Clinically Oriented Anatomy, 5th Edition - 1. Thorax

Ovid: Clinically Oriented Anatomy
A ut ho r s:
T i tl e :
Page 1 of 139
M o o re , K e it h L . ; Da l le y, A rt hu r F.
C l in i cal l y O ri e nt ed A na t o m y, 5t h E di t io n
Co p yri gh t 2 0 0 6 Li p pi n c ot t W i ll iam s & W ilk in s

> T a b l e o f C o n te n t s > 1 - T h o r a x
1
Thorax
P .7 5
T h e t h o r a x i s t h e s u p er io r p art of t h e t ru n k b et w ee n th e n ec k an d a bd o m en . Co m m o n ly th e t er m c h es t i s
u s e d a s a s yn o n ym f or t h o r ax , bu t ou r co n c ep t of t h e c h es t (u p p er p a rt o f th e to rs o ) i s m u c h m or e
e xte n s ive th a n th e th o rac i c w al l a n d c a vit y c o n ta in e d w it h in i t. T h e ch es t i s g en era ll y c on c e ive d a s b ein g
b ro ad es t s u p eri or ly o w i n g t o t h e p re s en c e o f t h e p ec t or al , or s h o u ld er , gi rd le (c l avi c le s a n d s c ap u la e) ,
w it h m u c h of it s g irt h ac c o u n t ed fo r b y t h e as s o c ia te d p ec t o ral an d s c ap u la r ( u p pe r li m b ) m u s c u lat u re .
O u r c o n c ep t o f th e w el l- f or m ed c h es t is on e th a t n a rro w s in f e rio rl y to th e w ai s t a n d , in ad u l t f em ale s ,
g ai n s f u rt h er d im en s io n f rom t h e b re as t s .
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Fi gu re 1 . 1. T ho r a cic s ke l et o n. A a n d B. T h e os t eo c art il ag i n ou s t h ora c ic c a ge in c lu de s t h e

s te rn u m , 1 2 p ai rs o f r ib s an d c os t al c art il ag es , a n d 1 2 th o rac i c vert eb r ae a n d i n te rve rte b ral di s c s .
T h e c la vic l es an d s c ap u l ae f o rm t h e p ec t ora l ( s h o u ld er) g ir dl e. T h e d ot t ed li n e in d i c at es t h e p os i ti on
of t h e d ia p h rag m , w h ic h s ep ar at es t h e th o ra c ic an d ab d o m in a l c av it ie s . Th e th o rac i c c avi ty is m u c h
s m al le r th an th e s u rro u n d in g th o ra c ic c ag e.

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P .7 6
T h e t ho r a cic c av it y a n d t h e w all s p ec if i c to it are a c tu a ll y t h e op p o s it e of t h is . T h ey h a ve t h e s h ap e of a
t ru n c a te d c o n e, b ei n g n a rro w e st s u p eri or ly, w it h th e c irc u m f e ren c e i n c rea s in g in f e rio rl y, an d re ac h in g i ts
m a xi m u m at th e ju n c t i on w i th t h e a bd o m in a l p o rti o n o f th e tru n k . Th e w al l o f th e t h o rac i c c a vi ty i s
re la ti vel y t h in , es s e n ti al ly a s th i c k as i ts s ke let o n . Th e t h o rac i c s kel et on t ake s t h e f o rm o f a do m e d
b i rd c ag e, t h e t ho r ac ic ca ge (r ib c ag e) , w i t h t h e h o ri z on t al ba rs f or m ed b y rib s a n d c o s ta l c a rti la g es
s u p p or te d b y t h e ve rt ic al s te rn u m ( b rea s tb o n e) an d th o ra c ic ver te br ae ( F ig . 1 .1 ) . F u rt h er m or e, t h e f lo or
o f th e t h o rac i c ca vi ty ( t h e d ia p h rag m ) is d ee pl y i n vag i n at ed in f er io rly ( i .e., i s p u s h e d u p w a rd ) by vis c e ra
o f th e a b do m i n al c a vi ty. C on s eq u e n tl y, n ea rly th e l ow er h a lf of t h e t h or ac ic w all s u rro u n d s an d pr ot ec t s
a bd o m i n al r at h er t h an
P .7 7
t h or ac i c v is c er a. T h u s th e t ru e th o rax a n d es p ec ia ll y t h e th o ra c ic c av it y ar e m u c h s m al le r th a n on e m ig h t
e xp ec t b a s ed on ex te rn al ap p ear an c es o f th e c h e s t.
T h e t h or ax i n c lu d es t h e p rim ary o rg an s o f th e r es p ir at ory an d c ard i ova s c u la r s ys t em s . T h e t h ora c ic c av it y
i s di vi de d i n t o t h ree m aj or s p a c es : T h e c e n tr al c o m p ar tm e n t, o r m e di as t in u m , h ou s es t h e c o n du c t i n g
s t ru c t u res t h at m ak e u p th e t h o rac i c vis c er a, ex c ep t f o r t h e lu n g s . T h e lu n g s o c cu p y t h e l at era l
c o m p art m e n ts o r p u lm o n ary c avi ti es t h at lie on ea c h s id e o f t h e m ed ia s ti n u m . T h u s t h e m a j ori t y of t h e
t h or ac i c c a vit y i s oc c u p ie d b y t h e l u n gs , w h ic h p ro vid e f o r t h e exc h a n g e of o xyg en a n d c a rb on d i oxi d e
b et w e en ai r an d b lo od , w h ere as m o s t o f t h e re m ai n d er o f t h e t h or ac i c c a vi ty i s oc c u p ie d w it h s tr u c tu r es
i n vo lve d i n c on d u c t in g th e air an d b lo od to an d f ro m th e lu n g s . N u t rie n ts ( f oo d ) t ra vers e th e t h o rac i c
c a vit y vi a t h e es o p h ag u s , p as s in g f ro m t h e in t ak e or ga n (m ou t h ) t o th e s i te of d ig es t io n an d ab s o rp ti on
( a b d o m en ) .
A l th o u g h in t erm s o f f u n c t io n an d d eve lo p m en t th e m am m ary g l an d s are m os t rel at ed t o t h e rep ro d u c ti ve
s ys t em , th e b r eas t s are lo c at ed on t h e t h ora c ic w a ll an d th u s a re i n c lu d ed in t h is c h a pt er .
Ch es t Pain
A lt h ou g h c h es t p ain c a n res u l t f ro m p u lm o n ar y d is ea s e, it is p ro b ab ly th e m os t im p o rt an t s y m p to m o f
c ard i ac d is ea s e ( S w ar tz , 2 0 0 2 ). H o w e ver , ch e s t p a in m a y al s o oc c u r in in t es t in a l, g a llb l ad d er, a n d
m u s c u lo s kel et al di s or de rs . W h e n eva lu a ti n g a pa t ien t w i th c h e st p ai n , th e exa m in a ti on i s lar ge ly
c on c er n ed w i th d is c r im i n at in g b et w ee n s eri ou s c o n di t io n s a n d t h e m an y m i n or c a u s es o f p a in . Pe op l e w h o
h ave h a d a h ea rt a tt a c k u s u all y d es c ri b e th e as s o c iat ed p ai n as a c ru s h i n g s u b - s t ern a l p ai n ( d ee p
to th e st er n u m ) th a t d oe s n ot d is ap p ea r w i th r es t.
The Bot tom Line

Th e th o rax , c on s i s ti n g o f th e t h o rac i c c avi ty , it s c on t en t s , an d th e w al l t h at s u rro u n d s i t , is t h e p art of
th e t ru n k be tw een n e c k an d ab d om en . T h e s h ap e a n d s i z e o f t h e t h or ac ic c a vit y a n d t h e w all s p ec if i c to it
are m u c h di f f eren t f ro m ( es p ec ia ll y s m al le r th an ) th a t o f t h e c h e s t ( u p pe r t ors o ) , be c au s e t h e l at te r
in c l u de s so m e u p p er lim b b o n es an d m u s c l es an d , i n a d u lt f em al es , t h e b rea s ts .
Tho rac ic Wall

T h e t ru e t ho r a ci c w al l in c l u de s th e t h o rac i c c ag e an d t h e m u s c l es th a t e xt en d be tw een i ts e lem en t s a s
w ell as t h e s ki n , s u bc u t an e ou s t is s u e, m u s c les , a n d f a s c ia c o ve rin g it s an t er ol at era l as p ec t ; th e s am e
s t ru c t u res c o veri n g it s po s t eri or a s pe c t a re c o n s id ere d to be lo n g t o th e b a c k. Th e m am m ary gl an d s of t h e
b re as t s lie w i th i n th e s u b c u t an e ou s t is s u e o f t h e t h o rac i c w al l. A l th o u g h t h e s h o u ld er s are c l ea rly p a rt o f
t h e u p p er l im b , t h e an t er ol at era l t h ora c oa p pe n d ic u l ar m u s c l es ( s ee Ch a p te r 6 ) t h at ov erl ie t h e t h or ac i c
c a ge an d f orm th e b e d o f th e b re as t (p e c to ral is m a j or a n d s e rrat u s an t er io r d is t i n c tl y u p pe r li m b
m u s c l es b as e d o n f u n c ti on an d i n n erv at io n ) a re en c o u n t ered i n th e t h o rac i c w al l a n d m a y b e c o n s id ere d
p ar t o f it (b u t w il l b e m en t io n ed on l y b rie fl y h er e) . S im i la r th o ra c oa pp e n di c u la r m u s c le s pl ac e d
p o s te rio rl y (t ra p ez iu s a n d l at is s i m u s d ors i ) h a ve c o m m o n ly b e en c on s i d ered t o b e s u p er fi c ia l m u s c l es of
t h e b ac k , alt h o u gh i n te rm s of f u n c t io n th e y are c lea rl y u pp e r li m b m u s c le s ( a n d a re a ls o c o ver ed in
Ch a p te r 6 ) .
T h e d o m ed s h ap e o f t h e t h or ac i c c a g e p rov id es re m ar kab l e rig i d it y, g iv en th e li gh t w e ig h t o f it s
c o m p on e n ts , e n ab li n g i t t o :
Pr ot ec t vit al th o ra c ic an d ab d o m in a l i n te rn al org a n s ( m o s t a ir o r f lu i d f ill ed ) f rom e xt ern a l f or c es .
R es i s t t h e n e ga ti ve ( s u b - at m os p h e ric ) in t er n al p re s s u res g en e rat ed b y t h e el as t ic rec o il of t h e lu n g s

an d i n s pi ra to ry m o vem en t s .

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Pr ovi d e at t ac h m e n t f o r an d s u p po rt th e w ei g h t o f t h e u p p er l im bs .
Pr ovi d e t h e an c h o rin g a tt ac h m en t ( o rig i n ) o f m an y o f th e m u s c les t h at m o ve an d m a in t ai n th e

p os i ti on o f th e u p p er li m b s r ela ti ve t o t h e t ru n k a s w el l a s p ro vi d e th e at ta c h m en t s f or m u sc l es o f
t h e ab d om en , n ec k , b a c k, an d re s pi ra ti on .
A l th o u g h th e s h a p e of t h e t h ora c ic c ag e p r ovi d es ri gi d it y, it s j oi n ts a n d t h e t h in n e s s a n d fl ex ib il it y o f t h e
ri b s al lo w rem arka b le f l exi b il it y, p erm it ti n g i t t o ab s or b m a n y ex te rn al bl ow s an d c om p r es s io n s w it h o u t
f ra c tu r e an d t o c h an g e i t s s h a p e rep e ti ti vel y an d s u f f ic i en t ly a s req u ir ed f or re s p ira ti on . B e c au s e t h e
m o s t i m p o rta n t s t ru c t u res w it h in t h e t h ora x ( h ear t, g re at ves s el s , lu n g s , a n d t ra c h ea) as w ell as it s f lo or
a n d w al ls ar e c on s t an t ly in m o ti on , t h e t h or ax i s o n e o f th e m os t dy n am i c reg i on s of t h e b od y. W it h ea c h
b re at h , th e m u s c les o f th e t h o rac i c w al l w o rki n g i n c on c er t w it h th e d i ap h ra gm an d m u s c le s o f th e
a bd o m i n al w al l v ary t h e v ol u m e of t h e t h or ac ic c a vit y, f i rs t b y e xp an d in g t h e c ap a ci t y of t h e c av it y,
t h ere b y c au s i n g t h e l u n gs t o e xp an d an d d raw ai r in a n d t h en ( m o s tl y ow in g t o lu n g el as t ic i t y an d m u s c le
re la xat io n ) de c rea s in g t h e vo lu m e o f th e c avi ty , c om p re s s in g th e lu n g s , an d c au s i n g th e m to exp el ai r.
Ske le ton of the T ho racic W all

T h e t ho r a cic s ke l et o n f o rm s t h e os t eo c art i lag i n ou s t h or ac ic c a ge (F i g . 1 .1 ) , w h ic h p ro t ec ts t h e t h or ac ic
vi s c era an d s om e a b d om in al or ga n s . T h e th o ra c ic s kel e t on i n c lu d es 1 2 p ai rs of ri b s an d as s o c iat ed c o s ta l
c a rt ila g es , 1 2 t h ora c ic ve rt eb rae an d th e in t erv ert eb ra l ( IV ) d i s c s i n t erp os e d b e tw een t h em , a n d t h e
s t ern u m . Th e rib s an d c o s ta l c ar ti la ge s fo rm t h e l arg es t p art of t h e t h ora c ic c a ge .
P .7 8
R ibs, Costal Cartilage s, and Inter costal Sp ac es

R i b s ( L. c o s t ae) ar e c u rve d, f l at bo n es t h at f orm m os t of t h e th ora c ic c ag e ( F i gs . 1 .1 a n d 1 .2 ). T h ey are
re m ar kab l y li g h t i n w ei gh t ye t h i gh l y re s ili en t . E ac h ri b h as a s p on g y i n t eri or c o n ta in i n g b o n e m a rro w
( h em at op oi et ic t is s u e ), w h ic h f or m s b lo od c el ls . T h ere a re t h re e ty p es of ri b :
T ru e ( ver t eb ro co s ta l ) ri bs ( 1 s t 7 t h rib s ) : T h e y at ta c h di rec t l y to th e s te rn u m t h rou g h t h ei r ow n

c os t a l c art i lag e s .
Fa l se ( ve rt eb ro ch o ndr a l) r i bs ( 8 th , 9 t h , a n d u s u a ll y 1 0 th r ib s ) : T h ei r c art i lag e s a re c o n n ec t ed to

t h e c art i lag e of th e rib ab o ve t h em ; t h u s th e ir c o n n ec t io n w it h t h e s te rn u m i s i n d ire c t.
Fl o a ti n g (ve rt e bra l , f re e) r i bs ( 1 1 t h , 1 2 th , a n d s o m et i m es 1 0 t h rib s ) : T h e r u di m en t ar y c ar ti la ge s

o f t h es e r ib s d o n o t c o n n ec t e ven i n d ire c tl y w i th t h e s t ern u m ; i n s tea d th e y en d in t h e p os t eri o r
ab d o m in a l m u s c u l at u re.
T yp ic a l ri b s (3 r d 9 th ) h av e t h e f ol lo w i n g c o m p on e n ts :
H ea d: w e dg e -s h a pe d an d h as t w o f a c et s , se p ara te d b y t h e cr e st o f t he he ad ( F i gs . 1 .2 a n d 1 .3 );
o n e f ac et f or a rt ic u l at io n w it h t h e n u m er ic al ly co rr es p on d in g ve rt eb ra a n d o n e f ac e t f o r th e ver te br a
s u p eri or t o it .
N ec k: c o n n ec ts t h e h e ad w i th t h e b od y a t t h e le vel of t h e t u be rc le .
T ub er cl e: at th e ju n c t io n of t h e n ec k a n d bo d y an d h as a s m oo th a rt ic u l ar p ar t, f o r art ic u l at in g w it h
t h e c or res p on d i n g tra n s ver s e p roc e s s o f th e vert eb ra , an d a r ou g h n on - a rti c u la r p art , f or
at t ac h m e n t o f t h e c o s to t ran s ve rs e l ig am en t .
B o d y ( sh a f t) : th i n , f la t, a n d c u r ved , m o s t m a rke d ly a t t h e co st a l a ng le w h er e th e rib t u rn s

an t er ol at era ll y ( als o th e po in t o f t h e l at era l li m i t o f a tt a c h m en t of t h e ere c to r s p in a e m u s c le s to th e
ri b s; s ee Ch ap t er 4 ) ; th e c o n c av e in t ern a l s u rf a c e of t h e b od y h a s a co st a l gr o o ve p ara ll eli n g th e
in f e rio r b or de r of t h e ri b , w h ic h p ro vi de s s om e pr ot ec t io n fo r t h e in t er c os t al n erve an d ves s e ls .
A t yp ic a l ri b s ( 1 s t , 2 n d , an d 1 0 t h 1 2 t h ) a re d is s i m il ar (F i g. 1 .3 ):
T h e 1 s t r ib is t h e b ro ad es t (i .e., i t s b o d y is w i d es t a n d n ear ly h o riz on t al ), s h o rt es t , an d m os t

s h ar pl y c u rv ed of th e s eve n t ru e rib s . It h as a s i n g le f ac e t o n it s h ead f o r art ic u l at io n w i th t h e T 1
ve rte b ra o n ly a n d t w o t ran s ve rs el y d ire c te d g ro o ves c ro s s in g it s s u p eri or s u rf a c e f or t h e s u b c l avi an

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ve s se ls ; t h e g roo ves a re s ep a rat e d b y a s cal e ne t u ber cl e a n d r id g e, t o w h ic h t h e an t eri or sc a le n e

m u s c l e is a tt ac h e d.
l
T h e 2 n d rib i s m ore typ i c al ; i ts b o dy is th i n n er , les s c u rv ed , an d s u b s ta n ti al ly l on g er th a n th e 1 s t

ri b , an d it s h ead h as t w o f ac et s f or a rt ic u l at io n w it h t h e b od ie s of t h e T1 a n d T2 ve rt eb rae ; i ts m ain
at yp i c al f e at u re i s a rou g h a rea o n it s u p pe r s u rf ac e , th e tu be ro si t y fo r s er ra t us a nt e ri o r, f ro m
w h i c h p art of t h at m u s c le o ri gi n at es .
T h e 1 0 t h 1 2 t h rib s , l ike t h e 1 s t ri b, h a ve o n ly o n e f ac e t o n th e ir h e ad s an d art i c u lat e w it h a

s in g l e ve rte b ra.
T h e 1 1 t h an d 1 2 th r ib s are s h ort an d h av e n o n e c k or t u b erc l e.
C o st a l ca rt i l age s p ro lo n g t h e r ib s an t eri or ly a n d c o n tr ib u t e t o t h e el as t ic i ty o f th e t h o rac i c w al l,

p ro vi di n g a f le xib l e at ta c h m en t f or t h ei r an t er io r or d i s ta l en d s ( t ip s ) . Th e c a rt il ag es i n cr eas e in le n g th
t h ro u g h t h e f i rs t 7 a n d t h en g ra d u all y d ec re as e. T h e f i rs t 7 c a rt il ag es ( an d s om et im e s t h e 8 t h ; Fi g . 1 .1 6 )
a tt ac h d i rec t ly a n d i n d ep en d en t ly to th e st er n u m ; th e 8 t h , 9 t h , an d 1 0 t h art ic u l at e w i t h t h e c o s ta l
c a rt ila g es j u s t s u p eri or to th e m , f orm in g a c o n ti n u ou s , a rt ic u l at ed , c art il ag i n ou s c o st a l m a rg in ( F ig .
1 .1 A ) . T h e 1 1 t h an d 1 2 t h c a rt il ag es f or m c ap s on t h e a n ter io r en d s of t h es e r ib s an d d o n o t re ac h or
a tt ac h t o a n y ot h er b o n e o r c art il ag e. T h e c o s ta l
P .7 9
c a rt ila g es of ri b s 1 1 0 c le arl y an c h o r t h e an t eri or en d (t ip s ) of t h e ri b t o th e s t er n u m , li m it in g i ts
o ver all m o vem e n t a s t h e p o s te rio r en d ro ta t es aro u n d th e t ra n s ver s e axi s of t h e ri b ( F ig . 1 .5 ) .
Fi gu re 1 . 2. T yp ica l r i bs. A . T h e 3 r d 9 t h r ib s h ave c om m on c h ar ac t eri s ti c s . E ac h ri b h a s a h ea d ,

n ec k, t u b erc l e, a n d b o dy (s h a f t) . B . Cr os s s ec t io n of a r ib at m id b o dy .

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Fi gu re 1 . 3. A ty pi ca l ri bs . Th e at yp ic a l 1 s t , 2 n d, 1 1 t h , a n d 1 2 t h ri bs d i ff e r f rom t yp i c al r ib s ( e.g .,
t h e 8 th r ib , s h ow n in c en t er) . T h e 1 s t rib i s s h o rt an d f la tt en e d a n d t h e t u b erc l e m er ge s w i th t h e
an g l e. T h e b od y o f t h e 2 n d ri b b e ars a t u b ero s it y f o r at ta c h m en t of t h e s er rat u s an t eri or . Th e 1 1 th
an d 1 2 t h rib s la c k a n e c k an d tu b e rc le , an d th e 1 2 th r ib is s h or te r th a n m o st ri b s .
I nt er co st a l s pac es s e pa ra te t h e r ib s an d th e ir c o s ta l c a rt ila g es f ro m on e a n ot h er ( F i g. 1 . 1 A) . T h e
s p ac e s are n a m ed a cc o rd i n g t o t h e ri b fo rm i n g th e s u p e rio r b or de r of t h e s p ac e f or e xam pl e, t h e 4 t h
i n te rc os t al s p ac e l ies b et w e en ri b 4 a n d r ib 5 . T h ere a re 1 1 i n te rc os t a l s p ac es a n d 1 1 i n te rc o st a l n erv es .
In t er c os t al s p a c es are oc c u p ie d b y i n t erc o s ta l m u s c l es an d m em br an es , a n d tw o s et s (m ai n a n d
c o ll at era l) of i n te rc os t al b lo od ves s e ls an d n er ves , i de n ti f ie d b y t h e s am e n u m b er a s s ig n ed t o t h e s p ac e.
T h e s p ac e be lo w t h e 1 2 t h r ib d oe s n o t l ie be tw een r ib s an d th u s i s ref er red t o as t h e su bco s ta l s pa ce,
a n d t h e a n te rio r ra m u s of s p in a l n er ve T 1 2 is t h e s u b c os t al n erve . Th e in t erc o s ta l s p ac e s are w id es t
a n te rol at er all y, a n d t h ey w id en w it h in s p ir at io n . Th e y c an b e f u rt h er w id en e d b y e xt en s io n an d / or l at er al
f l exi on o f t h e t h or ac ic v ert eb ra l c ol u m n t o t h e c on t ra la te ral s id e.
Ri b Fr act ures
Th e sh o rt , b ro ad 1 s t ri b , p os t ero in f er io r to t h e c la vic l e, i s r are ly f ra c tu r ed be c au s e o f it s pr ot ec t ed
po s it i on ( it c an n o t b e p al p at ed ) . W h en i t i s br ok en , h ow eve r, in j u ry t o th e b ra c h ia l p le xu s of n er ves a n d
s u bc l av ian v es s el s m ay o c c u r. T h e m id d l e ri bs a re m o s t c o m m o n ly f ra c tu r ed . R ib f ra c tu r es u s u al ly re s u lt
fr om b l ow s o r f ro m c ru s h in g i n ju r ies . T h e w eak es t pa rt of a ri b is j u s t an t er io r to it s an g l e; h ow e ver ,
di rec t vi ol en c e m a y f rac t u re a ri b a n yw h e re, a n d i ts b ro ken e n d m ay i n ju r e in t er n al o rg an s s u c h as a
lu n g an d / or t h e s p l een . L ow er ri b fr ac t u res m a y t ear t h e d i ap h rag m a n d res u l t i n a d iap h ra g m at ic h e rn ia
(s e e Ch ap t er 2 ) . R i b f r ac t u res ar e p ai n f u l b ec au s e th e b r oke n pa rt s m ove du rin g re sp i rat i on , c o u gh i n g ,
lau gh i n g , an d s n eez i n g .
Flail Ch est

