends on an adequate knowledge

of anatomy. No matter how good the doctors are at communication skills
and patient empathy, unless they know what lies beneath their examining
fingers or under the bell of their stethoscopes, they will have great difficulty in the interpretation of clinical signs. Understanding the exquisite
details of modern radiological imaging also requires a good knowledge of
the structure of the human body.
This was true over 50 years ago when I wrote the first edition of this
book, and is perhaps even more so today, when anatomy in the medical
student’s curriculum has been greatly reduced.
Over these many years, during which time I have taught students and
postgraduates in five medical schools, and examined them in eight countries and sixteen universities, my belief in the importance of an adequate
knowledge of anatomy as an adjunct to clinical training has been strongly
reinforced.
In the preparation of the 12th edition and this edition, I have been fortunate indeed in having been able to recruit Professor Vishy Mahadevan,
the Barbers’ Company Professor of Anatomy at the Royal College of Surgeons of England, as co-author. He is a renowned and revered teacher of
surgical trainees as well as being a current examiner in the MRCS and in
overseas medical schools. Together, in this new edition, we have carried
out a careful revision and updating of the text and diagrams, as well as
adding new figures and images.
We hope that this book will continue to help our students and postgraduate trainees throughout the English-speaking world.
Harold Ellis
July 2013



Preface to the First Edition

Experience of teaching clinical students at three medical schools has convinced me that there is still an unfortunate hiatus between the anatomy
which the student learns in his pre-clinical years and that which he later
encounters in the wards and operating theatres.
This book attempts to bridge this gap. It does so by high-lighting those

features of anatomy which are of clinical importance, in medicine and
midwifery as well as in surgery. It presents the facts which a student might
reasonably be expected to carry with him during his years on the wards,
through final examinations and into his post-graduate years; it is designed
for the clinical student.
Anatomy is a vast subject and therefore, in order to achieve this goal, I
have deliberately carried out a rigorous selection of material so as to cover
only those of its thousands of facts which I consider form the necessary
anatomical scaffolding for the clinician. Wherever possible practical applications are indicated throughout the text – they cannot, within the limitations of a book of this size, be exhaustive, but I hope that they will act as
signposts to the student and indicate how many clinical phenomena can
be understood and remembered on simple anatomical grounds.
Harold Ellis
Oxford, 1960



Acknowledgements to the
Thirteenth Edition

We wish to thank the many students, undergraduates and postgraduates
who have sent suggestions to us, many of which have been incorporated
into this new edition.
New and revised illustrations were skilfully produced by Jane Fallows.
A novel feature in this edition is the use of the overlay technique in some
of the illustrations, wherein colourful line drawings have been superimposed on photographs of a living anatomy model. We are grateful to the
Wiley-Blackwell team for coming up with the suggestion and to Jane
Fallows for executing the task with such skill and precision.
CT and MRI scans were provided by Dr Sheila Rankin and Dr Jeremy
Rabouhans of the Department of Radiology at Guy’s Hospital, and Professor Adrian Dixon of Cambridge. Our thanks to all three.
Our gratitude to Lindsey Williams for her editorial advice and help.

We are grateful to the following authors for permission to reproduce
illustrations:
The late Lord Brock for Figs 20 and 21 (from Lung Abscess); and
Professor R. G. Harrison for Figs 12, 32 and 67 (from A Textbook of Human
Embryology).
We acknowledge with gratitude the generosity of the trustees of the
Royal College of Surgeons of England in allowing us to use images of
corrosion casts of various viscera for the cover design. Source: The Wellcome Museum of Anatomy and Pathology at the Royal College of Surgeons of England, London; photographed by John Carr, Photographer, The
Royal College of Surgeons of England.
Our thanks to Jason Wallace of the Technical Resources team at the Royal
College of Surgeons of England for being an anatomy model for several
of the new illustrations, and to John Carr for his expertise in capturing the
optimal photographic images.
Finally, we wish to express our debt to Rebecca Huxley and the staff of
Wiley-Blackwell for their continued and unfailing help and support.
Harold Ellis
Vishy Mahadevan
July 2013



Acknowledgements to
the First Edition

I wish to thank Dr Max Cowan of the Department of Anatomy, Oxford,
who has given freely of advice and criticism in the production of this book.
My colleagues – the registrars and house surgeons at the Radcliffe Infirmary – have kindly perused and commented on the text and have given
valuable help in proof-reading.
The majority of the illustrations are by Miss Margaret McLarty and Miss
Audrey Arnott; I must thank them sincerely for all their care.

I am grateful to the following authors for permission to reproduce
illustrations:
Sir Russell Brock for Fig. 15 (from Lung Abscess); Professor R. G. Harrison
for Figs 10, 23, 53, 67 and 155 (from A Textbook of Human Embryology);
Professor David Sinclair for Figs 69, 92, 95, 97, 100–1, 105, 107, 114,
126, 132, 137, 139, 177 and 181 (from An Introduction to Functional
Anatomy); and Professor Sheila Sherlock for Fig. 55 (from Diseases of
the Liver and Biliary System).
The illustrations for an anatomical textbook are inevitably a costly item,
yet I was anxious that this book should be within the budget of the students for whom it is primarily intended. It is therefore a pleasure to
acknowledge here the generosity of Upjohn of England Ltd in contributing
towards the cost of the blocks: their gesture will be widely appreciated.
To my sister, Mrs L. Witte, go my grateful thanks for invaluable secretarial assistance. Finally, I wish to express my debt to Mr Per Saugman and
staff at Blackwell Scientific Publications for guiding the hesitant steps of
the beginner.
Harold Ellis



About the Companion Website

Clinical Anatomy has its own resources website:
www.ellisclinicalanatomy.co.uk/13edition
with digital flashcards of the images from the book for easy revision.



Part 1
The Thorax