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M u l ti pl e ri b fr ac t u res m a y al lo w a s i z ab l e s eg m en t of t h e an t er io r an d / or l at er al t h o rac i c w al l t o m o ve
f re ely . Th e lo os e s e gm en t of th e w al l m ove s p a rad o xic a ll y ( in w ard on i n s p ira ti on a n d o u t w ar d o n
e xp ira ti on ) . F l ail c h es t (s t ov e- in c h es t ) is an e xt rem e ly p ai n f u l i n ju r y an d im pa ir s v en t il at io n , th e reb y
a f fe c ti n g oxy ge n at io n of t h e b lo od . D u rin g t rea tm e n t, t h e l oo s e s eg m e n t i s o f t en f ixe d b y h o ok s a n d /o r
w ire s so t h at i t c a n n ot m o ve.
Th orac otomy , I ntercost al Sp ace In cision s, Rib Excision , an d B one Gr afti ng

T h e s u rg i c al c r eat io n of a n o p en i n g t h ro u g h th e t h o rac i c w al l t o en ter a p le u ral ca vi ty i s a t h ora c ot o m y
( F ig . B 1 .1 ) .
Fi gu re B 1. 1
A n an t er io r th o ra c ot om y m ay i n vo lve m ak in g H - s h ap ed c u ts t h ro u g h t h e p er ic h o n d riu m o f on e o r m o re
c o s ta l c ar ti la g es an d t h en s h ell in g o u t s e gm en t s o f c os t al ca rt il ag e t o g ai n en t ran c e to th e th o rac i c c avi ty
( F ig 1 .1 6 ) . T h e p os t er ol at era l as p ec t s of t h e 5 t h 7 t h in t erc o s ta l s p ac e s are i m p or ta n t s i te s fo r
p o s te rio r t h ora c ot om y in c i s io n s . In ge n era l, a lat er al a p pr oa c h i s m o s t s at i sf a c to ry f o r en t ry i n to th e
t h or ac i c c a g e. W i th t h e p at i en t l yi n g o n th e c on t ral at er al s i d e, t h e u p pe r li m b is f u ll y ab d u c t ed , p lac i n g
t h e f o rea rm b eh in d t h e p at ie n t' s h ead . T h is el ev at es an d la te ral ly r ot at es t h e in f e rio r an g l e of s c a pu l a,
a ll ow in g ac c es s a s h i g h as t h e 4 th i n te rc o st a l s p ac e. S u r ge on s u s e a n H -s h a p ed in c i s io n t o in c is e th e
s u p er fi c ia l a s pe c t o f t h e p er io s te u m th a t e n s h eat h s t h e rib , s t ri p t h e p er io s teu m fr om t h e ri b , an d th e n
re m o ve a w id e s eg m en t o f th e rib t o g ai n be tt er a c c es s , as m ig h t b e r eq u ire d to en t er t h e t h ora c ic c av it y

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a n d r em o ve a l u n g (p n e u m on e c to m y) , f or e xam p le. In t h e ri b 's ab s en c e , en t ry i n to th e t h o rac i c c avi ty

c a n be m ad e t h ro u gh t h e d ee p a s p ec t o f th e pe rio s t eal s h eat h , s p ari n g th e a d ja c en t in t erc o s ta l m u s c l es .
A f t er t h e o pe rat io n , t h e m i ss i n g pi ec e s o f rib s re ge n era te fr om t h e i n ta c t p er io s te u m , al th o u g h
i m p erf e ct l y. S om eti m es s u r ge on s u s e a pi ec e o f rib s o r em o ved f or au t og en o u s b on e g ra f ti n g i n
p ro c ed u re s s u c h a s r ec o n s tru c t io n of t h e m a n d ib le ( l ow er j aw ) a f ter tu m o r ex c is i on .
S upern um erary Ribs

P eo pl e u s u al ly h ave 1 2 r ib s on e ac h s id e, b u t th e n u m b er i s i n c rea s ed b y th e pr es en c e o f c erv ic al an d / or
l u m b ar r ib s , or d e c rea s ed by f a il u re o f t h e 1 2 t h p ai r to f or m (s e e Ch ap t er 4 f o r d et ai ls ) . Cerv ic a l ri bs a re
re la ti vel y c o m m on ( 0 .5 2 % ), b u t lu m ba r ri bs a re l es s c om m on . Ce rvi c al r ib s m ay in t erf er e w i th
n e u rov as c u la r s t ru c tu r es exi t in g th e s u pe rio r t h or ac ic a pe rt u re ( S ee T h or ac i c O u t le t S yn d ro m e s, i n
Ch a p te r 6 .) Su pe rn u m er a ry ( e xtr a) rib s a ls o h a ve c l in i c al s i g n if ic a n c e in t h at t h ey m a y c on f u s e t h e
i d en t if ic a ti on o f vert eb ra l l eve ls in ra d io g rap h s an d o th e r di ag n o s ti c im a g es .
Prot ect ive Fu nct ion an d Agin g of Cost al Cart ilages

Co s t al c a rt il ag es p ro vid e r es il ie n c e to th e th o ra c ic c ag e, p re ven t in g m a n y b lo w s f ro m f rac t u ri n g t h e
s t ern u m an d / or ri b s . B ec au s e of th e rem a rka b le e las t i c it y of t h e ri bs a n d c o s t al c a rt il ag es in c h i ld re n ,
c h e s t c o m p res s i on m a y p rod u c e i n j u ry w i th i n th e th o rax eve n i n th e ab s en c e o f a ri b f ra c tu r e. In el d erl y
p eo p le , th e c o s ta l c a rt ila g es lo s e s o m e of t h ei r el as t ic i ty a n d b e c om e br it tl e; th e y m ay u n de rg o
c a lc i fi c at io n , m a kin g t h em ra d io pa q u e ( e.g ., in ra d io g rap h s ) .
P .8 0
P .8 1
Thor ac ic Ve rte brae

T ho r ac ic v er te br ae are ty pi c al vert eb ra e i n t h a t t h ey a re i n de pe n d en t , h ave b o d ies , v ert eb ra l ar c h es ,
an d s ev en p roc e s s es f or m u s c u l ar a n d art ic u l ar c o n n ec t io n s (F i g s . 1 .4 an d 1 .5 ) . Ch ar ac t eri s ti c fe at u res o f
t h ora c ic ve rte b rae i n c lu d e
B il at era l c os t al f ac et s ( de m if a c et s ) o n th e ir b o di es , u s u a ll y oc c u rr in g in i n f eri or a n d s u p er io r p ai rs ,
f or a rti c u la ti on w it h th e h ead s o f r ib s .
Cos t al f ac et s on t h ei r tr an s ve rs e p ro c es s es f or art ic u l at io n w i th t h e t u be rc l es of ri b s, e xc ep t f or t h e
in f er io r tw o o r th r ee t h or ac i c v ert eb ra e.
Lo n g , in f er io rly s l an t in g s p in o u s p roc e s s es .
S u p er i or a n d i n f eri or co s t al f a c et s , m os t of w h i c h ac t u al ly o c c u r in t h e f o rm of de m if ace t s, m a ke u p on l y
a p o rti on o f a c om po u n d art ic u l ar s u r f ac e. T h ey o c c u r as b i lat er al ly p ai red , p l an ar s u r f ac es o n th e
s u p eri or a n d in f eri or po s t ero la te ral m arg i n s of ty p ic al (T 2 T9 ) t h ora c ic ve rt eb rae . F u n c ti on a ll y, th e
f ac et s ar e arr an g ed in p a irs o n ad j ac en t ver te br ae, f l an ki n g an in t er po s ed IV d is c : an in f e rio r ( d em i )f a c et
of t h e s u p eri or vert eb ra an d a s u p eri or (d em i) f ac e t o f t h e i n f eri or ve rt eb ra . T yp i c al ly, t w o d em i fa c et s
p ai red in t h is m a n n er a n d t h e p o s te rol at era l m a rg in o f th e I V d i s c b e tw een t h em f o rm a s i n g le s o c ket to
rec e ive th e h ead o f t h e ri b th a t i s a s s ig n ed t h e s am e n u m b er a s th e i n f eri or v ert eb ra . A ty pi c al th o rac i c
ver te b rae b e ar w h o le c os t al fa c et s in p la c e of d em i f ac e ts :
Th e s u pe rio r c o s ta l f ac et s o f v ert eb ra T 1 ar e n ot d em i f ac et s b ec au s e th e re ar e n o d em if ac e ts o n th e
C7 ver te br a ab o ve, a n d r ib 1 art i cu l at es o n ly w it h ver te br a T 1 . T1 h a s a ty p ic al in f er io r c os t al
(d e m i) f ac e t.
T1 0 h a s on l y on e b i la te ral pa ir o f ( w h ol e) c os t al f ac et s , lo c at ed p art l y on i ts b od y a n d pa rt ly o n it s
pe d ic l e .
T1 1 a n d T 1 2 a ls o h a ve o n ly a s in g le pa ir o f ( w h ol e) c os t al f ac et s , lo c at ed o n t h ei r p ed ic l es .
T h e s p in o u s p r oc es s e s p ro j ec t in g f ro m th e v ert eb ra l a rc h es of t yp ic a l t h or ac ic v ert eb ra e are lo n g a n d

s lo p e in f e rio rl y, u s u al ly o ver lap p i n g t h e ve rt eb ra b el ow ( Fi g . 1 .4 D) . T h ey c o ver t h e i n te rva ls b et w e en th e
l am i na e o f ad j ac en t ver te br ae, t h er eb y p rev en ti n g s h arp o bj ec t s s u c h as a kn if e f ro m en t eri n g th e
ver te br al c a n al an d in j u ri n g t h e s p i n al c o rd . T h e su per i o r ar t ic ul ar fac et s o f t h e s upe ri o r a rt i cu la r
pr o ces se s f ac e m a in l y p os t eri or ly a n d s l ig h t ly l at era ll y, w h e rea s th e i n fer i o r ar t ic ul ar fa cet s o f th e
i nfe ri o r a rt i cu la r pr o ce sse s f ac e m ain ly a n te rio rly an d s li gh t l y m ed i all y. T h e b il at era l j oi n t p l an e s
b et w ee n th e r es p ec t ive art ic u l ar f a c et s of th e ad j ac en t ver te br ae d e sc r ib e a n a rc , c en t er in g on a n axi s o f

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ro t at io n w it h i n th e v ert eb ra l b od y ( F ig . 1 .4A C) . Th u s s m a ll rot at o ry m o vem en ts a re p er m it t ed

b et w e en ad j ac e n t ve rt eb ra, b u t th e y ar e li m it ed b y t h e at t ac h ed ri b c a g e.
P .8 2
Fi gu re 1 . 4. T ho r a cic v er t ebr a e. A. T 1 h as a vert eb ra l f o ram en an d b od y s i m il ar t o a c ervi c al

ve r te br a . B . T 5 T 9 ve rt eb rae h ave t yp i c al c h a rac t er is t ic s o f t h or ac i c v ert eb ra e. C . T1 2 h a s bo n y
p roc e s s es an d a b o dy s iz e s i m il ar t o a lu m b a r ver te br a. T h e p la n es of t h e ar ti c u la r f ac et s of t h or ac ic
ver te br ae d e fi n e an a rc ( red ar row s ) t h at c en t ers o n an ax is t rav ers i n g t h e ve rt eb ral b od ie s
ver ti c al ly. D . S u p eri or a n d i n f eri or c os t al f a c et s ( d em if ac e ts ) on t h e ve rt eb ral b od y, c o s ta l f ac e ts o n
t h e tr an s ve rs e p ro c es s es , a n d l on g s lo p in g s p in o u s pr oc es s e s are c h a rac t er is t ic o f t h o rac i c
ve r te br ae .
Fi gu re 1 . 5. C o st o ve rt e bra l a rt i cu la t io n s o f a t ypi ca l r i b. Th e c os t ov ert eb ra l j oi n ts i n c lu d e t h e

j oi n t o f h e ad of ri b , in w h i c h th e h ead ar ti c u la te s w it h t w o a d ja c en t vert eb ra l b o di es an d t h e
in t er vert eb ra l d i sc b et w e en t h em , a n d t h e c o s to tr an s ve rs e j oi n t, i n w h i c h th e t u b erc l e o f t h e ri b
ar ti c u la tes w it h th e tra n s ver s e p roc e s s of a ve rt eb ra. T h e r ib m ov es ( ele vat es a n d d e pr es s es ) aro u n d
an a xis t h at tr ave rs es t h e h ea d a n d n e c k of t h e ri b ( a rro w s ) .

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P .8 3
The Ste rnum

T h e st e rn u m ( G. s t ern o n , c h es t ) i s th e fl at , el on g a te d b o n e th a t f o rm s t h e m i dd l e o f t h e a n te rio r p art of
t h e t h or ac ic c a ge (F i g . 1 .6 ) . Th e s t er n u m c on s i s ts o f t h re e p art s : m an u b ri u m , b od y, a n d x ip h o id p roc e s s .
T h e m a nub ri u m ( L. h a n d le, a s in t h e h an d l e of a s w or d, t h e s t ern a l b od y f o rm i n g t h e b l ad e) is a r ou g h l y
t ra pe z oi d al b o n e. T h e m a n u br iu m i s th e w id es t an d t h ic ke s t o f t h e t h re e p art s of t h e s te rn u m . T h e ea s il y
p al p at ed c on c a ve c en ter of t h e s u p eri or b o rd er o f t h e m a n u b riu m is t h e j ugu la r n o tc h ( sup ra st e rn al
n o tc h) . T h e n ot c h is d ee pe n ed in a n a rt ic u l at ed s kel et on ( an d in l if e ) b y t h e m ed i al (s t ern a l) en d s o f t h e
c l avi c le s , w h ic h a re m u c h l arg er th a n th e r ela ti ve ly s m a ll cla v i cu la r n o t ch e s in t h e m a n u b riu m t h a t
re c ei ve t h em , f o rm i n g t h e s t ern o c la vic u l ar ( S C) j oi n ts . In f e rol at era l t o t h e c l avi c u la r n ot c h , th e c os t al
c a rt ila g e of t h e 1 s t rib is t ig h t ly at ta c h ed to th e lat er al b o rd er o f th e m an u b ri u m t h e s yn c h o n d ros i s of
t h e f ir s t ri b (F i g . 1 .1 A ). T h e m an u b riu m an d b od y o f t h e s t ern u m l ie in s li g h tl y d if f er en t p l an es s u p er io r
a n d i n f eri or t o t h ei r j u n c ti on , t h e m a nu bri o st e rn al j o in t ( F ig . 1 .6 A & B ) ; h e n c e, th e ir j u n c t io n f orm s a
p ro j ec t in g st er na l a ng le ( of L ou i s) .
T h e b o d y of t h e s t ern u m , w h ic h i s l on g e r, n arr ow er, a n d t h in n e r t h an th e m an u b ri u m , i s l oc a te d a t t h e
l eve l o f t h e T 5 T 9 ver te br ae ( F ig . 1 .6 A C) . Its w id t h v ari es b ec a u s e of t h e s c al lo p in g of it s la te ral
b o rd ers b y t h e co st a l n o tc he s. In yo u n g p e op le , f ou r s t ern e b ra e ( p ri m or d ial s eg m en t s of t h e s t ern u m )
a re o bv io u s . Th e s te rn eb ra e art i c u lat e w it h eac h o th e r at p rim ary c a rt il ag in o u s jo in t s ( s te rn al
s yn c h o n d ro s es) . Th e s e jo i n ts b eg in t o f u s e f r om t h e i n fe rio r en d b et w e en p u b ert y ( s exu a l m a tu ri t y) a n d
a ge 2 5 . Th e n ear ly f l at an t eri or s u r fa c e o f t h e b o dy o f th e s te rn u m is m a rke d i n ad u lt s b y t h ree v ari ab le
t r an sve rs e ri dg es ( F i g. 1 .6 A) , w h ic h rep r es en t th e lin e s of f u s io n (s y n os t os i s ) o f it s fo u r o rig i n al ly
s e pa rat e s t ern e b rae .
T h e x i pho i d pr o ces s, t h e s m al le s t an d m o s t v ari ab l e p art of t h e s te rn u m , i s th i n an d el on g at ed . It li es
a t t h e l evel of T 1 0 ver te br a. A lt h o u gh o f te n po in t ed , t h e p ro c es s m ay be bl u n t, b i f id , c u rve d , or d ef l ec t ed
t o o n e s id e or a n te rio rl y. It i s c art il ag i n ou s i n y ou n g p eo pl e b u t m ore or l es s os s i f ie d i n ad u lt s ol d er t h an
a ge 4 0 . In el de rly pe op l e, t h e xip h o id p ro c es s m ay f u s e w it h t h e s te rn al b od y.
T h e xi p h oi d p ro c es s i s a n im p o rt an t lan dm ark i n th e m ed ia n pl an e be c au s e
It s ju n c t io n w i th t h e s t ern a l b od y a t t h e x i phi st e rn al jo i n t i n d ic at es t h e in fe rio r l im i t o f th e c e n tr al

p art o f t h e t h or ac ic c a vit y p ro je c te d o n t o t h e an t er io r b od y w a ll ; t h is j o in t is al s o t h e s it e o f th e
i nfr as t er na l a ngl e (s u b c o s ta l an g l e) of t h e in f e rio r t h ora c ic ap e rt u re ( F ig . 1 .1 ) .
It is a m i d li n e m a rker f o r t h e s u p eri or l im it of th e li ver, t h e c e n tra l t en d o n o f th e di ap h ra g m , an d

t h e in f e rio r b or de r of t h e h ea rt .

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Fi gu re 1 . 6. St e rn um . A. T h e f el t -l ik e c ove ri n g o f th e s t er n u m f or m ed as t h e t h in , b ro ad
m em br an o u s b a n d s o f th e rad i at e s te rn oc o s t al l ig a m en t s pa s s fr om t h e c o s ta l c ar ti la g es to th e
an t er io r an d p os t eri or s u r f ac es o f t h e s t ern u m is s h o w n o n t h e u p p er r ig h t s i d e. B . O b s er ve t h e
t h ic kn e s s o f th e s u p e rio r t h ird o f t h e m a n u b riu m b e tw een t h e c l avi c u la r n ot c h es . C . Th e rel at io n s h ip
of t h e s t ern u m t o t h e ve rt eb ra l c ol u m n is s h o w n .
P .8 4
Ossified X iph oid Proc esses

Ma n y p eo p le i n th e ir ea rl y 4 0 s s u dd e n ly b ec o m e a w ar e of t h ei r p art ly os s if i ed xi ph o id p ro c es s an d
c on s u l t t h ei r ph y s ic i an ab o u t t h e h ar d l u m p in t h e p it of t h eir s to m ac h ( ep ig a s tr ic f os s a). N e ver
h avi n g b e en aw are of th e ir x ip h oi d pr oc e ss b ef o re, t h ey fe ar t h ey h a ve d ev elo p ed a t u m o r, s u c h as
s t o m ac h c an c e r.
St ern al Fractu res

Des p i te th e s u b c u t an e ou s lo c at io n of t h e s t ern u m , s t er n al f ra c t u res ar e n ot c om m on . Cr u s h in j u ri es c an
oc c u r a ft er tra u m a ti c c o m p re s s io n o f th e th o rac i c w al l i n au t om o b il e ac c i d en t s w h en t h e d riv er' s c h e s t i s
fo rc e d i n to th e s te eri n g c o lu m n , fo r ex am p l e. T h e in s t al la ti on a n d u s e o f ai r b ag s in ve h ic l es h as re du c e d
th e n u m b er of s t ern a l f ra c tu r es . A f rac t u re o f th e s t er n al b o d y is u s u al ly a c om m in u t ed f rac t u re ( t h e
s te rn u m is b ro ken i n to s eve ral p iec e s ). D is p l ac em e n t o f th e b o n e f ra gm en t s i s u n c om m on b ec a u s e th e
s te rn u m is i n ves t ed b y d eep f as c i a ( f ib ro u s c on t in u i ti es of ra d ia te s t er n oc o s ta l l ig am e n ts ; F ig . 1 .6A ) an d
th e s t er n al a tt a c h m en t of t h e p ec to ra li s m aj or m u s c les . T h e m o s t co m m o n s it e o f s t er n al f ra c t u re is a t
th e s t er n al a n g le, a f te r th e m an u b ri os t er n al j o in t h as f u s ed in el d erl y p eo pl e, re s u lt in g i n d i s lo c at io n of
th e ( re - es ta b li s h ed ) m an u b ri os t ern a l j oi n t.
In s te rn al in j u ri es , th e c on c er n is n ot p ri m ari ly f o r t h e f rac t u re i t s elf b u t f o r t h e li kel ih o od o f h e art in j u ry
(m yoc a rd ia l c o n tu s i on , c a rd iac r u pt u re , ta m p on a de ) o r p u lm on a ry in j u ry . Th e m or ta li ty ( d ea th ra te )
as s oc i at ed w i t h s t er n al f ra c t u res is re p ort ed a s 2 5 4 5 % , la rg el y ow in g t o t h es e u n d er lyi n g i n j u rie s . A ll
pa ti en t s w i th s t ern a l c o n tu s i on s h o u ld b e eva lu a te d f o r u n d erl yi n g v is c er al i n ju ry ( R os e n , 1 9 9 8 ) .
Med ian S ter not omy

To g ain a c c es s to th e th o ra c ic c avi t y f or s u rg i c al o p era ti on s i n th e m ed ia s ti n u m f o r ex am p le , f or
c oro n ar y art er y by p as s g raf t in g t h e s t ern u m i s d ivi d ed (s p l it ) i n th e m ed ia n p lan e an d ret ra c te d. T h e
fl ex ib il it y o f r ib s an d c os t al c art il ag es e n ab le s sp r ead i n g o f th e h a lv es of t h e s t ern u m . S t ern a l s p li t ti n g
als o g ive s go od e xp os u re fo r re m ov al o f tu m ors i n th e s u p e rio r lo b es of t h e l u n gs . A f t er s u rg e ry, t h e
h al ves of t h e s t ern u m a re j oi n ed ( e.g ., w i t h w ir e s u tu r es ) .
St ern al Biop sy
Th e st er n al b o d y is o f ten u s e d f o r b on e m arr ow n e ed le bi op s y b ec a u s e o f i ts b re ad t h a n d su b c u t an e ou s
po s it i on . T h e n ee dl e p ie rc es t h e t h in c or ti c al bo n e a n d e n te rs th e vas c u l ar t rab e c u lar (c a n c ell ou s ) b on e .
S te rn al bi op s y i s c om m on l y u s ed to ob t ai n s p e c im e n s o f m ar row fo r t ran s p l an t at io n an d f or d e te ct i on o f
m et as t at ic c a n c er an d b lo od d ys c ra s ia s ( a bn o rm a li ti es ) .
St ern al Anomalies
Th e ca rt il ag in o u s h al ves o f t h e s t ern u m of t h e f et u s ( s t ern a l p la te s ) m ay n o t f u s e b ec a u s e of d ef e c ti ve
os s i fi c at io n . Co m p let e s t er n al c l ef t i s u n c om m on . S t ern a l c l ef ts i n vol vi n g t h e m a n u b riu m an d s u pe ri or
h al f o f th e b o d y are V - o r U -s h a p ed an d c an b e re pa ir ed du r in g in f a n c y b y di re ct ap p o s it io n an d f ixa ti on
of t h e c art il ag i n ou s s t ern a l h al ve s.
S om e ti m es t h ere is a p er fo ra ti on ( s te rn al f ora m en ) i n t h e s t ern a l b o dy be c au s e o f in c o m p let e f u s i on of
th e f e ta l s t ern a l p la te s . It i s n ot c li n ic al ly si g n if i c an t ; h o w e ver, o n e s h o u ld b e aw are o f it s p os s ib l e
pr es en c e s o th a t i t w il l n o t b e m i s in t er pr et ed on a m ed ic a l im ag e o f t h e t h or ax a s a b u lle t w ou n d .
A lt h ou g h t h e xi ph o id p ro c es s is c o m m on ly p er fo ra te d i n eld e rly p e rs on s b ec a u s e of a ge -r ela t ed c h an g es ,
th i s pe rf or at io n is n ot c li n ic a ll y s ig n i fi c an t . S im ila rl y, a p ro tr u di n g xip h o id p roc e s s in in f a n ts i s n ot
u n u s u al; w h en it oc c u rs , i t u s u a ll y d oe s n o t r eq u ir e c or rec t io n .
The Bot tom Line

Th e fu n c t io n s of t h e t h ora c ic w all are to p rot ec t th e c on t en t s of t h e th o ra c ic c avi t y; t o pr ovi d e t h e
m ec h a n ic s f or b re at h in g ; an d t o p ro vid e f o r at t ac h m en t o f n e c k, b ac k, u p p er l im b a n d a b do m i n al
m u s c u la tu r e. It s d o m ed s h ap e e n d ow s t h e t h or ac i c c a g e w i th t h e n ec e s s ary s t re n gt h , an d i ts l ig h t ,
rel at ive ly f l exi b le o s te oc a rt ila g in o u s ele m en t s an d j oi n ts en a b le t h e f l exi bi li t y n ec es s a ry es p ec i al ly f o r
res p ir at io n . Po s te rio rl y, t h e th o ra c ic c ag e c o n s is t s of a c o lu m n o f 1 2 th o rac i c ver te br ae a n d i n te rp os e d I V

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d i s cs . L at er al ly a n d a n te rio rl y, it c on s i s ts o f 1 2 rib s , m o s t c o n ti n u ou s w it h a c os t al c art i lag e a n t eri orl y

t h at art i c u lat es d i rec t ly o r in di rec t ly w it h t h e s te rn u m . T h e ri b s , th e i n t erc o s ta l s p ac e s b e tw een t h em ,
a n d v ert ic a l l in es ex tr ap ol at ed f ro m vis i b le o r p al p ab le s t ru c t u re s p ro vi d e a g ri d f o r p rec i s ely lo ca t in g
re la te d s t ru c t u res o r p at h ol og i es .
Thorac ic Ap e rtures
W h i le th e t h o rac i c ca g e p ro vid es a co m p l et e w a ll p er ip h er al ly, i t i s op en s u p eri or ly a n d i n f eri or ly. T h e
m u c h s m a lle r s u p eri or o p en i n g i s a p as s ag e w ay th a t a ll ow s c o m m u n i c at io n w it h t h e n ec k a n d u p p er lim b.
T h e la rg er i n f eri or o p en in g p ro vid e s t h e r in g - li ke o rig i n o f th e di ap h ra g m , w h i c h co m p l et ely o c c lu d e s t h e
op e n in g , an d t h e exc u r s io n s o f w h i c h p r im a ril y c on t ro l t h e vo lu m e/ in t ern a l p re ss u r e of t h e t h ora c ic
c av it y, p rov id in g t h e b as i s fo r t id al res p i rat io n .
P .8 5
Supe rior Thoracic Ap erture

T h e su per i o r t ho r aci c a per t ur e, t h e a n at om i c al th o rac i c in l et , is b ou n d ed a s f o ll ow s ( F i g. 1 . 7 ):
Po s te rio rl y, b y ver te br a T 1 (p ro t ru d in g or c o n ve x po s t eri or b o u n d ary/ l an d m a rk) .
La te ral ly, b y t h e 1 s t p ai r of ri bs a n d t h ei r c o st a l c ar ti la ge s .
A n te rio rl y, b y th e s u pe rio r b or de r of t h e m a n u b riu m ( a n ter io r la n d m ark ).
S tr u c tu r es th a t p a s s b e tw een t h e t h ora c ic c av it y an d t h e n ec k t h ro u g h th e o b li q u e, ki dn e y- s h ap ed
s u p eri or t h o rac i c ap ert u re i n c lu d e t h e t ra c h ea, e s op h ag u s , n er ves , a n d v es s el s t h a t s u p p ly a n d d ra in t h e
h ea d, n e c k, an d u p p er l im b s . T h e ad u l t s u p er io r th o ra c ic ap er tu r e m ea s u res a pp ro xi m at el y 6 .5 c m
an t er op os t er io rly a n d 1 1 c m tr an s ver s ely . To vi s u ali z e t h e s iz e of t h is op e n in g , n ot e t h at it is s l ig h t ly
la rg er t h an n e c es s ary to al lo w th e pa s s ag e o f a 2 4 p i ec e o f lu m b er . B ec au s e o f th e ob li q u it y o f t h e 1 s t
p ai r of ri b s , t h e a p ert u re s l op es a n te roi n f eri or ly.
Infe rior Thoracic Ape rture

T h e in fe ri o r t ho r a cic a pe rt u re , th e a n at o m ic a l t h ora c ic o u tl et , is b ou n d ed a s f o ll ow s :
Po s te rio rl y, b y th e 1 2 th t h or ac i c v ert eb ra (p o s te rio r la n d m ar k) .
Po s te rol at era ll y, b y t h e 1 1 t h a n d 1 2 th p ai rs o f r ib s .

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Fi gur e 1 . 7. T ho r ac ic a pe rt ur es . Th e s u pe rio r t h ora c ic a pe rt u re i s t h e d oo rw ay b et w e en

th e t h o rac i c c avi ty a n d th e n e c k an d u p p er l im b . T h e in f e rio r t h ora c ic a pe rt u re ( th o ra c ic ou tl et )
pr ovi d es at t ac h m e n t f o r th e d i ap h ra g m , w h i c h p ro t ru d es u p w a rd so t h at u p p er ab d om i n al
vis c e ra re c eiv e p ro te ct i on f ro m th e th o rac i c c a g e. T h e c o n ti n u ou s c a rti la g in o u s b a r f or m ed b y
th e a rt ic u l at ed c art i lag e s o f th e 7 th 1 0 th ( f al s e) rib s m a kes u p th e c os t al m arg i n .
A n t ero la te ral ly, b y t h e j oi n ed c os t al c art i lag e s o f rib s 7 1 0 , fo rm i n g th e c o s t al m arg i n s.
A n t eri orl y, b y t h e xi ph i s t ern a l j oi n t ( an t er io r la n dm ark ).
T h e i n f eri or t h or ac i c a p ert u re i s m u c h m or e s p ac io u s th an th e s u pe ri or t h or ac ic a p ert u re a n d i s irr eg u la r

i n ou t li n e. It is al s o o b li qu e be c au s e t h e p o s ter io r th ora c ic w a ll is m u c h lo n g er t h an t h e an ter io r w a ll . In
c l os i n g t h e i n f eri or t h or ac i c a p ert u re, t h e d i ap h rag m s e p ara te s t h e t h or ac i c a n d a b d om i n al c avi ti es
a lm o s t c o m p le te ly. S t ru c t u res p as s i n g fr om o r t o t h e t h ora x f ro m th e a b d om e n p a s s th ro u g h op en i n g s
t h at tr ave rs e t h e d ia p h rag m ( e.g ., e so p h ag u s an d i n fe rio r ve n a c av a) , or p a s s p o s te rio r t o i t ( e.g .,
a ort a ).
J u s t a s th e s iz e o f th e t h o rac i c c avi ty ( o r it s c on t en t s ) is of t en o vere s ti m at ed , i ts i n f eri or e xte n t
( c or res p o n di n g to th e bo u n d ary be tw een t h or ac i c a n d ab d om i n al c avi ti es ) is o ft en i n c or rec t ly e s ti m at ed
b ec a u s e of t h e d is c r ep an c y b et w e en t h e in f er io r t h ora c ic ap e rtu r e an d t h e lo c at io n of t h e d ia ph rag m ( th e
f l oo r of t h e t h ora c ic c av it y) in l ivi n g p e rs on s . A l th o u g h th e d i ap h ra gm ta kes o rig i n f r om t h e s t ru c t u res
t h at m ak e u p th e i n f eri or th o rac i c ap ert u re , th e do m es o f th e d i ap h ra gm ris e t o t h e l eve l o f t h e 4 t h
i n te rc os t al s p ac e, a n d a b do m i n al v is c er al , in c lu d i n g t h e l arg e l iv er, s p l een , a n d s t om ac h , li e s u p eri o r to
t h e p la n e o f t h e i n f eri or t h or ac i c a p ert u re, w it h in t h e t h or ac ic w al l ( F ig . 1 .1 A & B ) .
Thoracic O ut let Sy ndr ome

A n at om i s ts r ef er t o t h e s u p eri or th o rac i c ap er tu re as t h e th o ra c ic in l et be c au s e n o n - c irc u l at in g
s u bs t an c e s (a ir a n d f o od ) m ay en t er t h e t h ora x on l y t h rou g h t h is a pe rt u re. W h en c li n ic i an s re fe r to t h e
s u pe rio r t h or ac ic a pe rt u re a s t h e t h or ac i c o u t let , t h ey a re em p h a s iz i n g t h e a rt eri es an d T 1 sp i n al n erve s
th a t e m erg e f ro m t h e t h ora x t h rou g h t h is ap e rtu r e t o en t er t h e l ow er n ec k an d u p pe r li m b s . H en c e ,
var io u s t yp es o f th o rac i c ou t le t s yn d ro m e ( T O S ) e xis t in w h ic h em e rg in g s t ru c tu r es ar e af f ec t ed b y
ob s t ru c ti on s o f th e s u p e rio r t h ora c ic ap e rt u re ( R ow la n d , 2 0 0 0 ). A l th ou g h TO S i m p li es a t h ora c ic l oc a ti on ,
th e o b s tr u c ti on a c tu a ll y oc c u rs o u ts i d e t h e ap er tu re in t h e ro ot of t h e n ec k ( s ee Ch ap t er 8 ) , an d t h e
m an i f es t at io n s o f th e s yn d rom es in v ol ve t h e u p p er li m b ( s ee Ch a pt er 6 ).
The Bot tom Line

A lt h ou g h t h e th o ra c ic w a ll is c om pl et e p eri p h era ll y, t h e th o ra c ic c ag e i s op en s u p er io rly a n d in f eri or ly.
Th e su p e rio r t h ora c ic a pe rt u re i s a rel at iv ely s m all p as s ag e w ay fo r t h e t ran s m i t ta l of s t ru c t u res t o a n d
fr om t h e n e c k an d u p pe r li m b s , an d t h e in f er io r th o ra c ic ap e rtu r e p rov id es a r im t o w h ic h t h e d ia ph r ag m
is at t ac h ed .
P .8 6
Joints o f the Thoracic Wall

A l th o u g h m ov em en t s of t h e j oi n ts o f th e t h o rac i c w al l a re f req u e n t fo r ex am p l e, in a s s oc i at io n w it h
n o rm a l re s pi ra ti on t h e r an g e o f m ove m en t at th e i n d iv id u al jo in t s is re la ti vel y s m al l; n o n et h ele s s , an y
d i s tu rb a n c e th a t r ed u c es t h e m o bi li ty of th es e j oi n ts i n te rf ere s w it h re sp i rat i on . D u rin g d ee p b re at h in g ,
t h e ex c u rs io n s of t h e t h ora c ic c ag e ( a n te rio rl y, s u p eri orl y, o r la te ral ly) ar e c on s i d era b le. E x te n di n g th e
ve rt eb ra l c ol u m n f art h er in c re as es t h e an t er op o s ter io r ( A P) di am et er of t h e t h or ax. J oi n t s o f th e th o rac i c
w al l ( Ta b le 1 .1 ) o c c u r be tw ee n t h e
V ert eb r ae ( in t er vert eb ra l j o in t s ).
R i bs a n d v ert eb ra e ( c os t ov ert eb ra l j oi n ts : j oi n ts o f h e ad s of ri b s a n d c os t ot ra n s vers e jo in t s ) .
R i bs a n d c o s t al c a rt ila g es ( c os t oc h o n d ral jo in t s ) .
Co s ta l c ar ti la g es (i n t erc h o n d ral jo in t s ) .
S t ern u m a n d c o s ta l c a rt ila g es ( s te rn oc o s ta l j oi n t s ).

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l
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S t ern u m a n d c l avi c le (s t er n oc la vi c u lar jo in t s ) .

Pa rt s of t h e s te rn u m ( m an u b ri os t er n al a n d xip h i s te rn al jo in t s ) in yo u n g p e op le t h e
m a n u br io s te rn al (a n d so m e ti m es t h e xi ph i s t ern a l) jo in t u s u al ly f u s e s i n th e eld e rly .
T h e i n te rver te br al j o in t s b etw ee n t h e b o di es o f a d ja c en t vert eb ra e a re j oi n ed to g et h er b y l on g it u d in a l

l ig am en t s a n d in t erv ert eb ra l d is c s . T h es e j o in t s a re d i s c u s s ed w it h t h e b ac k i n C h ap t er 4 ; th e
s t ern o c la vi c u lar jo in t s are di s c u s s ed in Ch a p te r 6 . Th e m an u b ri os t er n al a n d x ip h is t er n al j o in t s w er e
d i s cu s s e d e arl ie r in t h is c h a pt er , w it h t h e s te rn u m .
Costover tebr al Joints

A t yp ic a l ri b a rt ic u l at es w i th t h e ve rt eb ral c ol u m n at tw o j oi n t s : t h e j oi n ts o f h ead s o f ri b s an d th e
c o s to t ran s ve rs e j oi n t s ( F i g. 1 . 8 ).
Joints of Heads of R ibs

T h e h ea d of ea c h t yp i c al r ib art i c u lat es w it h de m i fa c et s or c o s ta l f ac e ts o f t w o ad j ac e n t t h or ac ic
ve rt eb ra e (F i g . 1 .4 ) an d th e IV d i s c be tw een t h em . T h e h e ad art i c u lat es w it h th e su p e rio r p art o f t h e
c o rre s po n d in g ( s am e -n u m be red ) ver teb r a, t h e in f er io r p art of t h e ve rte b ra s u p er io r to it , an d t h e
a dj a c en t I V d i s c u n it in g th e tw o ve rt eb rae . F or e xam pl e, t h e h ea d o f th e 6 th ri b art ic u l at es w i t h t h e
s u p er io r p art of t h e b od y o f t h e T 6 ve rte b ra, t h e i n fe ri or p ar t o f T 5 , a n d t h e IV d is c b et w e en t h es e
ve rt eb ra e (F i g . 1 .8 ) . Th e c res t of th e h ead o f t h e r ib at ta c h es t o t h e IV d is c b y an i n tr a- art ic u l ar l ig a m en t
w it h in t h e j oi n t, d i vid i n g t h e e n c lo s ed sp a c e in t o t w o s yn o via l c a vit ie s . E xc ep t io n s t o th i s ge n era l
a rra n ge m en t of ar ti c u la ti on o c c u r w i th t h e h ea d s of th e 1 s t, s o m et im es th e 1 0 th , a n d u s u all y t h e 1 1 t h
a n d 1 2 t h ri b s ; t h ey a rt ic u la t e on l y w i th t h ei r ow n vert eb r al b o di es ( b od i es of t h e s am e n u m b er a s t h e
ri b ) . In th e se c as es n o in t ra- a rti c u la r li g am e n ts ex is t , an d t h e jo in t c av it ie s a re n o t d i vid e d.
A j oi n t c a p su l e s u rr ou n d s ea c h j o in t an d c on n e c ts t h e h ea d o f th e rib w i th t h e c i rc u m f er en c e o f t h e j oi n t
c a vit y. T h e f ib r ou s la yer of th e c ap s u le is s tr on g es t an t er io rly, w h ere it f orm s a ra di at e s te r no co s ta l
l i ga me nt t h at fa n s ou t f rom t h e a n te rio r m a rg in o f t h e h e ad of t h e ri b t o t h e s i d es of t h e b od ie s of t w o
ve rt eb ra e an d t h e IV di s c b et w ee n t h em . Th e h ead s o f t h e ri b s co n n ec t s o c l os el y t o t h e ve rte b ral bo d ie s
t h at on l y s li g h t g l id in g m o vem en t s o c c u r at t h e (d e m i) f ac e ts ( p ivo t in g aro u n d th e in t ra- a rti c u la r
l ig am en t ) o f th e j o in t s of t h e h ea ds o f r ib s ; h ow ever , eve n s l ig h t m ov em e n t h er e m a y pr od u c e a
re la ti vel y la rg e ex c u rs io n of t h e d is t al (s t er n al o r an t er io r) en d of a ri b .
Costotransverse Joints
T h e t u b erc l e of a t yp i c al r ib art i c u lat es w it h th e t ra n s ver s e c os t al fa c et on t h e an t er io r s u rf ac e o f th e en d
o f th e t ra n s vers e pr oc e s s o f it s ow n v ert eb ra (v ert eb ra o f th e s am e n u m be r) . Th e s e s m a ll s y n ovi al jo in t s
a re s u rr ou n d ed b y t h in j oi n t c a ps u l es t h at at ta c h to th e ed ge s of t h e art i c u lar fa c et s . A co s t o t ra nsv er se
l i ga me nt p as s i n g f ro m t h e n ec k o f th e r ib t o t h e tr an s ve rs e p ro c es s an d a l a te ra l c o st o tr a nsv er se
l i ga me nt p as s i n g f ro m t h e t u be rc le of t h e rib t o t h e t ip of t h e t ran s v ers e p ro c es s s t ren g t h en t h e an t eri or
a n d p o s te rio r as p e c ts o f t h e j oi n t , res p ec t iv ely . A s upe ri o r c o st o tr a nsv er se l i ga me nt is a br oa d b a n d
t h at j oi n s t h e c re s t o f th e n e c k of t h e ri b t o t h e t ra n s vers e pr oc e ss s u p er io r to it . T h e ap er tu r e b et w ee n
t h is l ig am en t a n d th e v ert eb ra pe rm i ts p as s a g e of t h e s p in a l n er ve an d t h e p os t er io r br an c h o f t h e
i n te rc os t al art er y. T h e s u p eri or c o s to t ran s v ers e l ig am en t m ay b e d i vid ed i n to a s t ron g a n ter io r
c o s to t ran s ve rs e l ig am en t a n d a w ea k p os t er io r c os t ot ra n s vers e li ga m en t . T h e s tr on g c os t o tra n s ver s e
l ig am en t s b i n d in g th e s e j oi n ts l im i t t h ei r m o vem e n ts t o s l ig h t gl id i n g. H ow ever , th e art ic u l ar s u rf a c es on
t h e t u b erc l es of t h e s u p eri or 6 r ib s are c on ve x an d f it in t o c o n c avi t ies o n th e t ra n s ver s e p roc e s s es ( Fi g .
1 .8 C ). A s a r es u lt , ro t at io n o c c u rs ar ou n d a m o s t ly t ran s v ers e a xi s t h a t t rav ers es t h e i n tr a- art ic u l ar
l ig am en t a n d th e h e ad an d n ec k o f th e rib ( F ig . 1 .8 A & B ). T h is r es u lt s in el ev at io n a n d de p res s i on
m o ve m en t s of t h e d is t al ( s t ern a l) en d s of t h e ri b s ( a n d t h e s t ern u m t o w h ic h t h ey a tt ac h ) in t h e s a gi t ta l
p l an e ( p u m p - h an d le m ove m en t ) (F i g . 1 .9 A & C) . F la t a rt ic u l ar s u rf a c es of t u b erc l es an d t ran s ve rs e
p ro c es s es o f th e 7 t h 1 0 th ri b s a ll ow gl id i n g h e re ( F ig . 1 .8 C ), re s u lt in g i n e le vat io n an d d ep res s i on o f
t h e l at era l- m o s t p or ti on s o f t h es e rib s in t h e t ra n sv ers e p l an e ( b u c ket - h an d l e m ov em e n t) ( F ig . 1 .9 B & C ).
T h e f l oat i n g 1 1 t h an d 1 2 t h rib s d o n o t a rt ic u l at e w i th t ra n s vers e pr oc es s e s an d h ave even f re er
m o ve m en t s as a re s u lt .
Costochondral Joints
T h e c o s to c h on d ra l a rti c u la ti on s a re h ya li n e c ar ti la gi n ou s j o in t s . E ac h ri b h a s a c u p -s h a p ed de p res s i on in
i ts s t ern a l en d i n to w h i c h t h e c o s ta l c a rti la g e f it s (T a bl e 1 .1 ) . T h e ri b a n d i t s c a rt il ag e ar e f irm ly b o u n d

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t og e th e r b y th e c o n t in u i ty o f th e pe rio s t eu m of t h e ri b w it h t h e p eri c h on d ri u m of t h e c ar ti la ge . N o
m o ve m en t n orm al ly o c c u rs at th e s e j oi n ts .
I nte rchondral Joints

T h e i n te rc h on d ra l j oi n t s ar ti c u la ti on s b et w e en th e ad j ac en t b ord e rs of t h e 6 t h a n d 7 th , 7 t h an d 8 t h ,
a n d 8 t h an d 9 t h c os t al ca rt il ag es are p l an e s y n ovi al jo in t s ( Ta bl e 1 .1 ) . E a ch o f
P .8 7
P .8 8
t h es e j o in t s u s u all y h a s a s yn ov ia l c av it y th a t i s en c lo s ed b y a j o in t ca p s u le. T h e j o in t s are s t re n gt h en e d
b y i n te rc h on d ra l l ig am en t s . Th e a rt ic u l at io n be tw een t h e 9 t h an d t h e 1 0 t h c o s t al c a rt il ag es is a fi b rou s
j o in t .
T abl e 1 . 1. J o in t s o f T h o ra ci c W al l
J o i nt
In t erve rt eb ral
Type
Ar t ic ul at i o n
L i ga m en t s
S ym p h ys i s
A dj ac e n t
A n te rio r an d
(s e c on d - ar y
vert eb ra l
p os t e ri or
c art il ag i n ou s )
bo d ie s b o u n d
lo n g it u d in al
C o m m en ts
to g et h er b y IV
di s c
Co st o ver t eb r al
Jo in t s of h ea d
of ri b
S yn ov ia l p la n e
jo in t
H ea d o f e ac h
R ad i at e an d
H ea d s o f 1 s t,
rib w i t h
in t ra- a rt ic u la r
1 1 t h , an d 1 2 t h
s u pe r io r
li ga m en t s of
ri bs
de m if a c et or
h ead o f r ib
( s om e ti m es
c os t al f a c et of
1 0 t h ) a rt c u lat e
c orr es p on d i n g
on l y w i t h
vert eb ra l b o dy
c or res p o n di n g
an d in f er io r
ver te b ral bo d y
de m if a c et or
c os t al f a c et of
vert eb ra l b o dy
s u pe rio r t o i t

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Cos t ot ra n s ver se
Page 16 of 139
A rti c u la ti on o f
La te ral an d
1 1 t h an d 1 2 th
tu b er c le o f rib
s u p er i or
ri bs d o n ot
w it h t ran s v ers e
c os t ot ra n s ver s e
ar ti c u la te w it h
pr oc es s o f
t r an s v e rs e
c orr es p on d i n g
p roc e s s of
ve rt e b r a
c or res p o n di n g
ve r te b ra e
Co st o c h on d r a l
Pr i m ar y
Car ti la ge an d
N o m ove m en t
c art il ag i n ou s
lat er al e n d o f
b on e b o u n d
n or m a l ly
jo in t
c os t al c a rt il ag e
to g et h er b y
oc c u r s a t t h i s
w it h s t ern a l
p e ri os t eu m
j oi n t
en d of ri b
In t erc h o n dr al
S yn ov ia l p la n e
A rti c u la ti on
In t erc h o n dr al
A rt ic u l at io n
jo in t
be tw een c o s ta l
li ga m en t s
b et w ee n c os t al
c art il ag es o f
c ar ti la ge s of
6 th a n d 7 t h ,
9 t h a n d 1 0 th
7 th a n d 8 t h ,
ri bs i s fi b ro u s
an d 8 th a n d
9 th ri b s
S te rn oc o s t a l
1 s t: p ri m ary
1 s t c o s ta l
jo in t
c art il ag es w it h
(s y n c h on d ro s is )
m an u b ri u m of
s te r n u m
2 n d 7 t h :
A n te rio r an d
s yn ov ia l p la n e
th e 2 n d 7 th
p os t e ri or
jo in t
pa ir s o f c os t al
ra d i at e
c art il ag es w it h
s te rn oc o s t al
s te r n u m
S te rn oc l a v ic u la r
M an u b ri os t ern a l
S ad d le t yp e o f
S ter n al en d of
A n te rio r an d
T h is j oi n t i s
s yn ov ia l j oi n t
c lav ic l e w i th
p os t e ri or
d ivi d ed in t o
m an u b ri u m of
s te rn oc l a v ic u la r
two
s te rn u m an d
li ga m en t s ;
c om pa rt m en t s
1 s t c o s ta l
c os t oc l a vi c u la r
b y an a rti c u la r
c a rt il ag e
li ga m en t
d is c
S e c on d a r y
A rti c u la ti on
be tw een
jo in t
m an u b ri u m an d
(s y m p h ys is )
bo d y of
T h is j oi n t o f te n
s te r n u m
f u s es an d
b ec o m es a
s yn o s to s is i n
X ip h i st er n al
Pr i m ar y
A rti c u la ti on
ol d er
be tw een
in d i vid u a ls
jo in t
xip h o id p roc e s s
(s y n c h on d ro s is )
an d b od y o f
s te r n u m

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Fi gu re 1 . 8 C o st o ve rt eb ra l j o i nt s. A a nd B . Th e li ga m en t s of t h e c os t o vert eb ra l a rt ic u la ti on s w it h
t ran s ve rs e a xes o f r ib rot a ti on ( as t eri s ks , d ot t ed li n es ) . C. Co n f or m at io n of ar ti c u la r s u rf ac e s ,
rev eal ed in s a g it ta l s ec t io n s of t h e c os t o tra n s ver s e j oi n ts , d em on s t rat es h o w t h e 1 s t 7 t h r ib s
ro ta te ab ou t an a xis t h at ru n s lo n g it u d in a lly th r ou g h th e n ec k o f t h e ri b to c h an g e t h or ac ic vo lu m e
f or r es p ira t io n ( l ef t) , w h ere as th e 8 th 1 0 th r ib s gl id e ( ri g h t) .
Ster noc ostal Joints

T h e 1 s t 7 t h rib s a rti c u la te th ro u g h th e ir c o s ta l c a rti la g es w i th t h e l at era l b or de rs of t h e s t ern u m ; in
m a t u re ad u l ts , t h e a rti c u la ti on s a re ( F ig . 1 .1 ; T ab le 1 .1 ) :
T h e 1 s t p a ir o f c art il ag es w it h th e m an u b ri u m on l y.
T h e 2 n d pa ir of c art i lag e s w it h th e m an u b ri u m an d b od y o f th e st er n u m ( i.e. , w it h c om po n en t s of

m a n u br io s te rn al jo in t ) .
T h e 3 rd 6 t h p ai rs of c ar ti la ge s w it h t h e b od y o f t h e s t er n u m .
T h e 7 t h p a ir o f c art il ag es w it h th e b o d y of t h e s t ern u m a n d t h e xi p h oi d p r oc es s ( i.e ., w i th t h e

c om p on en t s of t h e xi p h is t ern a l j oi n t) .
T h e 1 s t p air of c os t al c art il ag es a rt ic u l at es w i th t h e m a n u br iu m b y m e an s o f a th i n de n s e la yer of ti g h tl y

a dh e ren t f ib ro c ar ti la ge in t erp o s ed be tw een c a rt il ag e an d t h e m a n u br iu m , t h e sy nch o nd ro si s o f t he 1 st
r ib (W il li am s et al ., 1 9 9 5 ) . T h e 2 n d 7 t h pa ir s o f c os t al c art il ag es a rti c u la te w i th t h e s t ern u m a t
s yn o vi al j o in t s w i th f ib r oc ar ti la g in o u s a rt ic u l ar s u rf a c es on b o th t h e c h on d r al a n d s t er n al a s p ec t s,
a ll ow in g m ov em e n t d u ri n g r es p ira t io n . T h e w ea k jo in t c ap s u l es of t h es e j oi n t s a re r ein f o rc ed ( th i c ken e d )
a n te rio rl y an d p os t eri or ly t o f o rm r adi a t e st er no c o st al li ga m en t s. T h es e c o n ti n u e as t h in , b ro ad
m e m b ran o u s b an d s p as s in g f ro m t h e c os t al c art il ag es t o t h e a n te rio r an d p os t er io r s u rf ac es o f th e
s t ern u m , f orm i n g a f el t- l ike c o ve rin g f or t h i s b o n e ( F ig . 1 .6A ; Ta b le 1 .1 ).
P .8 9

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Fi gu re 1 . 9. M o ve me nt s o f t ho r ac ic w al l . A . W h e n th e u pp e r rib s ar e el eva te d, t h e A P di m en s i on
of t h e t h ora x is i n c rea s ed (p u m p- h a n dl e m o vem en t ), w it h a g rea te r exc u r s io n ( i n c rea s e) oc c u rr in g
in f e rio rl y, at th e en d of t h e p u m p h a n d le . B . Th e m id d l e p art s of t h e lo w e r rib s m o ve l at era ll y w h e n
t h ey ar e el eva te d, i n c rea s in g t h e tr an s ve rs e d im en s io n ( bu c k et -h a n d le m o ve m en t ) . C . T h e
c om bi n at io n of ri b m ov em en t s ( arr ow s ) t h at oc c u r d u ri n g fo rc ed i n s pi ra ti on i n c rea se th e AP an d
t ran s ve rs e d im en s io n s of t h e t h ora c ic c ag e . D. T h e t h ora x w i d en s d u rin g f o rc ed in s p i rat io n as t h e
ri bs a re el ev at ed (a rro w s ) . E . Th e th o rax n arr ow s d u ri n g exp ir at io n as t h e rib s a re d ep re ss e d
( arr ow s ) . F . T h e p ri m ar y m o vem e n t o f in s p ir at io n ( re s ti n g or f o rc ed ) is c on t ra c ti on o f th e
d ia ph r ag m , w h i c h in c re as e s t h e ve rt ic a l d im e n s io n of t h e th o ra c ic c avi t y (a rro w s ) . W h en th e
d ia ph r ag m re lax e s , d ec o m p res s i on o f t h e a bd o m in a l vi s c era p u s h es th e di ap h ra g m u p w ar d, r ed u c in g
t h e ver ti c al d i m en s i on f o r exp i rat io n .
P .9 0
Di slocation of Ribs
A r ib d is l oc at i on ( s li pp i n g r ib s yn d ro m e) is t h e d is p l ac em e n t o f a c os t al c art il ag e f r om t h e
s te rn u m d i s lo c at io n o f a s t ern o c os t al jo in t or th e d i s p lac e m en t of t h e in t er c h on d ra l j oi n ts . R i b
di s lo c at io n s are c om m on in b o dy -c o n t ac t s po rt s ; c o m p li c at io n s m ay r es u lt f ro m p res s u re on or da m ag e t o
n ear by n erve s , ves s el s , an d m u s c l es . Di s p lac e m en t of i n te rc h on d ra l j oi n t s u s u a ll y oc c u r s u n i la te ral ly an d
in vo lv es rib s 8 , 9 , a n d 1 0 . T ra u m a s u f f ic i en t to d is p la c e t h es e j oi n t s o f te n in j u res u n d er lyi n g s tru c t u re s

08-May-15
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s u c h as t h e d ia p h rag m a n d /o r li ver , c au s i n g s e vere pa in , p ar ti c u la rly du r in g d eep in s p i rat o ry m o vem e n ts .

T h e i n ju r y p rod u c es a lu m p - li ke d ef o rm i ty at t h e d i s pl ac e m en t s it e.
S eparati on of Rib s
R i b s ep ara ti on r ef ers t o d is l oc a ti on o f a c os t o c h on d ra l j u n c ti on b et w e en t h e rib a n d i ts c o s ta l c ar ti la g e. In
s e pa rat i on s of t h e 3 rd 1 0 th ri b s , te ari n g o f th e pe ric h o n d ri u m an d p eri os t eu m u s u a ll y oc c u rs . A s a
re s u lt , t h e rib m a y m o ve s u p eri or ly, o ve rri di n g th e r ib ab o ve an d c a u s in g p ain .
Mo vem ents of the Tho rac ic Wall

M ov em en t s of t h e t h ora c ic w all an d d ia ph r ag m d u ri n g i n s p ira ti on p ro d u c e in c re as e s i n th e in t rat h o rac i c
vo lu m e an d d iam et ers o f t h e t h or ax ( F ig . 1 .9 D & F ) . Co n s eq u en t pr es s u re c h a n g es res u l t i n ai r be in g
al te rn at el y d raw n in t o t h e l u n gs ( i n sp i rat i on ) th r ou g h t h e n os e , m ou t h , la ryn x , an d tr ac h ea an d exp el le d
f ro m th e l u n g s (e xp ir at io n ) t h ro u gh t h e s a m e p as s a ge s . Du ri n g pa s s iv e exp i rat io n , t h e d iap h r ag m ,
in t er c os t al m u s c les , a n d o t h er m u s c l es rel ax , de c rea s in g in t ra th o rac i c vo lu m e a n d in c re as in g t h e
in t ra th o ra ci c p res s u re (F i g . 1 .9 E & C ) . Co n c u rre n tl y, in t ra - ab d om i n al pr es s u re d e cr eas e s an d ab d om in al
vi s c era a re d ec o m p re ss e d . Th i s all ow s th e s tre tc h e d e la s ti c ti s s u e of t h e lu n g s t o re c oi l, ex p ell in g m o s t o f
t h e ai r.
T h e ver ti c al d i m en s i on ( h ei gh t) of t h e c en t ra l p art of t h e t h ora c ic c a vit y in cr eas e s du r in g in s p i rat io n as
c on t ra c ti on o f t h e d i ap h ra gm c a u s es it t o d es c en d , c o m p res s i n g t h e a b do m i n al v is c er a ( F ig . 1 .9 F ) . Du ri n g
exp i rat i on , t h e ver ti c al di m en s i on r et u rn s to th e n eu t ral po s it io n as t h e el as t ic re c oi l o f t h e l u n gs
p rod u c e s s u b - at m o s p h eri c p r es s u re i n th e p l eu ra l c av it ie s , be tw een t h e l u n gs a n d t h e t h o rac i c w al l. A s a
res u l t o f th i s an d th e ab s en c e o f res i s ta n c e to t h e p revi ou s l y c om p res s ed vi s c era , th e do m es o f th e
d ia ph r ag m as c e n d, d i m in i s h in g t h e ve rti c al di m en s i on . T h e A P di m en s i on o f th e t h o rax i n c rea s es
c on s i d era bl y w h e n th e in t erc o s ta l m u s c l es c on t ra c t: M ov em en t of t h e ri b s ( p ri m ar il y 2 n d 6 t h ) a t t h e
c os t o vert eb ra l j oi n t s a ro u n d a n axi s pa s s in g t h rou g h t h e n ec k s o f th e r ib s c au s e s t h e a n te rio r en d s o f t h e
ri bs t o r is e th e p u m p- h a n dl e m o vem en t ( F i g. 1 . 9 A & C ) . B ec a u s e th e rib s s lo p e in f e rio rl y, t h eir
el eva ti on a ls o r es u lt s in a n te rio r po s t eri or m o ve m en t of t h e s te rn u m , es p e c ial ly i t s i n f eri or en d , w i th
s li g h t m o vem en t oc c u rri n g at th e m an u b ri os t ern a l j oi n t i n yo u n g p eo p le , in w h o m it h as n o t y et
s y n o s to s ed .
T h e tr an s ve rs e d im en s io n of t h e t h ora x al s o i n c rea s es s li gh t l y w h en t h e i n te rc os t al m u s c le s c o n t rac t ,
ra is in g t h e m i d dl e ( la te ral - m os t p art s ) o f th e rib s ( es p ec i all y t h e lo w e r on e s ) th e bu c k et -h a n d le
m o vem e n t ( F ig . 1 .9 B & C ) . T h e c om b i n at io n of al l t h es e m ove m en t s m ov es t h e th o ra c ic c ag e a n te rio rl y,
s u p eri or ly, a n d l at era ll y ( F ig . 1 .9 C & F ).
Paralysis of th e Diaph ragm

P ara ly si s of h al f of t h e d ia ph r ag m ( on e d o m e o r h em i d ia ph r ag m ) b ec au s e o f in j u ry t o i t s m ot or s u p p l y
f ro m t h e p h ren i c n erve do es n o t a ff e c t t h e o th e r h al f b ec a u s e ea c h do m e h a s a s ep ar at e n er ve s u p p ly.
O n e c a n de te c t p ar al ys is o f t h e d ia p h rag m r ad io g rap h i c all y b y n o ti n g i ts p a rad o xic a l m o vem en t . In s te ad
o f de s c en d in g as i t n o rm a ll y w o u ld d u rin g i n sp i rat i on o w in g t o d ia p h rag m a ti c c on t ra c ti on ( F ig . B 1 .2 A ) ,
t h e p ar aly z ed d om e as c en d s as i t i s p u s h e d s u p er io rly by t h e a b do m i n al v is c er a t h at a re b e in g
c o m p res s e d b y t h e a ct i ve c o n tra la te ral d om e (F i g . B 1 .2B ). In st ea d of as c e n di n g du r in g exp i rat io n , t h e
p ar al yz ed d om e d es c en d s in re s p on s e t o t h e p os i t ive p r es s u re i n th e l u n g s .

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Fi gu re B 1. 2
Th e B ott om Lin e
T h e m o vem en t s of m o s t ri b s o c c u r ar ou n d a g en e ral ly t ra n s ver s e axi s th a t p a ss e s th r ou g h th e h ead ,
n e c k, an d t u be rc le . Th i s axi s , p lu s t h e s lo p e an d c u rva tu r e of t h e ri b s , res u l ts i n b u c ke t- h a n dl e- t yp e
m o ve m en t s th a t a lt er t h e t ran s v ers e d i am e te r of t h e th o ra x an d p u m p -h an d le -t yp e m o ve m en t s th a t a lt er
i ts A P d i am e te r. M os t im p o rt an t , h ow eve r, is c o n tr ac t io n a n d rel axa ti on o f th e s u p er io rly c on ve x
d i ap h rag m t h at al te rs it s ver ti c al di m en s i on s . In c r eas i n g di m en s i on s re s u lt in i n h ala t io n , an d de c rea s in g
d i m en s i on s p ro du c e exh a lat i on .
P .9 1
S urface An atomy of th e Th oracic Wal l S kelet on

T h e cl a vi cl es ( c o ll ar b on e s ) l ie su b c u t an e ou s l y, f or m in g b on y r id g es at t h e ju n ct i on o f t h e t h or ax a n d
n e c k (F i g . S A1 .1 ). T h ey c an b e p al pa te d eas i ly t h ro u g h ou t th e ir l en g th , e s p ec ia ll y w h e re t h eir m ed ia l
e n ds a rt ic u la t e w i th t h e m a n u br iu m o f th e s t er n u m . Th e c la vic l es d em a rc at e t h e s u p eri or d i vid e b e tw een
z o n es o f l ym p h at i c d ra in a g e: ab ov e th e c lav ic l es , ly m p h fl ow s u lt im a t ely t o i n f eri or ju g u l ar l ym p h n od es ;
b el ow th e m , p ari et al lym p h ( t h at fr om t h e b od y w al l an d u p p er l im b ) f lo w s t o t h e ax il lar y ly m p h n o d es .
T h e st e rn u m li es s u b c u ta n eo u s ly i n th e a n t eri or m e d ian l in e an d is p al p ab le t h ro u g h ou t it s le n gt h .
B e tw een t h e p ro m in e n c es of t h e m ed i al e n d s o f th e c lav ic l es at th e s te rn oc l avi c u la r j oi n ts , t h e j u g u l ar
n o tc h in t h e m a n u b riu m c a n b e p alp a te d b e tw een t h e p ro m in e n t m e di al en d s of t h e c la vic l es . T h e n o tc h
l ie s a t t h e l eve l of t h e in f e rio r b or d er of t h e b od y o f T2 v ert eb ra an d th e s p a c e b et w ee n th e 1 s t an d 2 n d
t h or ac i c s p i n ou s p ro c es s es .
T h e m a nub ri u m , a pp ro xi m at el y 4 c m lo n g , li es at th e lev el o f th e b o d ies o f T3 a n d T 4 ve rte b rae ( F i g.
S A 1 .2 ) . T h e st e rn al an gl e i s p a lp ab l e an d o ft en v is ib l e in y ou n g p eop l e b ec au se of t h e s li g h t m o vem en t
t h at oc c u r s a t t h e m a n u b rio s t ern a l j oi n t d u ri n g f o rc ed re s pi ra ti on . T h e s t ern a l an g l e li es at t h e le vel of
t h e T 4 T 5 IV d is c an d t h e s p ac e b et w e en t h e 3 rd an d 4 t h t h o rac i c s pi n ou s p ro c es s es . T h e s t ern a l a n gl e
m a rks t h e l evel of t h e 2 n d p air of c os t al c art il ag es . T h e l ef t si d e o f t h e m a n u b riu m i s an t eri or t o th e a rc h
o f th e a or ta , an d it s rig h t s id e d i rec t ly o ver li es th e m erg i n g o f th e br ac h i oc ep h a li c v ein s t o f o rm t h e
s upe ri o r v en a ca va (S V C) . B ec a u s e it is c o m m o n c li n ic al p rac t ic e to in s er t c at h et er s in t o t h e S V C f or
f ee d in g ext re m el y il l p at ie n ts a n d o th e r p u rp os e s (G er e t a l., 1 9 9 6 ) , i t i s e s s en t ial to kn o w t h e s u rf ac e
a n at om y of t h is la rg e ve in . T h e S V C p as s es i n f eri orl y d ee p t o t h e m a n u b riu m a n d m an u b ri os t ern a l
j u n c t io n bu t p roj e ct s as m u c h a s a f in g er br ead t h to th e rig h t of t h e m a rg in of t h e b on y s tru c t u re s . Th e
S V C e n ter s th e r ig h t at riu m o f th e h ear t o pp o s it e t h e ri gh t 3 rd c os t al c art i lag e .
T h e bo d y o f t h e st e rn um, ap p ro xim at ely 1 0 c m lo n g, l ie s an t eri or t o t h e ri g h t b o rd er o f t h e h e art an d
ve rt eb ra e T5 T 9 . Th e i n te rm a m ma r y cl eft ( m id l in e d ep r es s io n or c l ea vag e b et w e en t h e m at u re
f em al e b rea s ts ) ov erl ies t h e s t ern a l b od y. T h e x i pho i d pr o ce ss li es i n a s li gh t d ep re s si on , t h e
e pi ga st ri c fo ss a, w h ere t h e c o n ver gi n g co s t al m arg i n s f o rm t h e i nfr a st er na l a ng le . Th i s an g le is u s ed
i n c ard i op u lm on a ry res u s c i ta t io n ( CP R ) f or l oc a ti n g t h e p ro p er h a n d p o s it io n on t h e in f e rio r p art of t h e
s t ern a l b o dy . Yo u c an f ee l t h e xi ph is t er na l j o i nt, of t en s ee n as a ri d g e, at th e lev el o f th e i n f eri or
b o rd er o f T 9 ve rt eb ra.
T h e co s ta l m a rg in s, f or m ed b y t h e jo in e d co s t al c a rt il ag es o f t h e 7 t h 1 0 t h c os t al c art il ag es , a re e as il y
p al p ab le b ec au s e t h ey ext en d in f er ol at era ll y f rom th e x ip h is t er n al j o in t . Th e c os t al m arg i n s fo rm t h e

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s i d es of t h e in f ra s te rn al an g l e.
T h e r ib s an d i nt er co st a l s pac es p ro vi de a b as i s f o r lo c at i n g o r d es c ri b in g th e po s it io n of s t ru c t u res o r
s i te s o f tr au m a or p at h o lo g y on o r d eep t o t h e th o ra c ic w a ll , m u c h li ke l in es o f lat i tu d e a re u s ed i n
n a vig a ti on . F o r exa m p le , th e b e at o f th e m it ra l va lve of th e h ear t m a y b e h ea rd by pl ac i n g t h e
s t et h os c o p e in t h e i n te rc os t al s pa c e b et w e en th e 5 th a n d 6 t h ri bs i n f eri or t o t h e l ef t n i p p le. B e c au s e
t h e 1 s t rib i s n o t p a lp ab l e, ri b c o u n t in g in p h ys i c al e xam in at i on s s t art s w i th t h e 2 n d rib a dj a ce n t t o t h e
s u b c u t an eo u s an d ea s il y p alp a te d s t ern al a n g le.
Fi gu re S A1 . 1
Fi gu re S A1 . 2
T o c o u n t t h e ri b s an d in t erc o s t al s p a ce s an t eri or ly, s l id e t h e f in g e rs la te ral ly f ro m t h e s te rn al an g l e on t o

t h e 2 n d c os t al c art il ag e a n d be gi n c ou n t in g t h e ri b s a n d s pa c es b y m o vin g t h e d ig it s f ro m h ere . Th e 1 s t
i n te rc os t al s p ac e i s t h a t s u p eri or to th e 2 n d c o s ta l c a rti la g e t h at is , i n te rc os t al s p ac es a re n u m b er ed
a c c ord i n g t o t h e r ib f orm in g th e ir s u p er io r b ou n d ar y. G en era ll y, it is m ore rel iab l e t o c o u n t i n te rc os t al
s p ac e s , s in c e t h e f in g e rt ip te n d s t o r es t i n ( s lip i n to ) t h e g a ps b et w e en ri bs . O n e f i n g er s h o u ld rem ain i n
p l ac e w h ile an o th e r is u s ed t o l oc at e t h e n e xt s p a ce . U s in g al l t h e f in g er s , it is p os s i bl e t o l oc a te f o u r
s p ac e s at a ti m e. T h e s p a c es are w id e s t an t er ol at era ll y ( ap p rox im a te ly i n th e m id c la vi c u lar li n e) . If th e
f i n ge rs are rem o ve d f ro m t h e t h ora c ic w a ll w h i le c o u n ti n g s pa c es , t h e f in g er m ay e as il y b e re tu rn ed to
t h e s am e s p ac e, m is t aki n g i t f o r t h e on e be lo w . P os t eri or ly, t h e m e d ial en d of t h e s p in e o f th e sc a p u la

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o ver li es th e 4 th ri b .
W h il e t h e rib s a n d/ o r in t erc o s t al s p a c es p rov id e t h e la ti tu d e f o r n av ig at io n an d lo c al iz a ti on o n th e
t h or ac i c w al l, s ev era l im ag in a ry l in es f a c ili t at e an a to m i c al a n d c l in i c al de s c rip t io n s by pr ovi d in g
l on g it u d e. T h e f ol lo w i n g l in e s are e xt rap o la te d o ver th e t h o rac i c w al l b as e d o n vi si b le o r p al p ab le
s u p er fi c ia l f ea tu r es :
T h e a nt er i o r m edi a n (m i dst e rn al ) l in e ( A M L) i n di c at es t h e in t er s ec ti on o f th e m ed ia n pl an e w it h
t h e an t eri or th o rac i c w a ll ( F i g. S A 1 .3 A ) .
T h e m id cla vi cu l ar l i ne (M CL ) p as s es t h rou g h t h e m i d po in t of t h e c l avi c le, p a ral le l t o t h e A M L.
T h e a nt er i o r ax i l la ry l i ne (A A L ) ru n s ver ti c all y a lo n g t h e an ter io r ax ill ar y f ol d t h at is f o rm ed b y

t h e in f e rol at era l b o rd er o f t h e p ec t or al is m a jo r as i t s p an s f ro m t h e t h ora c ic c ag e t o t h e h u m eru s in
t h e ar m (F i g . SA 1 . 3 B ).
T h e m id ax i ll a ry l i ne (M A L ) r u n s f ro m t h e ap e x (d e ep es t pa rt ) o f th e a xi ll ary f o s s a, p ar all el to th e
A A L.
T h e po st e ri o r a x il l ar y l in e ( PA L ) , als o p ara ll el t o t h e A A L , is d ra w n ver ti c al ly a lo n g t h e p o s te rio r

ax il lar y f ol d f o rm e d b y t h e l at is s i m u s do rs i an d te res m a jo r m u s c l es as t h ey s p an f ro m t h e b ac k t o
t h e h u m er u s .
T h e po st e ri o r m e dia n ( mi dv er t ebr al ) l i ne (P M L) is a v ert ic a l l in e a lo n g t h e t ip s o f t h e s p in o u s

p ro c es s es o f t h e ve rt eb rae (F i g . SA 1 . 3C) .
T h e sca pu la r l i ne (S L ) is p ara ll el t o t h e p o s te rio r m ed i an l in e a n d i n te rs ec t s th e in f er io r an g le s of

t h e s c ap u la .
A d d it io n al li n es ( n ot il lu s t rat ed ) are ext ra po la te d a lo n g th e b o rd ers o f pa lp ab l e b on y f o rm a ti on s s u c h a s

t h e s t ern u m a n d vert eb ra l c o lu m n , s u c h a s t h e pa r as te rn a l a n d pa r av er t ebr al l in es ( G . p ar a , al on g s id e
o f , ad j ac en t to ) .
Fi gu re S A1 . 3
P .9 2
P .9 3
Musc le s o f the Thorac ic Wall

S eve ral u p pe r li m b (t h o r ac o ap p en d ic u l ar ) m u s c l es at t ac h t o t h e th ora c ic c ag e in c l u d in g th e pe c to ra lis
m a jo r, p ec t or ali s m in o r, s u b c la vi u s , an d s erra tu s a n te rio r m u s c l es an t er io rly a n d lat i ss i m u s d or s i m u s c le s
p os t eri or ly as d o t h e an t er ol at era l a bd o m in a l m u s c l es an d s o m e b ac k a n d n e c k m u s c le s (F i g . 1 .1 0 ) .
T h e th o ra c oa pp e n di c u la r m u s c le s u s u all y ac t o n t h e u p p er l im bs ( s ee C h ap t er 6 ) . B u t s e vera l, i n c lu d in g
t h e pe ct or a li s m aj o r an d pe ct o ra li s m i no r a n d th e i n f eri or p a rt o f th e ser r at us a n te ri o r m ay a ls o
f u n c ti on a s ac c es s o ry m u s c l es of re s pi ra ti on , h e lp in g el eva te th e rib s t o ex pa n d th e t h o rac i c c a vi ty w h en
in s p i rat io n is d ee p a n d f o rc ef u l (e .g ., af t er a 1 0 0 -m d a s h ). T h e sc al e ne m u scl es of th e n ec k, w h ic h
d es c en d t o t h e 1 s t a n d 2 n d r ib s , al s o s er ve as a c c es s or y res p i rat o ry m u s c l es by f ixi n g t h es e rib s an d
en a bl in g t h e m u s c l es c on n e c ti n g t h e ri b s be lo w t o b e m o re e f fe c ti ve i n ele vat i n g t h e l ow e r ri bs d u ri n g
f or c ed in s p ir at io n .

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T h e s er rat u s p os t eri or , lev at or es c os t aru m , in t erc o s ta l, s u b c o s ta l, a n d t ra n sv ers e t h o rac i c are m u s c les o f

t h e t h or ac ic w al l ( Ta b le 1 .2 ) .
T h e s er rat u s p os t eri or m u s c les , e xt en d in g f ro m th e vert eb ra e t o t h e ri b s, h a ve t ra di t io n all y b ee n
d es c r ib ed as i n s pi ra to ry m u s c l es , b u t t h is f u n c t io n is n o t s u p p ort ed b y el ec t ro m yo gr ap h y o r ot h er
e vid en c e . Th e se rr at us p o st er io r sup er io r li es at t h e j u n c ti on o f t h e n e ck an d b ac k. It ari s es f ro m th e
i n f eri or p a rt o f th e n u c h a l l ig am en t ( L . li g am en t u m n u c h a e) in t h e n ec k a n d t h e s p in o u s p roc e s s es of t h e
C6 o r C7 t h ro u gh T 2 or T3 v ert eb ra e. T h is m u s c le ru n s in f er ol at era ll y an d at t ac h es b y a s e rie s of
d i gi ta t io n s t o t h e s u p er io r b ord e rs of t h e 2 n d 5 t h rib s , i m m ed i at ely lat er al t o t h ei r an g l es . O n th e ba s is
o f it s a t ta c h m en t s an d d is p os i ti on , t h e s e rrat u s p os t er io r s u pe rio r w as s ai d t o e le vat e t h e s u p eri or f o u r
ri b s , th u s i n c rea s in g th e A P d ia m et er o f th e t h o rax a n d rai s in g th e s te rn u m .
T h e se r ra t us po st e ri o r i nf er io r li es at th e ju n c t i on of t h e t h ora c ic a n d l u m b ar r eg io n s (s e e Ch ap t er 4 ) .
It ar is es f ro m t h e s p in o u s p ro c es s e s o f th e las t t w o t h o rac i c sp i n ou s p ro c es s es , t h e f ir s t t w o lu m b a r
s p i n ou s p ro ce s s es , an d t h e t h ora c ol u m b ar f a s c ia. I t ru n s s u p er ol at era ll y an d at t ac h es t o t h e in f e rio r
b o rd ers o f t h e i n f eri or t h re e or f o u r ri bs , a ls o ju s t la te ral to th e ir a n g les . O n t h e b as i s o f it s at ta c h m en t s
a n d d i s po s it i on , t h e s err at u s po s t eri or i n f eri or w as s ai d to de p res s t h e in f er io r ri bs , p re ven t in g t h em f ro m
b ei n g pu l le d s u p e rio rly by th e d i ap h ra gm . H ow eve r, rec e n t s t u d ies ( V il en s k y et a l., 2 0 0 1 ) s u g g es t th a t
t h es e m u s c les , w h ic h s p an t h e s u p eri or a n d in f eri or th o rac i c ap er tu re s as w e ll a s th e tra n s it io n s f rom th e
re la ti vel y in f l exi b le t h o rac i c vert eb ra l c o lu m n t o t h e m u c h m o re f l exi b le c e rvi c al a n d l u m b ar s e g m en t s of
t h e c o lu m n , m a y n o t b e p ri m ar ily m ot o r in f u n c t io n . R at h er, t h ey m ay h a ve a p ro p rio c ep t ive f u n c ti on .
T h es e m u s c les , p a rti c u la rl y th e s u p e rio r o n e, h av e b een i m p li ca t ed as a s o u rc e o f c h r on i c p a in in
m y of a sc i al p ain s y n dr om e s .
Fi gu re 1 . 10 . T h o ra co a ppe nd icu l ar a n d an te ro l a t er al ab do m in al m usc le s o ve rl yi ng t h o ra ci c

w a l l. T h e p ec t or al is m aj o r h as b ee n r em o ved o n t h e l ef t s id e t o ex po s e t h e p ec t or ali s m in o r,
s u b c la viu s , a n d e xt ern a l in t er c os t al m u s c les . W h en t h e u p p er li m b m u s c le s are rem o ved , t h e d om ed
s h ap e o f th e t h o rac i c c ag e is r evea le d.
P .9 4

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T ab le 1. 2 . M us cl es o f T ho r a ci c W a l l
P .9 5
T h e l ev at o r es co s ta r um mu scl e s are at ta c h ed to th e tr an s ve rs e p ro ce s s es of t h e C7 a n d T 1 T 1 1
ve rt eb ra e (F i g . 1 .1 4 ) an d p as s in f er ol at era ll y to at t ac h to t h e rib s , c l os e t o t h ei r t u be rc le s . A s th e ir n a m e
i n d ic at es , t h es e 1 2 f a n -s h a p ed m u s c le s ele vat e t h e ri b s ; b u t t h ei r ro le , if an y , i n n or m al in s p ir at io n is
u n c e rta in . T h ey m ay p l ay a r ol e in ve rt eb ral m o vem e n t a n d/ o r p rop r io c ep ti on .
T h e i n te rc os t al m u s c le s o c c u p y t h e in t erc o s t al s p a c es (F i g s . 1 .1 0 , 1 .1 1 , a n d 1 .1 2 ; T ab l e 1 .2 ) . Th e
s u p er fi c ia l l aye r is f or m ed b y t h e ext er n al i n te rc o s ta ls , t h e in n e r la yer b y t h e i n te rn al in t erc o s ta ls . T h e
d ee p es t f i b ers of t h e l at te r, ly in g in t ern a l t o t h e i n te rc os t al ves s e ls are s om e w h a t ar ti f ic i al ly d es i g n at ed
a s a s ep ar at e m u s c le , th e in n er m os t in t er c os t al s .
T h e ex t er na l in te r co st al m usc le s ( 1 1 p air s ) o c c u p y th e in t erc o s ta l s p ac e s f r om t h e t u b erc l es of

t h e ri bs p o s te rio rly to th e c os t oc h o n d ral ju n c t io n s an t eri or ly ( F ig s . 1 .1 0 , 1 . 1 1 , an d 1 .1 3 ) .
A n t eri orl y, t h e m u s c l e f ib er s a re re p la ce d by t h e e x te rn a l i nt er co st a l m e mb ra ne s ( F ig . 1 .1 3 A ) .
T h es e m u s c l es ru n i n fe ro an t eri orl y f ro m th e rib a bo ve t o t h e ri b be lo w . E a c h m u s c le a tt ac h e s
s u p eri or ly t o t h e i n fe ri or b o rd er o f t h e ri b ab ov e an d in f e rio rl y to th e s u pe ri or b o rd er o f t h e ri b
b el ow ( F i g. 1 . 1 3 C) . Th e s e m u s c le s are c o n t in u o u s i n f eri or ly w it h th e e xt ern a l o bl iq u e m u s c les i n th e
an t er ol at era l ab d o m in a l w a ll . T h e ext er n al i n te rc o st a ls are m os t ac t iv e d u rin g i n s pi ra ti on ; th e y
m a in t ai n or i n c rea s e th e to n u s of t h e in t er co s t al s p a c e. T h ey el eva te th e rib s d u rin g f o rc ed
in s p i ra t i on .
T h e i nt er na l i n te rc o st al m uscl e s ( 1 1 pa ir s ) ru n d ee p to an d at rig h t an g le s to th e ext ern a l

in t er c os t al s (F i g s. 1 .1 2 an d 1 .1 3 C) . T h eir fi b ers ru n i n f ero p os t eri or ly f ro m t h e f lo ors o f th e c o s ta l
g ro ove s to th e s u p e rio r b or de rs of t h e ri bs i n f eri or t o t h em . Th e in t ern a l in t er c os t al s at ta c h to th e
b od i es of t h e ri bs a n d t h ei r c o st a l c ar ti la ge s as f ar a n te rio rl y as t h e s te rn u m a n d a s f a r p os t eri or ly
as t h e a n gl es o f t h e ri b s . B et w ee n t h e r ib s p os t eri or ly, m e d ial to t h e an g le s , th e in t ern a l
in t er c os t al s are r ep la c ed by th e i n te r na l i nt e rco s ta l m e mb ra ne s ( F ig . 1 .1 3 A ) . T h e in f e rio r
in t er n al i n t erc o s ta ls ar e c on t in u ou s w i th t h e i n te rn al ob li q u e m u s c l es in t h e an t er ol at era l ab d o m in a l
w a ll . Th e in t ern a l i n te rc os t al s w e ake r t h an t h e ext er n al i n te rc os t a l m u s c le s ar e m o s t
P .9 6
ac t iv e d u rin g e xp ira ti on ; t h ey m a in t ai n or i n c rea s e t h e to n u s of t h e in t er c os t al sp a c e. T h eir
in t er os s eo u s ( vs . in t erc h o n d ra l) po rt io n s m ay d e pr es s ri bs d u ri n g f o rc ed re s pi ra ti on ( F ig . 1 .1 3C ).
T h e in t er c h on d ra l p or ti on o f t h e i n te rn al in t erc o s t als a pp e ars t o a c t w i t h t h e e xt ern a l in t er c os t al s
d u ri n g a c ti ve i n s pi ra ti on ( d is c u s s ed l at er i n t h i s c h a p te r) .

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Fi gur e 1 . 11. D i sse ct io n o f a nt e ri o r a spe ct o f a n te ri o r t h o ra ci c w a ll . T h e ext er n al

in t erc o s ta l m u s c l es ar e rep l ac ed b y m e m b ran e s b e tw een c o s ta l c ar ti la g es . Th e H - s h ap ed c u ts
th r ou g h th e pe ric h o n d ri u m of t h e 3 rd an d 4 t h co s t al c a rt il ag es ar e u s ed t o s h el l o u t p ie c es of
c art il ag e, a s w as d o n e w i th t h e 4 t h c os t al c art il ag e, i ll u s tr at in g h ow on e t yp e o f th o rac o t om y i s
pe rf or m ed . It is n o t u n c o m m o n f o r t h e 8 th r ib to at t ac h to t h e s te rn u m , a s i n th i s s pe c im e n .
Th e in t ern a l t h ora c ic ve s s els a n d t h e p ar as t ern a l l ym p h n od es ( g ree n ) l ie in s id e t h e t h or ac i c
c ag e la t era l t o t h e s te rn u m .
Fi gur e 1 . 12. P o st e ri o r a spe ct o f a nt e ri o r t h or a ci c w al l . Th e in t ern a l t h or ac ic a rt eri es ari s e

fr om t h e s u b c la vi an ar te rie s a n d h ave p a ire d a c c om p a n yin g ve in s ( L. v en ae c om i ta n te s )
in f er io rly . Su p e rio r t o t h e 2 n d c os t al ca rt il ag e, t h er e is o n ly a s i n g le i n t ern a l t h ora c ic ve in on
eac h s i de , w h i c h d r ain s i n to th e b rac h i oc ep h a li c v ei n . Th e c o n t in u i ty o f th e t ra n s ver s e th o ra c ic
w it h t h e t ran s ve rs e a bd o m in a l b ec o m es a pp a ren t w h e n t h e d i ap h rag m i s rem o ve d, a s h as b een

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do n e h e re o n t h e ri g h t s i d e.
T h e i nn er mo s t i nt e rco s ta l m u scl es are s i m i lar to th e in t ern a l in t er c os t al s an d are es s en t ia ll y

t h eir de ep er p a rts . T h e i n n erm os t in t erc o s ta ls a re s ep a rat ed f ro m th e i n t ern a l in t er c os t al s b y t h e
in t er c os t al n erve s an d ves s e ls ( F ig . 1 .1 3 ) . Th e s e m u s c l es p as s b et w ee n th e i n t ern a l s u rf ac e s of
ad j ac e n t ri b s an d oc c u p y t h e la t era lm o s t p ar ts o f t h e i n te rc o st a l s p ac es . It is l ik ely ( b u t
u n d et erm in ed ) th a t t h ei r ac t io n s ar e th e s am e a s th o s e o f t h e i n te rn al in t erc o s ta l m u s c l es .
T h e su b co s ta l m u scl es are v ari ab l e in s i z e an d s h ap e, u s u a ll y b ein g w ell d evel op e d o n ly i n th e lo w er

t h or ac i c w al l. T h es e t h in m u sc u l ar s l ip s ex te n d f ro m t h e in t er n al s u r fa c e o f t h e a n gl e o f o n e ri b to th e
i n te rn al s u rf ac e o f th e se c on d o r th i rd rib i n f eri or t o i t. C ros s i n g o n e o r t w o i n te rc o s ta l s p ac es , t h e
s u b c o s ta ls ru n in t h e s a m e d ir ec ti o n a s th e i n t ern a l in t er c os t al s an d bl en d w i th t h em ( F i g. 1 . 1 3 B ). T h u s it
i s as s u m ed t h at th e s u bc o s ta ls a c t w it h th e i n te rn al in t er c os t al s, a n d th a t t h ey m ay d ep re s s r ib s .
T h e t ra n sve rs e t ho r aci c ( L . tra n s ver s u s t h o rac i s ) m u sc l es , c on s i st o f f o u r or f i ve s l ip s th at a t ta c h
p o s te rio rl y to th e xip h o id p roc e s s , th e i n f eri or pa rt of th e b od y o f t h e s t ern u m , an d th e ad ja c en t c os t al
c a rt ila g es ( F ig s . 1 .1 1 an d 1 .1 2 ) . T h ey p as s s u p er ol at era ll y an d at t ac h to t h e 2 n d 6 t h c os t al c a rt il ag es .
T h e t ran s v ers e t h o rac i c m u s c le s a re c o n ti n u ou s i n f eri orl y w i t h t h e t ra n s vers e ab d om i n al m u s c le s i n th e
a n te rol at er al b o dy w al l. T h es e m u s c les a p pe ar t o h a ve a w ea k exp i rat or y f u n c ti on , d ra w i n g d o w n w ard on
t h e c o s ta l c ar ti la ge s to w h i ch t h ey a t ta c h . Th e y m ay p r ovi d e p rop r io ce p ti ve i n f orm at io n .
A l th o u g h th e e xt ern a l an d i n te rn al in t erc o s ta ls a re ac t iv e d u rin g i n s pi ra ti on a n d e xp ira ti on , r es p ec t ive ly ,
m o s t a c ti vi ty i s is o m et ri c ; t h e ro le of th e s e m u s c l es in p ro d u c in g m ov em e n t o f t h e ri b s ap p ear s to be
re la te d m ain l y t o f o rc ed res p i rat io n . T h e d ia ph r ag m is t h e p ri m ar y m u s c le o f in s p i rat io n . E xp ir at io n is
p as s i ve u n l es s on e is ex h ali n g ag ai n s t r es is t an c e ( e .g. , in f la ti n g a b al lo on ) or t ry in g to exp e l ai r m o re
ra p id ly th a n u s u al ( e.g ., c o u g h in g , s n ee z in g , b lo w i n g o n e' s n o s e, o r s h ou t i n g) , t h e el as t ic re c oi l o f t h e
l u n g s a n d de c om p re s s io n of
P .9 7
P .9 8
a bd o m i n al v is c er a exp e l p rev io u s ly i n h al ed air . Th e pr im a ry ro le of th e in t erc o s t al m u s c l es i n r es p ira t io n
i s to s u pp o rt (i n c rea s e t h e to n u s or r ig id i ty of ) th e i n t erc o s ta l s p ac e, r es is t i n g p ar ad o xic a l m o vem e n t
e s pe c ia lly du r in g in s p i rat io n w h e n i n t ern a l t h ora c ic p res s u r es are lo w es t ( m os t n eg at i ve) . T h is is m o s t
a pp a ren t f ol lo w i n g a h ig h s p in al c or d i n ju r y, w h e n th e re is a n in i ti al f l ac c i d p a ral ys is o f t h e e n ti re t ru n k
b u t th e d i ap h ra gm rem a in s ac t i ve. In t h es e c i rc u m s t an c es , t h e v it al c a p ac it y i s m ark ed ly c o m p ro m is e d b y
t h e p ar ad ox ic al in c u r si on o f th e th o rac i c w al l d u ri n g in s p ir at io n . Se ver al w eek s lat er , th e p a ral ys i s
b ec o m es s p as t i c ; t h e t h ora c ic w all s ti f f en s an d vi ta l c ap a c it y ri s es (W il li am s e t a l., 1 9 9 5 ) .

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Fi gu re 1 . 13 . C o n te nt s o f a n i nt er co st a l sp ace . A. T h i s t ra n s vers e s ec t io n s h o w s n e rves ( ri gh t

s id e) an d a rt eri es (l ef t s id e) in re la ti on t o t h e i n te rc os t al m u s c le s . B . T h e p os t eri or p a rt o f an
in t er c os t al s p a c e is s h o w n . T h e j oi n t c a ps u l e ( rad i at e li g am e n t) o f o n e c o s to ver teb r al j o in t h as b een
rem ove d . In n erm os t in t erc o s ta l m u s c l es b rid g e o n e in ter c os t al s pa c e; s u b co s t al m u s c les b ri d ge tw o.
T h e m n em on i c f o r t h e or de r of t h e n eu r ova s c u la r s tr u c tu re s in t h e in t er co s t al s p a c e f rom su p e rio r t o
in f e rio r is V A N vei n , art ery , an d n erv e. Co m m u n i c at in g b ran c h e s ( L . ram i c om m u n ic a n te s ) e xt en d
b et w ee n th e i n t erc o s ta l n er ves an d t h e s ym p a th e ti c tr u n k. C. A s i m p le m o d el of th e ac t io n of t h e
in t er c os t al m u s c les i s s h ow n . C on t rac t i on o f t h e m u s c l e f ib er s th a t m o s t c l os e ly p ar al lel th e s lo pe of
t h e rib s a t a g i ven p oi n t ( f i be rs A an d C ) w il l e lev at e t h e rib s a n d s t ern u m ; c o n tr ac t io n of m u s c le
f ib er s t h a t ar e ap p ro xim at el y p erp en d i c u lar to th e s l op e o f th e rib s ( f ib ers B ) w i ll de p res s t h e rib s .
T h e m e c h an i c al a c ti on o f t h e i n te rc o s ta l m u s c l es in ri b m ove m en t , es p ec i al ly d u ri n g fo rc e d re s p ira ti on ,
c a n be ap p rec i at ed b y m ea n s o f a s im pl e m o d el ( F i g. 1 . 1 3 C) . A p a ir o f c u r ved le ver s , rep re se n ti n g th e
ri b s bo rd er in g an i n te rc os t al s pa c e, a re h in ge d p o s te rio rl y to a f ix ed , ver ti c al (v ert eb ra l) c ol u m n ; t h ei r
a n te rio r en d s ( c os t al c art il ag es ) ar e h in g ed t o a m ov eab l e, ver ti c al c ol u m n (t h e s t ern u m ). T h e r ib s (a n d
i n te rve n in g in t erc o s t al s p ac e ) d e s ce n d as th e y ru n an t er io rly , rea c h in g th e ir l ow po in t ap p ro xi m at el y at
t h e c o s to c h on d ra l j u n c ti on , a n d th e n a s c en d to t h e s te rn u m . T h e c o n ce n tr ic c o n tra c ti on o f th e m u s c le
f i be rs th a t m os t c lo s ely ap p rox im a te th e s l op e o f th e rib s at t h eir a t ta c h m en t s (f i be rs A an d C in F i g.
1 .1 3 C ) r ot at e t h e ri bs s u p er io rly a t t h ei r p os t er io r axe s , ele vat i n g t h e ri b s a n d s te rn u m . T h e c on c e n tr ic
c o n tr ac t io n of m u s c le f ib ers t h at ar e ap p ro xim a t ely p e rp en d ic u l ar t o t h e s l op e o f th e r ib s at th e ir
a tt ac h m en t ( f ib e rs B in t h e f ig u re ) ro t at e t h e rib s i n fe rio rl y at th e ir p o s te rio r ax es , d ep re s si n g th e rib s
a n d s t er n u m . F ib er s A re p res en t t h e ext er n al i n t erc o s ta l m u s c l es , an d f ib e rs B r ep res e n t t h e i n te ros s e ou s
p o rti o n o f th e in t ern a l in t er c os t al m u s c le s. F i b ers A ru n n ea rl y pe rp en d i cu l ar t o fi b ers B . T h u s th e

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e xte rn al in t er co s t al m u s c les el ev at e an d t h e in t ero s s eo u s in t ern a l i n te rc os t al m u s c le s d e pr es s th e rib s .

N o t e th a t e ven t h ou g h t h e f ib er s o f th e in t erc h o n d ral po rt io n of t h e in t er n al i n t ero s s eou s m u sc l es ( f ib er s
C) ru n p ar al lel to th e f ib ers o f th e i n te ro s s eou s p o rti on ( f ib e rs B ), t h ey ap p rox im a te th e s l op e o f th e rib s
( in s t ea d of b ein g p er pe n d ic u la r t o t h e s lo p e) . Th e ref o re, t h e i n te rc h on d ra l p o rti on o f th e i n t ern a l
i n te rc os t al m u s c le s (f i b ers C) ac t w i th t h e ext er n al i n t erc o s ta l m u s c l es ( fi b ers A ) to el eva te t h e r ib s
( S la b y et al. , 1 9 9 4 ) .
T h e di a ph r a g m i s a s h ar ed w a ll ( ac t u a lly fl oo r/ c ei li n g ) s ep a rat in g t h e t h ora x an d a bd o m en . A l th o u g h it
h a s fu n c t io n s rel at ed t o b ot h c om pa rt m en t s of t h e t ru n k, i ts m o s t i m p or ta n t ( vi ta l) f u n c ti on i s s e rvi n g a s
t h e p ri m ar y m u s c le o f in s p ir at io n . Th e d eta il ed d es c ri p ti on o f t h e t h or ac ic d i ap h ra gm a p pe ars i n Ch ap t er
2 b ec a u s e t h e at ta c h m en t s of i ts c ru r a oc c u r a t a b do m i n al l eve ls ( i.e ., to lu m ba r ve rte b rae ) a n d a ll of it s
a tt ac h m en t s a re b es t ob s e rved f ro m it s in f er io r ( ab d om i n al ) a s p ec t; t h ey a re es s e n ti al ly i n ac c es s i b le
f ro m t h e th o ra c ic s id e i f th e ab d om i n al vis c e ra ar e s t ill in p la c e. Co n s eq u en t l y, th e di ap h ra g m is u s u al ly
m o s t f u l ly s t u d ie d w h en , d u ri n g d i s s ec t io n s, t h e a b do m i n al v is c er a an d ki d n eys h av e b een re m o ved .
H o w e ver , y ou m a y w i s h to rea d a b ou t th e di ap h ra g m at th i s ti m e.
Dy spn ea: Difficu lt Breat hi ng

W h en p eo p le w it h res p i rat o ry p ro bl em s ( e.g ., a s th m a) or w it h h ear t f ai lu r e s tr u g gl e t o b rea t h e, th ey u s e
th e ir a c c es s or y res p i rat or y m u s c le s to as s is t t h e exp a n s io n o f th e ir t h or ac i c c a vi ty. T h ey lea n on t h ei r
kn ee s o r o n t h e a rm s o f a c h air to fi x t h ei r p ec to ra l g ir dl e s o t h es e m u s c les a re a bl e t o a c t o n t h ei r ri b
at ta c h m en t s an d ex p a n d t h e t h or ax.
The Bot tom Line

Th e th o rax is ov erl ap p ed b y th e th o rac o ap p en d i c u lar m u s c le s o f th e u pp er li m b . Th e s e m u s c le s ac c ou n t
fo r m a n y of t h e an a t om i c al f e at u res o f i t s s u r fa c e, a lo n g w it h th e br eas t s . M os t of t h es e m u s c l es c an
ef f ec t d e ep res p i rat io n w h en t h e p ec t or al g i rd le is f ixe d . Th e m u s c les t h at ar e tr u ly t h or ac i c, h o w e ver ,
pr ovi d e f ew i f an y s u rf a c e f ea tu re s . Th e s erra tu s p o s te rio r m u s c l es are th i n w it h s m a ll b e ll ies t h at m ay
be pr op ri oc e pt i ve o rg an s . T h e c os t al m u s c le s c an m o ve t h e ri bs a n d d o s o d u ri n g f o rc ed res p i rat io n , b u t
m os t of t h e t im e th ey fu n ct i on t o s u p p ort ( p rov id e t on u s f o r) t h e i n te rc os t al s p ac es , r es is t in g n eg a ti ve
an d p os i ti ve i n tra t h ora c ic p res s u r es . T h e d iap h r ag m is t h e p ri m ary m u s c le o f res p i rat io n .
F asc ia of the Tho rac ic W all

E a c h pa rt of th e de ep f as c i a is n a m ed f or t h e m u s c l e it in v es t s o r t h e s t ru c tu r e( s ) t o w h ic h i t i s a t ta c h ed .
Co n s eq u en t l y, a l arg e p o rt io n o f th e de ep f as c ia ove rl yin g t h e an t eri or th o rac i c w a ll, f o rm i n g a m aj o r p art
o f th e b ed o f t he b re as t ( a rea o r s t ru c t u res im m ed ia t ely d e ep to th e br eas t , i. e., on w h ic h t h e b rea s t
l ie s) , i s ca ll ed pe ct o ra l o r p ect o r al i s fa sci a f o r it s as s o c iat i on w i t h t h e p ec t o ral is m a jo r m u s c l es ( Fi g .
1 .1 5 ). D eep t o t h e p ec t or ali s m aj o r an d it s f as c i a is a n ot h er l aye r of d ee p f a s ci a s u s p en d ed f ro m t h e
c l avi c le a n d in ve s ti n g t h e p ec t o ral is m i n or m u s c le, t h e cl a vi pe cto r a l fa sci a . (T h e p ec t o ral an d
c l avi p ec t ora l f as c i as ar e ex pl ai n ed an d il lu s t ra te d i n Ch ap t er 6 i n r ela t io n t o t h e a xil la ry f o s s a or a rm p i t.)
T h e t h or ac ic c a ge is li n ed in t er n al ly w it h en do t ho r aci c fa sci a . Th i s th i n fi b ro are ol ar l aye r at ta c h es t h e
a dj a c en t p o rt io n of t h e li n in g of t h e lu n g c a vit ie s (t h e c o s ta l p ar iet al p leu r a) to th e th o rac i c w a ll. I t
b ec o m es m o re f i b rou s o ver th e a p ic es o f t h e l u n g s a s th e s u pr ap le u ral m em b r an e ( s ee c l in i c al c o rre la ti on
[ b lu e ] b o x E xtr ap le u ral In t rat h or ac i c S u r gi c al Ac c e s s .
Ext rap leu ral In tr at horacic Sur gical Access

F ixa ti on m a kes i t d i ff i c u lt to ap p rec i at e i n t h e e m b al m ed c ad av er, b u t in s u rg er y th e rel at ive ly l oo s e
n at u re o f t h e t h in e n do t h ora c ic f as c i a p ro vid e s a n at u ral c le ava ge pl an e , al lo w in g t h e s u rg eo n to
s ep ara te th e co s t al p a rie ta l p le u ra l in i n g t h e l u n g c a vi ty f ro m t h e t h ora c ic w a ll . Th i s al lo w s in t ra th o ra c ic
ac c es s t o ex tr ap le u ral s tr u ct u re s (e .g ., lym ph n o d es ) an d in s t ru m e n t p la c em e n t w it h ou t op en i n g an d
pe rh ap s c o n ta m in a ti n g th e p o te n ti al s pa c e ( p leu r al c a vi ty) t h at s u rro u n ds t h e l u n gs .
P .9 9
The Bot tom Line

Dee p f a s c ia o ve rli es an d i n ves t s th e m u s c les o f t h e t h o rac i c w al l, a s i t d o es el s ew h e re. W h ere th e f l es h y
po rt io n s of t h e in t er c os t al m u s c les a re ab s e n t, t h ei r f as c ia is c o n ti n u ed as in ter c os t al m em b ra n es , s o
th a t t h e w a ll is c om p let e. T h e e n do t h ora c ic f as c i a is a th i n , f ib ro are ol ar l aye r b et w ee n th e i n te rn al as p ec t
of t h e th o ra c ic c ag e a n d t h e l in i n g o f th e pu l m o n ary c a vit i es , w h i c h c an b e op e n ed s u rg ic al ly to ga in
ac c es s t o i n tr at h ora c ic s t ru c t u res .
N e rves of the Tho rac ic W all

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T h e 1 2 p ai rs of t h or ac i c s p i n al n e rve s s u p p ly th e t h o rac i c w al l. A s s o on as t h ey l ea ve t h e IV f or am i n a in
w h ic h t h ey ar e f or m ed , t h e m ix ed th o ra c ic s p in a l n erv es d ivi d e in t o a n t eri or a n d p o s te rio r p ri m ary ram i
( F ig . 1 .1 3 A ) . T h e an t er io r ram i o f n e rves T 1 T 1 1 f or m th e in t erc o s ta l n e rves t h at ru n al on g t h e ex te n t
o f th e i n t erc o s ta l s p ac es . T h e a n te rio r ra m u s of n er ve T 1 2 , c ou r s in g in f er io r t o t h e 1 2 t h r ib , is t h e
s u b c o s ta l n erv e ( s ee Ch a p te r 2 ) . T h e p o s te rio r ra m i o f th o rac i c s pi n al n erv es p as s p os t eri or ly,
i m m ed i at el y la te ral to th e art ic u l ar p ro c es s es o f th e v ert eb ra e ( F ig . 1 .1 4 ) , t o s u p p ly t h e j oi n ts , m u s cl es ,
a n d s k in of t h e b ac k i n th e th o rac i c reg i on ( s ee Ch a p te r 4 ) .
Typ ical I nte rcostal Ner ves

T h e 3 rd 6 th i n te rc os t al n erv es en t er t h e m e di al -m os t p art s of t h e p os t eri or in t erc o s ta l s p ac e s , ru n n in g
i n it ia ll y w i th i n th e en d ot h or ac i c f a s c ia b et w een t h e p ari et al pl eu ra ( se ro u s l in i n g of t h e p u lm o n ary c avi ty )
a n d t h e i n te rn al in t erc o s t al m e m b ran e n ear ly i n th e m id d le of th e in t erc o s ta l s p ac e s (F i g s . 1 .1 3
P .1 0 0
a n d 1 . 1 4 ). N e ar t h e a n gl es o f t h e ri b s , th e n erve s pa s s be tw een t h e i n te rn al in t erc o s ta l a n d t h e
i n n erm os t in t erc o s ta l m u s c l es . A t t h i s p o in t , t h e in t erc o s t al n e rves p a ss t o a n d th en c o n t in u e t o c o u rs e
w it h in t h e c os t al g roo ve s, r u n n in g in f e rio r t o t h e in t er c os t al a rt eri es ( w h i c h , in t u rn , ru n in f e rio r t o t h e
i n te rc os t al vei n s ) ( F i g. 1 . 1 3 B ). T h e n e u rov as c u la r b u n d les a re t h u s s h elt er ed b y th e in f eri or m arg i n s of
t h e o verl yi n g r ib s . Co ll at era l b ran c h e s of th es e n er ves ar is e n e ar t h e an g l es of t h e ri b s a n d ru n al on g th e
s u p er io r b ord e r of t h e rib b el ow . Th e n erve s c on t in u e a n t eri orl y b et w ee n th e in t ern a l an d t h e in n e rm o s t
i n te rc os t al m u s c le s , g ivi n g b ra n c h es t o t h es e a n d o t h er m u s c l es an d g ivi n g ris e to lat er al c u t a n eou s
b ra n c h es in a pp r oxi m at el y t h e M A L. A n t eri or ly, t h e n e rves a pp e ar o n th e i n t ern a l s u rf ac e of th e in t ern a l
i n te rc os t al m u s c le . N ea r th e s ter n u m , t h e in t er co s t al n e rve s t u rn a n te rio rl y, p as s in g b et w e en th e c os t al
c a rt ila g es t o b ec o m e an t er io r c u ta n eo u s br an c h es .
Fi gu re 1 . 14 . D i sse ct i o n o f po st er i o r a spe ct o f t ho r a cic w al l . Th e ili oc o s t ali s an d lo n g is s i m u s

m u s c le s (t w o of t h e t h ree c o m p on e n ts o f th e e rec t o r s pi n ae m u s c les o f th e b a c k) h ave b e en rem ove d
t o ex po s e t h e le vat o res c os t ar u m m u s c le s . In th e 8 th a n d 1 0 t h in t er c os t al sp a c es , va ryi n g p a rts o f
t h e ext er n al i n te rc o st a l m u s c le h ave be en re m ov ed to exp o se th e u n de rly in g in t er n al i n te rc o s ta l
m em br an e, w h ic h i s c o n t in u o u s w it h t h e in t ern a l i n te rc os t al m u s c le . In th e 9 th i n te rc os t al s p ac e, t h e
le vat o r c os t ae h a s be en re m ov ed to exp o s e th e in t erc o s ta l ve s s els a n d n e rve .
T h ro u g h i t s p o s te rio r ra m u s an d t h e la te ral an d an t eri or c u ta n eou s b ra n c h es of i ts a n te rio r ra m u s , ea ch

s p i n al n e rve s u p p li es a s t ri p- l ike de rm a to m e e xte n d in g f rom th e p o s te rio r m e di an l in e t o t h e a n te rio r
m e d ian l in e (F i g . 1 .1 6 ) . T h e g ro u p of m u s c l es s u p pl ie d b y t h e p o st er io r ra m u s an d an t eri or r am u s

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( in t er c os t al n erve ) o f eac h p ai r o f t h o rac i c s p i n al n erve s c o n s t it u te s a m y o to m e . Con s t it u t in g th e

m y ot om e s u p pl ie d b y t h e m u s c u l ar b ra n c h es o f a typ i c al i n t erc o s ta l n er ve i s t h e i n te rc os t al , s u b c os t al ,
t ra n s vers e th o rac i c , le vat or es c os t ar u m , an d s err at u s po s t eri or m u s c l es as s o c ia te d w it h th e in t erc o s ta l
s p ac e th a t i n c lu d es t h e n er ve. T h e b ra n ch e s of a t yp ic a l i n te rc os t al n erv e are :
R am i co mm u ni ca nt e s, or c o m m u n i c at in g b ra n c h es , th a t c o n n ec t eac h i n te rc os t a l n erv e t o t h e
ip s i la te ral s ym p at h et ic t ru n k ( F ig . 1 .1 3 A & B ) . Pre s yn ap t ic f ib er s lea ve t h e i n it ia l p or ti on s o f t h e
an t er io r ram u s o f ea ch t h o rac i c ( a n d u p p er l u m b ar ) s p i n al n e rve b y m e an s o f a w h i te c o m m u n i c at in g
ra m u s an d p as s t o t h e s ym p at h et i c t ru n k. P os t s yn a pt i c f i b ers d is t ri bu t ed t o t h e b od y w al l an d l im b s
p as s f ro m th e ga n g li a of t h e s ym pa th e ti c tr u n k via g ray r am i to jo in t h e a n te rio r ra m u s of t h e
n ea res t s p in al n erv e, in c l u d in g al l i n te rc os t al n erv es . S ym p at h et i c n e rve f i b ers ar e d is t rib u t ed
t h rou g h a ll b ra n c h es o f a ll sp i n al n erve s (a n te rio r an d p o s te rio r ra m i) to rea c h th e bl oo d ves s el s ,
s w e at gl an d s , a n d s m o ot h m u s c l e of t h e b od y w al l an d li m b s .
C o ll a te r al bra nc he s t h at a ri s e n ea r th e a n g le s o f th e rib s an d d es c en d t o c o u rs e a lo n g t h e s u p eri or

m a rg in o f t h e l ow er ri b , h elp i n g s u p p ly in t erc o s ta l m u s c l es an d p ar iet al p leu r a ( F ig . 1 .1 3 B ) .
L a te r al cut a ne o us br a nch es t h a t ar is e n e ar t h e M A L a n d p i erc e t h e i n te rn al an d ex ter n al

in t er c os t al m u s c le s a p pr oxi m a te ly h a lf w a y aro u n d th e th o rax (F i g s . 1 .1 3 A & B , 1 .1 5 , a n d 1 .1 6 ). T h e
la t era l c u ta n eo u s br an c h es d i vid e i n
P .1 0 1
t u rn in t o a n te rio r an d p o s te rio r b ran c h e s th a t s u p p ly t h e s ki n of t h e la te ral th o ra c ic an d ab d o m in a l
w a ll s .
Fi gur e 1 . 15. S upe rf ici a l di ss ec ti o n o f m al e p ect o r al re gi o n. T h e p la ty s m a i s c u t s h or t o n

th e r ig h t s id e an d i s r ef le c te d o n th e lef t s id e, t o ge th e r w i th t h e u n d erl yi n g s u p ra c la vic u l ar
n erve s . O bs e rve t h e f i lm y , d e ep f as c ia c ove rin g t h e ri g h t p ec t or al is m aj o r. T h e f as c i a h as b ee n
rem o ve d o n th e l ef t s id e. T h e c u t an e ou s b ran c h e s of th e in t erc o s ta l n e rves t h at s u p pl y t h e
br eas t ar e s h ow n .

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Fi gur e 1 . 16. S egm e nt a l i nn er va t io n ( de rm at o m e s) o f t ho r aci c w a l l. S p i n al n e rve C 5

s u pp l ie s s k in at t h e le vel o f th e c lav ic l es an d im m ed ia te ly b e lo w . A n t eri orl y, t h e d erm a t om e
im m ed ia te ly i n fe ri or t o t h e C5 d er m at om e is t h at of s p in a l n er ve T 1 . De rm a to m es C6 C7 are
lo c at ed m os t l y in t h e u p p er li m b s an d ar e rep re s en t ed on t h e p os t er io r, b u t n o t t h e an t er io r,
bo d y w a ll . S in c e t h e a n ter io r ra m i o f s p i n al n e rve s T 2 T 1 2 a re n o t i n vol ved i n p l exu s
fo rm a t io n , th e re is n o d if f ere n c e b et w ee n th e d e rm at o m es an d t h e z o n es of p e ri p h era l n er ve
di s t rib u t io n h ere . D er m at om e T 4 i n c lu d e s t h e n i p pl e; d erm a to m e T 1 0 i n c lu d es t h e u m b il ic u s .
A nt er i o r cu ta ne o us b ra nch e s th a t s u p p ly t h e s k in on t h e a n te rio r as p ec t o f t h e t h or ax a n d
ab d o m en . A f t er p en et ra ti n g th e m u s c les a n d m em b ra n es of t h e in t er c os t al sp a c e in t h e p ar as t ern a l
li n e, t h e a n ter io r c u ta n eo u s br an c h es d i vid e i n to m ed i al a n d lat er al b r an c h es .
M usc ul ar bra n che s t h at s u pp l y th e in t erc o s ta l, s u b c o s ta l, t ran s v ers e t h o rac i c , lev at ore s c os t aru m ,
an d s er rat u s p os t eri or m u s c les ( F ig . 1 .1 3 A ) .
A typic al Interc ost al N erve s

A l th o u g h th e a n te ri or ra m u s of m o s t t h o rac i c s pi n al n erve s is s im pl y t h e in t er co s t al n e rve f o r t h at lev el,
t h e a n ter io r ra m u s of t h e 1 s t t h or ac i c ( T 1 ) sp i n al n erve fi rs t d ivi d es in t o a lar ge s u pe ri or a n d a s m al l
i n f eri or p a rt. T h e s u p er io r p art j oi n s t h e b ra chi a l pl e xu s, t h e n erv e p lex u s s u pp l yin g t h e u p p er l im b
( s ee C h ap t er 6 ) , an d t h e in f er io r p art b ec o m es t h e 1 s t i n te rc os t al n erv e. O th e r at yp i ca l f ea t u res of
s p ec i f ic in t er c os t al n erve s in c lu d e th e f o ll ow in g :
T h e 1 s t a n d 2 n d i n te rc o st a l n erv es c ou r s e on t h e i n te rn al s u rf ac e o f th e 1 s t an d 2 n d ri bs , i n s te ad of
al on g t h e in f e rio r m a rg in i n c o s t al g ro ov es ( F ig . 1 .1 2 ) .
T h e 1 s t i n t erc o s ta l n er ve h as n o an t eri or c u t a n eou s b ra n c h an d of t en n o l at era l c u t an e ou s b ran c h .

W h e n th e re i s a la te ral c u ta n eo u s b ra n c h , it s u p pl ie s th e s k in of t h e a xil la a n d m ay c o m m u n i c at e
w i th e it h er t h e i n te rc os t ob r ac h ia l n e rve o r t h e m ed i al c u t an e ou s n er ve o f t h e a rm .
T h e 2 n d (a n d so m e ti m es 3 rd ) in t er co s t al n e rve g i ves ri s e t o a l arg e l at er al c u t an e ou s b ra n c h , th e

in t er c os t ob ra c h ia l n er ve; it em e rg es f ro m th e 2 n d i n te rc os t al s p ac e a t t h e M A L, p en e tr at es t h e
s er rat u s an t eri or , an d en t ers t h e ax il la a n d a rm . T h e i n te rc os t o br ac h ia l n e rve u s u a ll y s u p pl ie s t h e
f lo or s ki n an d s u bc u t an e ou s t is s u e of t h e ax il la a n d th e n c o m m u n i c at es w i th t h e m e d ial
b rac h i al c u ta n eo u s n e rve t o s u p p l y th e m ed ia l a n d p o s te rio r s u rf ac e s of t h e arm . Th e lat er al
c u t an eo u s b ran c h o f t h e 3 r d i n te rc os t al n erv e f req u en t l y g ive s r is e t o a s ec on d i n te rc os t ob r ac h ia l
n e r v e.
T h e 7 t h 1 1 t h in t erc o s ta l n er ves, a ft er gi vi n g r is e t o l at era l c u t an eo u s b ran c h e s , c ros s t h e c o st a l

m a rg in p os t er io rly a n d c on t in u e o n to s u p p ly a bd o m in a l s ki n an d m u s c le s . N o l on g er be in g b et w ee n
ri b s ( i n te rc os t al ) , th e y n ow b e c om e th e t h o ra co a bdo m in a l ne r ves of t h e an t eri or ab d om i n al w al l
( s ee Ch a p te r 2 ) . Th e ir a n te rio r c u t an eo u s b ran c h es p i erc e t h e re c tu s s h e at h , be c om i n g c u ta n eo u s
c lo s e t o t h e m e di an p la n e.

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Herp es Zoster In fect ion of the S pin al Gangl ia

A h e rp es z o s te r in f ec t io n c au s es a c las s i c , d erm a to m a ll y d is t rib u t ed s ki n l es i on s h i n g le s an
ag on i z in g l y p ai n fu l c on d i ti on ( F ig . B 1 .3 ) . H er p es z os t er i s pr im a ri ly a v ira l d is e as e o f s pi n al ga n g li a,
u s u all y a r eac t iv at io n of t h e var ic el la - z os t er vi ru s ( V Z V ), o r c h ic k en p ox v iru s . A f t er i n vad i n g a g an g li on ,
th e v iru s p ro d u c es a s h a rp b u r n in g p ain i n th e de rm a to m e s u p p li ed b y th e in vo lv ed n erve (F i g . 1 .1 6 ) .
Th e af f ec t ed s kin a rea be c om e s red , an d ve s ic u la r er u pt i on s ap p ea r. T h e p ai n m ay p re c ed e or fo ll ow th e
s kin e ru p ti on s . A l th o u g h p r im a ril y a s e n s ory n e u ro pa th y (p a th o lo g ic al c h an g e i n th e n e rve ) w eak n es s
fr om m ot or i n vo lve m en t oc c u r s i n 0 .5 5 .0 % o f p eop l e, c om m on l y i n e ld er ly c a n c er p at ie n ts ( R o w la n d ,
2 0 0 0 ) . Mu s c u l ar w eak n es s u s u al ly o c c u rs in t h e s am e m yo t om a l d is t ri bu ti on , a s d o th e d e rm a to m al pa in
an d ves i c u la r eru p t io n s .
F igu re B1 . 3
Int er costal Nerve B lock

Lo c al a n es t h es i a of a n i n t erc o s ta l s p ac e i s p rod u c ed b y i n je c ti n g a lo c al a n es t h et ic a ge n t a rou n d t h e
in t erc o s ta l n e rves b et w e en t h e p ara vert eb r al l in e a n d th e a rea of re qu i red a n es t h es ia . Th i s p roc e du r e, an
in t erc o s ta l n er ve b lo c k, i n vol ves i n f il tra t io n o f th e an es t h et ic a rou n d t h e in t er c os t al n erve tru n k an d it s
c ol lat er al b r an c h es ( F ig . B 1 .4 ) . T h e w o rd b lo c k in d ic a te s th a t t h e n er ve en d i n gs i n th e sk in a n d t h e
tr an s m i s si o n o f im p u l s es th r ou g h t h e s en s o ry n er ves c ar ryi n g i n f orm at io n ab ou t p ai n a re i n te rru p t ed
(b l oc ke d ) b ef o re t h e i m p u ls es re ac h t h e s p in a l c or d a n d b r ain . B e c au s e a n y p art ic u l ar a rea of s ki n
u s u all y re c eiv es in n e rva ti on f ro m tw o a d ja c en t n erve s , c on s i de rab l e ov erl ap p in g of c o n ti g u ou s
de rm a to m es o c c u rs . T h eref o re, c o m p le te lo s s o f s en s at io n u s u al ly d o es n ot oc c u r u n les s t w o or m o re
in t erc o s ta l n e rves a re an e s th e ti z ed .
F igu re B1 . 4

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P .1 0 2
V asc ulature of the Thorac ic Wall

In g en e ral , t h e p at te rn of va s c u lar di s t rib u t io n in t h e th o ra c ic w a ll ref le c ts t h e s t ru c t u re o f t h e t h or ac ic
c a ge t h at is , i t ru n s i n th e i n t erc o s ta l s p ac es , p a ral le l t o t h e ri bs .
A rteries of the Thoracic Wall

T h e a rte ri al s u p p ly t o th e t h o rac i c w al l ( F ig . 1 .1 7 ; T ab le 1 .3 ) d e riv es f rom t h e:
T h ora c ic a ort a, t h ro u g h th e p o s te rio r i n te rc os t al an d s u b c os t al a rt eri es .
S u b c la via n art ery , th r ou g h th e in t ern a l t h or ac ic a n d s u p re m e i n te rc os t al art er ies .
A xi ll ary a rt ery, t h ro u g h th e s u p e rio r an d l at era l t h ora c ic ar te rie s .
T h e i n te rc os t al art er ies c o u rs e t h ro u gh t h e t h or ac ic w al l b et w ee n th e rib s . W i t h t h e e xc ep t io n of t h e 1 0 th

a n d 1 1 t h in t er c os t al s pa c es , ea c h in t erc o s ta l s p ac e is s u p pl ie d b y t h re e art er ie s: a l ar ge po s t eri or
i n te rc os t al art er y ( an d it s c ol la ter al b r an c h ) an d a s m a ll p a ir o f an t eri or i n te rc os t a l ar ter ie s .
T h e po s te r io r i n te rc o st al ar t er i es:
O f th e 1 s t an d 2 n d in t er c os t al s p a c es ari s e f ro m th e su p re m e ( su p er io r) in t er co st a l a rt er y, a
b ran c h o f th e c o s t oc er vic a l t ru n k o f t h e s u b c l avi an ar te ry.
O f th e 3 r d 1 1 t h i n t erc o s ta l s p ac e s ( a n d t h e s u b c os t al art er ies o f th e s u b c o s ta l s p ac e ) a ris e

p os t er io rly f r om t h e t h ora c ic
P .1 0 3
P .1 0 4
ao rt a ( F ig . 1 .1 7 ) . B ec a u s e t h e ao rt a is s l ig h t ly t o t h e l ef t o f th e v ert eb ra l c o lu m n , t h e ri g h t
3 rd 1 1 th i n te rc os t al art er ies h a ve a l on g er c ou rs e th a n t h o s e on t h e l ef t s i d e. T h e ri gh t ar ter ie s
c ro s s th e v ert eb r a e an d p as s p os t er io r to th e es op h a g u s , t h o rac i c du c t , az y g os ve in ( F ig . 1 .2 7 ) , an d
t h e ri gh t lu n g a n d p l eu ra .
T a bl e 1 . 3. Ar t er ia l Sup pl y o f T h o ra ci c W al l
A r te ry
O r ig in
Po st e r io r
S u p eri or in t erc o s ta l
in t erc o s ta ls
a rte ry ( in t er c os t al
Co u rs e
D is tr i b ut i o n
s p ac e s 1 a n d 2 ) a n d
t h or ac ic a ort a
( rem ai n in g in t erc o s t al
s p ac e s )
An t er io r
In t ern a l t h or ac i c
in t erc o s ta ls
( in t er c os t al s p a c es
In t erc o s t al
P as s b et w ee n in t ern a l a n d
m u s c l es ,
i n n erm os t in t erc o s ta l
o verl yi n g s k in ,
m u sc l es
a n d p ar ie ta l
p le u ra
1 6 ) a n d
m u s c u l op h re n ic
a rte rie s (i n t erc o s ta l
s p ac e s 7 9 )
In te rn al
th o rac i c
S u b c la via n art er y
P as s es i n f eri orl y an d
B y w ay o f
l at era l t o s t ern u m b e tw een
a n ter io r
c o s ta l c a rti la g es an d
i n te rc os t al
t ra n s vers e th o rac i c m u s c le
a rte rie s to
t o d i vid e i n t o s u p eri or
i n te rc os t al

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e pi g as t ric a n d
s p ac e s 1 6
m u sc u l op h r en ic a rte ri es
Su b c o s ta l
T h or ac ic a ort a
Co u rs e s a lo n g in f eri or
M u s c le s of
b o rd er o f 1 2 th ri b
a n ter ol at era l
a bd o m in a l w all
Fi gur e 1 . 17. A rt e ri e s o f t h o ra ci c w a ll . T h e art er ia l s u p p ly t o t h e t h ora c ic w all d eri ves f ro m

th e t h o rac i c ao rta th r ou g h t h e p os t eri or i n t erc o s ta l an d s u b c os t al art er ies ( A , B , an d D ), f r om
th e a xi ll ary a rt ery ( B) , a n d f ro m t h e s u b c la via n art ery th ro u g h th e in t ern a l t h or ac ic ( C ) a n d
s u pr em e ( s u p er io r) i n t erc o s ta l ar te rie s ( B ). C on n ec t io n s ( an as t o m os e s ) b et w e en t h e art er ies

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pe rm i t c o ll at era l c ir c u la ti on p at h w a ys t o d eve lo p ( D ) .
A ll g ive o f f a p os t eri or br an c h t h at ac c om pa n ie s th e p o s te rio r ra m u s of t h e s p in a l n er ve t o s u p p ly

t h e s p in a l c or d, v ert eb ra l c o lu m n , b ac k m u s c le s, a n d s kin .
G ive ris e t o a s m al l c o ll at era l b ran c h t h at c ro s s es th e in t erc o s ta l s p ac e an d ru n s al on g t h e s u p eri or

b or de r of t h e ri b .
A c c om pa n y t h e in t er co s t al n e rve s t h ro u g h th e i n t erc o s ta l s p ac es . C lo s e to th e an g le of t h e rib , t h e

ar te rie s en te r t h e c os t al gr oo ves , w h ere th ey li e b et w ee n t h e i n te rc o s ta l vei n an d n er ve. A t fi rs t th e
ar te rie s ru n in t h e en d o th o rac i c f as c ia be tw ee n t h e p ar ie ta l p le u ra a n d t h e i n te rn al in t erc o s ta l
m e m b ran e ( F i g. 1 . 1 4 ); t h en t h ey ru n b et w e en t h e in n e rm o st in t er c os t al an d in t ern a l i n te rc os t al
m u s c l es .
H a ve t erm i n al an d c ol la te ral br an c h es t h at an a s to m o s e an t eri or ly w it h an t eri or i n t erc o s ta l ar te rie s

( F ig . 1 .1 7 A ) .
T h e i nt e rn al th o ra ci c a rt er i es ( h i s to ric a ll y, t h e in t er n al m am m a ry a rte ri es ) :
A ri s e in t h e ro ot of t h e n ec k f r om t h e in fe rio r s u rf a c es of t h e f irs t p art s of t h e s u b c la via n art er ies .
D es c en d in t o t h e t h or ax p o st er io r to t h e c la vic l e an d 1 s t c os t al ca rt il ag e ( F ig s . 1 .1 1 , 1 .1 2 , an d
1.17).
A re c r os s ed n ea r t h eir ori g in s b y t h e ip s il at er al p h re n ic n er ve.
D es c en d on t h e i n te rn al s u rf ac e o f th e t h o rax s l ig h t ly l at era l t o t h e s t ern u m a n d po s te ri or t o t h e

u p p er s i x c os t al ca rt il ag es a n d i n te rve n in g in t ern a l i n te rc os t al m u s c le s . A ft er de s c en d in g p as t th e
2 n d c os t al c art il ag e, t h e i n te rn al th o ra c ic art er y ru n s an t er io r to th e tr an s ver s e t h ora c ic m u s c l e
( F ig s . 1 .1 3 A an d 1 .1 7 C ). B e tw een s l ip s of t h e t ran s ve rs e t h or ac ic m u s c l e, t h e ar te ry c o n ta c ts
p ari et al p leu r a p os t eri or ly.
T erm i n at e i n th e 6 t h in t er c os t al s pa c e b y d ivi d in g in t o t h e s upe ri o r e pi ga st ri c an d t h e

m usc ul o ph re ni c ar t er ie s.
D ire c tl y g ive ris e t o t h e a n te rio r i n te rc os t al art er ies s u p p ly in g th e s u pe rio r s ix in t erc o s ta l s p ac e s .
Ip s i la te ral pa irs o f an te r io r in te r co st al ar t er i es:
S u p p ly t h e an t er io r p art s of t h e u p p er 9 in t er c os t al sp a c es .
Pa s s la te ral ly i n th e i n t erc o s ta l s p ac e , on e n e ar t h e in f e rio r m a rg in o f t h e s u p er io r rib a n d t h e o th e r

n ea r t h e s u p eri or m a rg in o f th e i n f eri or r ib .
O f th e f i rs t 2 i n t erc o s ta l s p ac es l ie i n it i all y i n t h e e n do t h ora c ic f as c i a b et w e en th e pa ri et al p l eu ra

an d t h e in t er n al i n t erc o s ta l m u s c l es .
S u p p lyi n g t h e 3 r d 6 th i n te rc o s ta l s p ac es a re s ep a rat ed f ro m th e pl eu ra b y s li ps o f th e t ra n s ver se

t h ora c ic m u s c l e.
O f th e 7 t h 9 t h in ter c os t al s pa c es d eri ve f ro m t h e m u s c u lo p h ren i c art er ies , a ls o br an c h es o f th e

in t er n al t h o rac i c art eri es .
S u p p ly t h e i n ter c os t al m u s c le s a n d se n d br an c h es t h ro u gh t h em t o s u p p l y th e p e c to ral m u s c le s ,
b rea s ts , a n d s k in .
A re a b s en t f r om t h e in fe rio r t w o in t erc o s ta l s p ac e s ; t h es e s p a ce s are su p p l ied o n ly b y t h e p os t er io r

in t er c os t al art eri es an d t h ei r c ol la te ral br an c h es .
Ve ins of the Thorac ic Wall

T h e i n te rc os t al vei n s ac c om pa n y t h e in t er c os t al a rt eri es an d n er ves a n d l ie m os t s u pe rio r i n t h e c o s ta l
g ro ov es ( Fi g s . 1 .1 3 an d 1 .1 8 ) . T h ere a re 1 1 p o st er io r in t er co st a l ve i ns a n d o n e su bco st a l v ei n o n

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e ac h s id e. T h e p o s te rio r in t er c os t al vei n s a n as t om os e w it h th e an te r io r i n te r co st al ve in s ( tr ib u t ari es of

i n te rn al th o ra c ic vei n s ) . A s t h ey a p p roa c h th e v ert eb ra l c o lu m n , t h e p os t er io r in t erc o s t al v ein s re c ei ve a
p o s te rio r b ran c h , w h ic h ac c o m p an i es t h e p os t eri or ram u s o f th e s p i n al n e rve of th a t l eve l, a n d a n
i n te rve rte b ral vei n dr ain i n g th e vert eb ra l ve n ou s p le xu s es . M o s t p os t er io r in t erc o s t al v ein s ( 4 1 1 ) en d
i n th e a z yg os / h e m ia z yg os ve n ou s s ys t em, w h ic h c o n veys v en ou s b l oo d t o t h e S V C ( s ee V e ss e ls an d
L ym p h N o de s of t h e Po s te rio r M ed i as t in u m i n t h i s c h a p te r) . Th e p o s te ri or i n te rc os t al vei n s of t h e 1 s t
i n te rc os t al s p ac e u s u a ll y
P .1 0 5
e n te r di re c tl y in t o t h e c o rres p o n d in g an d n ea rb y b rac h i oc e ph a li c vei n s . Th e po s t eri or i n te rc os t al vei n s of
t h e 2 n d an d 3 rd ( an d oc c a s io n al ly 4 t h ) in t erc o s ta l s p ac e s u n i t e to f orm a t ru n k, t h e s u p eri or i n te rc o s ta l
ve in ( F ig . 1 .6 0 A & B ). T h e r i ght sup er i o r in t er co st a l ve i n is t yp i ca ll y t h e f in a l t rib u t ary of t h e az yg o s
ve in , b ef o re i t e n te rs th e SV C . Th e l e ft s upe ri o r i n te rc o st al ve in, h ow eve r, u s u al ly e m p ti es in t o t h e
l ef t b r ac h io c ep h al ic ve in . T h is re q u ire s th e v ein t o p a s s a n te ri orl y al on g t h e le f t s i de of th e s u pe ri or
m e d ias t i n u m , s p ec if i c al ly a c ros s t h e ar c h o f th e ao rta or t h e ro o t o f t h e g re at ves s el s ari s in g f ro m it an d
b et w e en t h e vag u s a n d p h re n ic n er ves ( F ig . 1 .6 0 B ) . It u s u all y re c eiv es th e lef t b ron c h i al vei n s an d m ay
re c ei ve t h e le f t p eri c ar di ac o p h ren i c vei n a s w el l. T yp i c all y, i t c o m m u n i c at es in f er io rly w it h t h e ac c es s o ry
h e m ia z yg os ve in . T h e i nt e rn al th o ra ci c ve in s ar e t h e c om pa n io n vei n s (L . ven a e c o m it an t es ) of t h e
i n te rn al th o ra c ic ar ter ie s.
Fi gu re 1 . 18 . V ei n s o f t h o ra ci c w a ll . A lt h o u gh d ep i c te d h e re a s c o n t in u o u s c h a n n el s , th e a n te ri or
an d p os t er io r in t erc o s ta l ve in s a re s ep a rat e ve s s els , n o rm a ll y d rai n in g in o p po s it e d i rec t io n s , th e
t rib u t ari es o f w h ic h c o m m u n ic a te (a n as t om os e) i n a p pr oxi m a te ly t h e an t er io r axi ll ar y li n e. B ec a u s e
t h es e ve in s la c k va lve s , h ow ever , f lo w c an b e re vers e d .
The Bot tom Line

Th e pa tt er n of d is t rib u t io n of n eu r ova s c u la r s tr u c tu r es to th e th o rac i c w a ll r ef le c ts t h e c on s t ru c t io n of
th e t h o rac i c c ag e. T h es e s t ru c t u res c o u rs e i n t h e i n te rc o st a l s p ac es , p a ral le l to t h e rib s , a n d s e rve t h e
in t erc o s ta l m u s c l es as w ell as t h e in t eg u m e n t a n d p a rie ta l p le u ra o n th e ir s u p er fi c ia l a n d d ee p a s p ec t s .
B ec au s e p l exu s f o rm at i on d oe s n ot oc c u r i n rel at io n s h ip to t h e th o ra c ic w a ll , th e p a tt er n o f p eri ph e ral
an d s eg m en t al ( de rm a to m al ) i n n er vat io n is i de n ti c al in t h is reg i on . T h e i n te rc os t al n erv es ru n a p o st er io r
to an t eri or c o u rs e a lo n g t h e l en g t h of ea ch i n t erc o s ta l s p ac e, a n d th e a n te ri or a n d p o s te rio r in t er c os t al
art eri es a n d v ein s c o n verg e to w a rd a n d an as t o m os e i n ap p ro xim at ely th e a n t eri or a xil la ry l in e. T h e
po s t eri or v es s el s a ri s e f rom t h e t h o rac i c a or ta an d d rai n to th e a z yg o s v en ou s s y s te m , an d th e an t eri or

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ve s s el s a ri se f rom t h e i n te rn al th o ra c ic ar te ry, b ran c h e s , an d tr ib u t ari es an d d ra in t o t h e in t er n al

t h or ac i c v ein , b ra n c h es , a n d t ri bu t a rie s .
Bre a sts
B ot h m en a n d w om en h ave bre a st s ( L. m a m m a e) ; n o rm a ll y t h ey ar e w e ll d e vel op ed o n ly i n w om en ( F ig .
1 .1 9 ) . T h e m am m ar y gl a nds i n th e br eas t s are ac c es s o ry t o r ep rod u c t io n in w om e n b u t are ru d im e n ta ry
an d f u n c t io n les s i n m en , c on si s t in g of o n ly a f e w s m a ll d u c t s or e pi t h eli al c ord s . U s u al ly, t h e f a t p re se n t
in t h e m a le b re as t is n o t d if f er en t fr om t h at of s u b c u t an eo u s ti s s u e el s ew h e re, a n d t h e g l an d u la r s ys t em
d oe s n o t n o rm a ll y d eve lo p . T h e b re as t s are th e m os t pr om i n en t s u p erf ic i al s tr u c tu re s in t h e an t eri or
t h ora c ic w a ll , es p ec i all y i n w om en . T h e m am m ar y gl an d s ar e in t h e s u b c u t an eo u s ti s s u e ov erl yin g t h e
p ec t ora li s m aj o r an d m in o r m u s c l es . T h e am ou n t of f at s u rro u n d in g th e gl an d u l ar t is s u e d e te rm in e s th e
s iz e of n on - l ac t at in g b rea s ts . A t th e gr eat es t p rom in en c e of t h e b rea s t i s t h e n i p pl e, s u rr ou n d ed b y a
c ir c u lar pi g m en t ed ar ea o f s k in , t h e a re o la ( L. s m a ll are a) .
Fem ale Bre asts

T h e ro u gh l y c ir c u la r b od y o f t h e f em ale br eas t re st s on a be d th a t ex te n ds t ra n s vers e ly f ro m t h e la te ral
b ord e r of t h e s t ern u m t o t h e m i d axi ll ary l in e an d ver ti c al ly f ro m t h e 2 n d th ro u g h 6 th r ib s . Tw o t h ir ds o f
t h e b ed of t h e b rea s t ar e f or m ed b y th e pec to r a l fa sci a o ve rly in g th e pe c to ra lis m aj or; t h e ot h er th i rd ,
b y th e f as c ia c ove rin g t h e s er rat u s an t eri or (F i gs . 1 . 1 9 an d 1 .2 0 ) . B et w ee n th e b re as t an d th e p ec to ra l
f as c i a is a l oo s e c o n n ec t ive ti s s u e p la n e or p o te n ti al s pa c e t h e r et r o ma m m ar y spa ce (b u rs a ) . Th i s
p la n e, c on t ai n in g a s m all am o u n t of f at , al lo w s th e b rea st s o m e d eg ree of m o vem e n t o n th e pe c to ra l
f as c i a. A s m al l p ar t o f t h e m am m a ry g la n d m ay e xt en d alo n g th e in f er ol at era l ed g e o f t h e p ec t o ral is
m a jo r t ow a rd th e axi ll ary fo s s a ( ar m p it ) , f o rm i n g an ax i l la ry p ro ce ss o r t ai l ( of S p en c e) . S om e w o m en
d is c o ver t h is ( es p ec i al ly w h en i t m a y en l arg e d u ri n g a m en s t ru a l c yc l e) an d b ec om e c on c e rn ed t h at i t
m a y be a lu m p ( t u m or ) o r en l arg e d l ym p h n o de s . Th e m am m ary g l an d is f ir m ly a t ta c h ed to th e de rm i s o f
t h e ov erl yin g s ki n , es p ec i all y b y s u b s ta n ti al s kin l ig am en t s ( L . ret i n ac u la c u ti s ), t h e s us p en so ry
l iga m en t s ( of Co op er ). T h es e co n d en s a ti on s o f f i b rou s c o n n ec t ive ti s s u e, p art ic u l ar ly w ell d evel op e d i n
t h e s u p eri or p ar t o f th e g l an d , h el p s u p p o rt t h e m a mm a ry g la nd l o bu le s.
Du r in g p u be rt y ( ag es 8 1 5 y ear s ), t h e b re as t s n o rm a ll y en l arg e, o w i n g in p art t o g la n d u lar
d eve lo pm en t bu t p rim ari ly f ro m i n c rea se d fa t d ep o s it io n . T h e are ol ae a n d n ip p les a ls o en la rg e. B re as t
s iz e an d s h ap e a re d et erm in ed b y g en et i c , et h n ic , an d d ie ta ry f ac t o rs . Th e la ct i fer o us d uct s g iv e ri s e to
b u d s t h at f or m 1 5 2 0 l o bu l e s of g l an d u la r ti s s u e, w h ic h c on s t it u t e t h e p are n c h ym a o f th e m am m ary
g la n d. E a c h lo bu l e i s d r ain e d b y a la c ti f ero u s d u c t , w h i c h u s u al ly o pe n s in d ep en d e n tl y on t h e n i pp l e. T h e
d u c ts c o n verg e to w a rd t h e n i p pl e l ike th e s p o kes o f a b ic yc l e w h e el. D ee p t o t h e a reo la , eac h d u c t h a s a
d il at ed
P .1 0 6
p ort i on , t h e l ac ti fe ro u s si nu s, in w h ic h a s m a ll dr op l et o f m il k ac c u m u lat es o r rem ai n s i n th e n u rs in g
m o th e r. A s th e i n f an t b eg in s t o s u c kl e, c o m p res s i on o f t h e a reo la ( a n d t h e l ac t if er ou s s in u s b en e at h it )
exp r es s es t h e ac c u m u l at ed d ro pl et s an d en c o u rag es t h e i n fa n t t o c o n t in u e n u r s in g as t h e h or m on a ll y
m ed i at ed le t- d ow n ref l ex en s u e s a n d th e m ot h er' s m il k is s ec r et ed in t o n ot s u c ked f ro m th e gl an d
b y t h e b ab y' s m ou t h .

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Fi gu re 1 . 19 . S up er fi cia l d is se ct io n o f fe m al e p ect o r al re gi o n. T h e p ec t or al f a s c ia h a s be en
rem ove d , exc ep t w h e re it li es d ee p t o t h e b re as t . Th e b e d o f th e b r eas t ext en d s f ro m th e 2 n d
t h rou g h t h e 6 t h r ib s . T h e ax ill ar y ta il of t h e b rea s t ex te n ds t ow ar d o r in t o t h e a xil la ry f o s sa . T h e
n on - l ac t at in g b rea s t c o n s is t s pr im a ril y o f f a t.
Fi gu re 1 . 20 . S a git t a l se ct i o n o f fem a le bre a st a n d a n te ri o r t h o ra ci c w a ll . T h e b rea s t c o n s is t s

of g la n d u la r ti s s u e an d f ib r ou s an d ad i p os e t is s u e be tw een t h e l ob es a n d l ob u l es of g la n d u lar ti s s u e,
t og et h er w it h b lo od ves s e ls , ly m p h at ic ve s s els , a n d n erve s . Th e s u pe rio r t w o t h i rd s of th e f ig u re
d em o n s tr at es t h e s u s pe n s or y li ga m en t s an d al veo li of t h e b rea s t w it h res t in g m a m m ar y g la n d
lo b u le s; t h e in f e rio r p art s h o w s la c ta ti n g m am m ary g l an d lo b u les .
T h e a reo la e c on t ai n n u m ero u s se ba ceo u s gl an ds, w h ic h en l ar ge du r in g p reg n an c y an d s ec re te a n oi ly

s u b s t an c e t h at p rov id es a p r ot ec t ive lu b ri c an t f o r t h e ar eol a a n d n i p pl e, w h ic h ar e p art ic u l arl y s u b j ec t t o
c h a f fi n g an d irr it at io n as m o th e r an d b ab y b eg i n t h e n u r s in g exp er ie n ce . Th e ni pp l e s are c on i c al o r

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c yl in d ri c al p rom i n en c e s i n th e c en t ers o f t h e a reo la e. T h e n ip p le s h ave n o f at , h ai r, or s w ea t g la n d s . Th e

t ip s o f t h e n i pp l es ar e f is s u re d w it h th e lac t i fe ro u s d u c t s op en i n g in t o t h em . T h e n i pp l es ar e c om po s ed
m o s t ly o f c i rc u l arl y ar ran g ed s m o ot h m u s c le f ib ers t h at c om pr es s th e lac t i fe ro u s d u c t s du rin g la c ta ti on
a n d e rec t th e n ip p le s i n res p o n s e to s ti m u l at io n , as w h e n a b ab y b eg in s t o s u c k le.
T h e m a m m a ry g la n d s a re m o d if i ed s w ea t g l an d s ; t h er ef or e, t h ey h av e n o s p ec i al c ap s u le o r s h ea t h . T h e
ro u n d ed c on t o u r an d m o s t o f t h e vo lu m e of t h e b rea s ts a re p ro d u c ed by s u bc u t an e ou s f at , ex c ep t d u ri n g
p re gn a n c y w h e n th e m am m a ry g l an d s en la rg e a n d n e w g la n du l ar t i s s u e f orm s . Th e m il k- s ec ret i n g a l veo l i
( L . s m al l h o llo w s p ac e s ) a re a rra n ge d i n g rap e- l ike c lu s t ers . In m o s t w om e n , th e br eas t s en l arg e s l ig h t ly
d u ri n g th e m en s t ru al pe rio d f rom i n c rea s ed rel ea s e of t h e g on a d ot rop i c h orm on es f ol li c le- s t im u l at in g
h o rm o n e ( F S H ) a n d lu t ein i z in g h o rm o n e ( LH ) o n t h e g lan d u l ar t is s u e .
Ch an ges in th e Breasts
Ch an g es , s u c h a s b ra n c h in g o f t h e l ac t if er ou s d u c ts , o c c u r in t h e b re as t t i s s u es d u rin g m en st ru a l p er io ds
an d p reg n an c y ( F er g u s on et al ., 1 9 9 2 ) . A lt h ou g h m a m m ar y g la n ds a re p rep a red f or s ec ret io n b y
m id p re gn a n c y, t h ey d o n o t p ro d u c e m i lk u n t il s h ort l y af t er t h e b ab y i s b o rn . Co lo s tr u m, a c re am y w h it e
to yel lo w i s h p r em i lk f lu i d , m ay se c ret e f ro m t h e n ip p le s du r in g th e la s t t rim es t er o f p re gn an c y an d
du r in g in i ti al ep is o d es of n u rs i n g . Col os t ru m i s be li eve d t o b e e s p ec ia ll y ric h i n p rot ei n , im m u n e ag en t s ,
an d a g ro w t h fa c to r a ff e c ti n g t h e i n f an t 's in t es t in e s . In m u lt i pa ro u s w om en , th e b reas t s of t en b ec o m e
lar g e an d p en d u lo u s . T h e b rea s ts in e ld er ly w om e n are u s u a ll y s m al l b ec a u s e of t h e d ec re as e i n f at an d
th e a t rop h y o f gl an d u l ar t is s u e.
Breast Qu adrant s
F or t h e an a t om i c al l oc a t io n a n d de s c rip t io n of t u m or s a n d c ys ts , t h e s u rf a c e of t h e b rea s t i s di vi de d in t o
fo u r q u ad ra n t s ( F i g. B 1 .5 ). F o r exa m p le , a p h ys ic i an ' s rec o rd m ig h t s ta te : A h ar d i rreg u l ar m as s w a s
fe lt in t h e s u p eri or m ed ia l q u ad ra n t o f th e br eas t at th e 2 o'c l oc k p o s it io n , ap p ro xi m at el y 2 .5 c m f rom
th e m arg i n of th e are ol a.
F igu re B1 . 5
P .1 0 7
Vasc ulature of the Br east

T h e a rte ri al s u p p ly o f th e br eas t ( F ig . 1 .2 1 A & B) d eri ve s f r om t h e:
M ed ia l m a mm a ry b ra nc he s o f p er fo ra t i ng br an che s a n d a n te rio r in ter c os t al br an c h es o f th e

in t er n al t h o rac i c art ery, ori g in a ti n g f r om t h e s u b c la via n art er y.
L a te r al th o ra ci c an d t ho r a co ac ro m i al ar t er ie s, b ra n c h es of t h e ax il lar y ar ter y.
Po s t eri or i n te rc os t a l ar ter ie s, b r an c h es o f t h e t h or ac i c a or ta i n th e 2 n d , 3 rd , an d 4 t h i n t erc o s ta l

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s p ac es .
T h e ve n ou s d ra in ag e o f th e br eas t is m a in l y t o t h e a xi l la ry v ei n , bu t t h ere i s s om e dr ain a g e t o t h e

i n te rn al th o ra c ic vei n ( Fi g . 1 .2 1 C) .
T h e l ym p h at ic d ra in a ge of t h e b rea s t i s i m p or ta n t b ec a u s e o f i ts ro le in t h e m et as t a si s of c an c e r c el ls .
L ym p h p as s e s f ro m t h e n ip p l e, ar eol a, a n d l ob u l es of t h e g la n d t o t h e s uba re o l ar ly mp ha t ic pl e xu s
( F ig . 1 .2 2 A & B ) . Fr om t h is p l exu s :
M os t ly m p h ( > 7 5 % ), e s p ec ia ll y f rom th e l at era l b re as t qu a d ran t s , d rai n s to th e axi ll ary l ym p h

n o de s , in i ti al ly t o t h e a n ter io r or pe c to ral n od e s f o r t h e m os t p art . H o w e ver,
P .1 0 8
P .1 0 9
s om e ly m p h m ay d ra in d ir ec t ly t o o th e r ax il lar y n od es o r ev en to in t er pe c to ral , d el to p ec t ora l,
s u p rac l av ic u la r, o r in f er io r d eep c er vic a l n o de s . (T h e a xil la ry l ym p h n od e s a re c o ver ed in d et ai l in
Ch a pt er 6 .)
Fi gur e 1 . 21. V as cul a tu re o f b re as t. A . Th e m am m ary gl an d is s u p p li ed f ro m it s m ed ia l

as p ec t m ai n ly b y p er f ora ti n g br an c h es o f th e i n te rn al th o ra c ic ar te ry an d b y s ev era l b ran c h e s of
th e a xi ll ary a rt ery ( p ri n c ip al ly t h e l at era l t h or ac ic a rt ery) s u p eri or ly a n d l at era ll y. B . T h e b re as t
is s u p p lie d de ep ly b y b ra n c h es ar is i n g f ro m t h e in t er c os t al a rt eri es . C . V en ou s d ra in a g e is t o
th e a xi ll ary ( m a in l y) an d in t ern a l t h or ac ic v ein s .

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Fi gur e 1 . 22. L y mp ha t ic dr a in ag e o f bre a st . A . T h e ly m p h n od es i n t h e r eg io n are s h o w n . B .

Th e red arr ow s i n d ic a te l ym p h f lo w f ro m t h e ri gh t b rea s t. M o s t l ym p h , es p ec i al ly t h at f ro m th e
s u pe rio r l at era l q u ad ra n t a n d c e n te r of t h e b rea s t, d ra in s t o t h e ax il la ry ly m p h n od es , w h ic h , in
tu r n , are d ra in e d b y t h e s u b c la vi an ly m p h at ic t ru n k an d t h en in t o th e v en o u s s y s te m via th e
rig h t lym ph a t ic d u c t. C . M os t lym ph f ro m t h e le f t b re as t r et u rn s to th e ven o u s s ys te m vi a t h e
th o rac i c d u c t, w h ic h en t ers t h e l ef t v en ou s a n g le.
M os t of t h e re m ai n in g ly m p h , pa rt ic u l arl y f ro m th e m ed ia l b rea s t q u a dr an t s , d rai n s to th e

p ara s te rn al ly m p h n o d es o r to th e op p os i te br eas t , w h e rea s lym p h f ro m t h e in f er io r q u ad ra n ts m a y
p as s d ee pl y t o ab d o m in a l l ym p h n od es ( s u b d iap h r ag m at i c i n f eri or p h re n ic l ym p h n od es ) .
L ym p h f ro m th e s kin o f t h e b re as t , exc e pt t h e n ip p le an d are ol a, d ra in s in t o t h e i p s il at era l ax il lar y,

i n f eri or d ee p c e rvi c al , an d in f ra c la vic u l ar l ym p h n od e s a n d als o in t o t h e p ar as t ern a l l ym p h n od es o f bo t h
si des.
L ym p h f ro m th e axi ll ary n od es d ra in s in t o c l avi c u la r ( in f ra c lav ic u l ar a n d s u p ra c la vic u l ar) ly m p h n od es
a n d f ro m t h em i n to th e sub cla vi a n l ym pha t i c t r un k, w h ic h al s o d ra in s l ym p h f rom t h e u p p er l im b.
L ym p h f ro m th e pa ra st er n al n o d es en t er s t h e br o nc ho m ed ia st i na l l ym ph at i c t ru nk , w h i c h a ls o dr ai n s

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l ym p h f ro m th e t h o rac i c vis c e ra. T h e t erm in at i on o f t h es e l ym p h a ti c tru n k s vari es ; t rad it i on a ll y, th e s e

t ru n ks a re d es c ri b ed as m e rg in g w i th e ac h ot h er a n d w it h t h e j ugu la r l ym ph at i c t ru nk , d rai n in g t h e
h e ad an d n ec k t o f o rm a s h o rt rig h t lym ph a ti c d u c t o n th e r ig h t s i d e or en t eri n g t h e t erm in at i on at t h e
t h or ac i c d u c t on t h e le f t s i de . H ow eve r, in m an y ( p erh a ps m os t ) c a s es , t h e tr u n ks op en i n d ep en d en t ly
i n to th e ju n c t io n of t h e in ter n al j u g u l ar an d s u b c la vi an vei n , th e ve no us a n gle , t o f o rm th e
b ra c h io c ep h al ic ve in s ( F ig . 1 .2 2 C) . In s o m e c as e s , th e y op en i n to b ot h of t h es e ve in s .
Ne rves of the Bre ast

T h e n er ves o f t h e b re as t de riv e f ro m an t eri or a n d lat er al c u t an e ou s b ra n c h es of t h e 4t h 6t h
i nt e rco s t al ne rv e s ( F ig . 1 .1 3 ) . T h e an t er io r p rim ary r am i of T 1 T 1 1 are ca ll ed in t er c os t al n e rve s
b ec a u s e t h ey ru n w it h in t h e in t er c os t al sp a c es . R am i c o m m u n ic a n te s c on n ec t ea c h an t eri or r am u s t o a
s ym pa t h et ic tr u n k. T h e b ran c h e s of th e in t erc o s ta l n e rves p as s t h ro u g h t h e d ee p f a s c ia c o ve rin g t h e
p ec t o ral is m a jo r t o re ac h t h e s kin , i n c lu d i n g t h e b re as t in t h e s u b cu t a n eou s t is s u e ove rly in g th i s m u s c le .
T h e b ra n c h es of t h e in t er c os t al n erve s th u s c o n vey s e n so ry f i b ers t o t h e s ki n o f th e br eas t an d
s ym pa t h et ic f ib er s t o t h e b l oo d v es s el s in t h e b rea s ts an d s m o ot h m u s c l e in t h e ov erl yi n g s ki n an d
n i p pl e .
Carcin oma of th e Breast

Un d e rs ta n d in g t h e lym ph a t ic d rai n ag e o f th e b re as t s is o f p ra c ti c al im p o rta n c e i n p r ed ic t in g t h e
m et as t as i s of c arc i n om a of t h e b rea s t ( b rea s t c a n c er) . Ca rc in o m as o f th e b r eas t are m al ig n an t t u m or s ,
u s u all y ad e n oc a rc in o m as a ris i n g fr om t h e ep i th e li al c e ll s of th e la c ti f ero u s d u c t s in t h e m a m m ar y g lan d
lo bu l es ( F ig . B 1 .6 A ) . M et as t at ic c an c e r c el ls t h at en t er a l ym p h at i c v es s el u s u all y p as s t h ro u gh t w o or
th r ee g ro u ps o f lym ph n o d es b ef or e en t eri n g th e v en o u s s y s te m .
In te rf ere n c e w i th t h e l ym p h at ic d ra in a g e b y c an c er m ay c a u s e ly m p h e d em a (e de m a, e xc es s f lu i d in t h e
s u bc u t an e ou s t is s u e ), w h ic h in t u rn m a y res u l t i n d evi at io n of t h e n ip p le an d a t h ic ke n ed , le at h er- li ke
ap p ear an c e o f th e s k in . P rom in en t or p u f f y s ki n be tw een d i m p led p or es g ive it an or an g e- p ee l
ap p ear an c e ( p ea u d ' ora n g e s ig n ) . La rg er d i m p les ( f in g e rti p s iz e o r b ig g er) re s u lt f rom c a n c ero u s in va s io n
of t h e g lan d u l ar t is s u e an d f ib ro s is ( f ib ro u s d e ge n era ti on ) , w h ic h c au s e s s h o rt en i n g o r p la c es tr ac t io n on
th e s u s p e n s ory l ig a m en t s . S u b areo la r b rea s t c a n c er m a y c au s e i n ve rs io n of t h e n ip p le by a s im i la r
m ec h a n is m i n vol vi n g t h e l ac t if er ou s d u c ts .
B rea s t c an c e r ty p ic al ly sp r ead s b y m ea n s of ly m p h at ic ve s s els ( ly m p h og en i c m et as t as i s ), w h ic h c a rry
c an c er c e ll s f r om t h e b rea s t t o t h e l ym p h n od e s , c h ief l y th o s e i n th e a xi lla . T h e c el ls lo d g e in t h e n od e s ,
pr od u c in g n e st s o f t u m o r c el ls ( m et as t as e s) . A b u n d an t c om m u n ic a ti on s am on g ly m p h at ic p at h w a ys an d
am o n g a xi ll ary, c e rvi c al , an d pa ra s te rn al n od es m a y al s o c au s e m et as t as e s f ro m t h e b rea s t t o d ev el op in
th e s u p r ac la vic u l ar l ym p h n o de s , th e op p os i te br eas t , o r th e ab d om e n . B ec au s e m os t of ly m p h at ic
dr ai n ag e o f t h e b re as t i s to th e axi ll ary lym p h n o d es , th e y ar e th e m os t c om m on s i te of m et as t as i s f rom
a b rea s t c a n c er. E n l arg em en t o f th e s e p al pa b le n o d es s u g ge s ts t h e p os s i b il it y of b re as t c a n c er a n d m ay
be key t o e arl y d et ec t io n . H ow eve r, t h e ab s en c e of en l arg ed a xil la ry ly m p h n od es i s n o g u ara n te e t h at
m et as t as i s fr om a br eas t c an c e r h as n ot oc c u r red b ec au s e th e m al ig n an t c el ls m a y h ave pa s s ed to ot h er
n od es , s u c h as t h e i n f rac l avi c u la r an d s u p rac l avi c u la r ly m p h n od es .
Th e po s te ri or i n te rc os t al vei n s dr ai n in t o t h e az y go s / h em i az yg o s sy s te m of ve in s al on g s i de th e b o d ies o f
th e v ert eb ra e ( F ig . 1 .3 1 B ) an d c om m u n ic a te w it h t h e in t ern a l v e rt eb ra l ven o u s p lex u s s u r ro u n di n g th e
s pi n al c ord . Ca n c er c e lls c a n als o s p rea d f ro m t h e b rea s t b y t h es e v en ou s r ou t es t o t h e ver te br ae a n d
fr om t h er e to th e c ran i u m an d b ra in . Ca n c er al s o s p re ad s b y c on t ig u i ty ( i n vas i on o f a d ja c en t ti s s u e) .
W h en b re as t c an c er c e ll s i n va de th e ret ro m am m ary s p a c e (F i g . 1 .2 0 ) , at ta c h to or i n va de th e d e ep
pe c to ra l f as c i a ov erl yin g t h e p ec t or ali s m aj o r, or m et as t as i z e to t h e in t erp e c to ral n od es , t h e b re as t
ele vat es w h en th e m u s c le co n t rac t s . T h is m o vem e n t i s a c li n ic a l s ig n o f a d van c e d c a n c er o f t h e b re as t .
To ob s er ve t h is u p w a rd m ov em en t , t h e p h ys ic i an h a s t h e p a ti en t pl ac e h e r h an d s o n h e r h ip s an d p re ss
w h il e p u ll in g h er elb o w s f or w ar d t o t en s e h er p ec t or al m u s cl es .
Mam mograph y
R ad io g rap h i c exa m in a ti on o f th e b re as t s , or m a m m o g rap h y , is on e of t h e te c h n iq u es u s ed t o d et ec t
br eas t m a ss e s (F i g . B 1 .6 B ). A c a rc in o m a a p pe ars a s a la rg e, j ag g ed d en s it y i n th e m a m m og ra m (u p p er
tw o ar ro w s in F i g. B 1 .6 C ).

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Fi gu re B 1. 6
T h e s ki n is t h ic ke n ed ov er t h e tu m or. T h e l ow er a rro w p oi n ts t o t h e d ep re s s ed n ip p le . S u rg eon s u s e

m a m m o g rap h y a s a g u id e w h en rem ovi n g br eas t tu m ors , c y s ts , a n d a b sc e s s es .
S urg ical In cision s of t he Breast

In c i s io n s are pl ac e d i n th e i n f eri or b r eas t q u ad ra n ts w h e n po s s ib l e b ec au s e th e s e q u ad ran t s ar e le s s
va s c u la r t h an th e s u pe ri or o n es . T h e t ran s i ti on b et w e en t h e th o ra c ic w a ll an d br eas t is m o s t a b ru p t
i n f eri orl y, p ro d u c in g a li n e, c re as e , o r d ee p s k in f ol d t h e in f er io r c u ta n eo u s c rea se . In c is i on s m a d e
a lo n g t h i s c r eas e w il l b e l eas t evi d en t an d m ay a c t u all y b e h i dd en b y o ver la p o f th e b re as t . In c is i on s t h at
m u s t b e m a de n ear t h e a reo la or o n th e br eas t it s el f are u s u a ll y d ire c te d r ad ia ll y to ei th e r s id e o f t h e
n i p pl e ( La n g er t en s i on li n es ru n t ra n sv ers e ly h e re; s ee t h e In t ro du c t i on ) or c i rc u m f er en t ia ll y.
M a st ec t o m y ( b rea s t e xc is i on ) is n o t a s c o m m o n as i t o n c e w a s a s a t rea tm e n t f o r b rea s t c a n c er. In
s i m p le m as t ec t om y, th e b re as t is re m ov ed do w n t o t h e re tr om a m m a ry s p ac e. R ad ic a l m a s te c to m y, a
m o re e xt en s iv e s u rg ic a l p ro c ed u re, i n vo lve s rem o va l of t h e b rea s t, p e c to ral m u s c le s , f at , fa s c ia , an d as
m a n y ly m p h n od es a s p o s s ib le in t h e ax il la a n d p e c to ral reg i on . In c u rr en t p r ac t ic e, o f te n on l y th e tu m o r
a n d s u r rou n d i n g t i ss u e s are r em o ved a lu m p e c to m y o r q u a d ran tec t o m y ( kn ow n as b rea s t- c o n s ervi n g
s u rg e r y, a w id e l oc a l ex c is io n ) f ol lo w e d b y r ad ia ti on t h era p y ( Go rol l, 2 0 0 0 ).
Poly mastia, Polyt helia, and Amastia

P o l ym a st ia ( su pe rn u m er ary b r eas t s ) or po l yt h el i a ( ac c e s so ry n i p p les ) m a y oc c u r s u p er io r or i n f eri or t o
t h e n o rm a l p ai r, oc c a s io n al ly d ev elo p in g in t h e a xil la ry f os s a or a n te rio r ab d o m in a l w a ll (F i g s . B 1 .7 an d
S A 1 .5 ) . S u p ern u m era ry b rea s ts u s u a ll y c on s i s t o f o n ly a ru d im en t ary n i p p le a n d a reo la , w h i c h m ay b e
m i s t ake n f o r a m o le (n e vu s ) u n ti l t h ey c h a n ge pi g m en t at io n w i th t h e n o rm a l n ip p le s du r in g p reg n a n c y.
H o w e ver , g l an d u l ar t is s u e m ay al s o b e p re s en t an d f u rth e r d eve lo p w it h la c ta ti on . E x tra b rea s ts m a y
a pp e ar a n yw h e re al on g a l in e ext en d in g f ro m t h e axi ll a t o t h e g ro in t h e l oc a ti on o f th e e m b ryo n ic
m a m m a ry ri d ge (t h e m i lk lin e ) f r om w h ic h t h e b rea st s d eve lo p ( M o ore an d Per s au d , 2 0 0 3 ) , an d al on g
w h ic h b rea s ts d ev elo p in an i m a ls w i th m u l t ip le br eas t s . In ei th e r s ex, t h er e m ay be n o b rea s t
d ev elo p m en t ( am a s ti a) , or th e re m a y b e a n i pp l e an d / or a reo la , b u t n o gl an d u l ar t is s u e .

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Fi gu re B 1. 7
B reast Can cer in Men

A p p ro xim at ely 1 .5 % of b rea s t c a n c ers o c c u r in m e n . As i n w o m en , t h e c an c e r u s u al ly m e ta s ta s iz e s t o
l ym p h n od e s b u t al s o t o b on e , p leu r a, l u n g, l iv er, an d s ki n . Car c in o m a o f t h e b re as t af f ec t s
a pp r oxi m at el y 1 0 0 0 m e n pe r yea r in t h e U n it ed S t at es ( S w ar tz , 2 0 0 2 ). A vi s ib l e an d / or p a lp ab l e
s u b ar eo lar m as s o r s ec ret i on f ro m a n i pp l e m ay in d ic a te a m a lig n a n t t u m o r. B rea s t c a n c er i n m al es te n d s
t o i n f il tra t e th e pe c to ra l f as c i a, p ec t or ali s m aj o r, an d ap i c al l ym p h n o de s in t h e axi ll a. A l th o u g h br eas t
c a n c er i s u n c o m m o n in m e n , th e c o n s eq u en c e s are s e rio u s b ec au s e t h ey are f r eq u en t ly n o t d e te ct ed u n t il
e xte n s ive m et as t as e s h a ve o c c u rre d f or e xam p l e, i n b o n e.
G ynecomast ia
S l ig h t t em po ra ry en l ar ge m en t of t h e b rea s ts i s a n or m al oc c u rre n c e ( f req u en c y = 7 0 % ) in m al es a t
p u b ert y ( ag e 1 0 1 2 yea rs ) . B rea s t h yp e rt rop h y i n m al es af t er p u b ert y ( gy n e co m ast i a ) i s rel at ive ly
ra re ( < 1 % ) a n d m a y b e ag e r el at ed or d ru g re la ted ( e.g ., a f te r tr eat m en t w i th d i et h yls t il b es t rol f or
p ro s ta t e c an c er ). G yn e c om a s ti a m a y al s o re s u lt fr om a n im b a lan c e be tw een e s tr og en i c an d an d ro g en ic
h o rm o n es or fr om a c h an g e i n t h e m e ta b ol is m o f se x h or m on e s by th e l iv er. T h u s a f in d i n g o f
g yn e c om a s ti a s h o u ld b e reg a rd ed as a s y m p to m , an d an e val u at io n m u s t b e in it i at ed to ru le ou t
i m p or ta n t p ot en t i al c a u s es , s u c h as s u p rar en al an d t es t ic u la r c an c e rs or c i rrh o s is ( G oro ll , 2 0 0 0 ) .
A p p ro xim at ely 4 0 % of p os t p u b ert al m al es w i th K l in e fe lt er s y n dr om e (X X Y tr is o m y) h ave gy n ec o m as t ia
( M oo re e t a l., 2 0 0 0 ) .
P .1 1 0
P .1 1 1
Th e B ott om Lin e
T h e m a m m a ry g la n d s a re i n th e s u b c u t an e ou s t is s u e o f th e b re as t , ov erl yin g t h e p ec t ora li s m aj o r an d
s e rrat u s an t er io r m u s c le s a n d as s oc i at ed d eep f as c i a ( t h e b ed of t h e b rea s t) . L ob u le s of g la n du l ar t is s u e
c o n ver ge to w a rd th e n i p p le, e ac h h av in g it s ow n lac t if e rou s d u c t , w h i c h o p en s t h ere . Th e s u p e rio r la te ral
q u ad r an t of th e br eas t h as t h e m o s t g l an d u la r t is s u e, l arg el y o w i n g t o a n ext en s i on t ow ard or in t o t h e
a xil la (a xi lla ry p ro c es s ) an d , t h eref o re, i s th e s it e of m o s t t u m o rs . T h e b rea s t i s s e rve d b y t h e i n te rn al
t h or ac i c a n d l at er al t h o rac i c v es s el s , an d t h e 2 n d 6 t h i n t erc o s ta l ve s s els a n d n e rves . M o s t l ym p h f ro m
t h e b rea s t d ra in s t o t h e a xil la ry ly m p h n od es ; t h is is s i gn i f ic a n t i n br eas t c an c e r. B ec au s e th e m am m a ry
g l an d s an d th e axi ll ary l ym p h n o de s are su p e rf ic i al , th e a b il it y to p al pa te p rim a ry a n d m et as t at ic t u m or s
d u ri n g rou t in e br eas t ex am i n at io n en ab l es ea rly d e tec t i on an d t rea tm en t .
S urface An atomy of th e Th oracic Wal l Mu scul at ure and Breasts

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T h e br ea st s a re t h e m o s t p ro m i n en t s u r f ac e f ea tu r es of t h e an t er io r th o ra c ic w a ll , es p ec ia ll y in w om e n .
E xc e p t w h en th e re i s a n ov era bu n d a n c e of s u b c u t an eo u s ti s s u e, t h e b rea s ts i n m en ar e m o st l y an
a c c en t u at io n of th e c on t ou r o f th e pec to r a li s m aj o r m u scl es , h ig h li g h te d b y t h e p re s en c e o f t h e n i p pl e
i n th e 4 th i n ter c os t al s pa c e, l at era l t o t h e M CL . I n th e m od er at ely at h let ic i n d ivi d u al , th e c o n t ou r o f t h e
p ec t o ral is m a jo r m u s c l es is a pp a ren t , s ep ar at ed in t h e m i dl in e by t h e i nt e rm a m ma ry cle ft ov erl yin g t h e
s te rn u m , w i t h t h e l at era l b o rd er f or m in g t h e a nt er i o r a xi l la ry fo ld ( F i g. S A 1 .4 ) . In f e rol at era ll y,
f o rm i n g a b ou t a t h ird of t h e b ed of t h e b rea s t , f i n g er- li ke s l ip s , o r di gi ta t io n s o f th e s er ra t us
a n t e ri o r, h a ve a s erra te d ( s a w t oo th ) ap p ea ran c e as t h ey at t ac h t o t h e ri bs a n d i n te rd ig i ta te w it h t h e
e xt e rn al o bl iq ue . Th e in fer i o r ri bs an d co st a l m ar gi ns a re o f te n ap p are n t, e s pe c ia lly w h en t h e
a bd o m i n al m u sc l es ar e c on t ra c te d t o p u l l t h e b el ly i n . Th e in t erc o s ta l m u s c u l at u re p er s e is n o t n o rm al ly
e vid en t ; h ow eve r, in ( ra re) c as es i n w h ic h t h er e is an a b s en c e o r at ro ph y of th e in t erc o s ta l m u s c u l at u re ,
t h e i n te rc os t al s pa c es b ec o m e ap p a ren t du r in g in s p i rat io n , w h e n th e y are co n c av e, an d ex p ira ti on , w h en
t h ey p ro t ru d e.
Fi gu re S A1 . 4
V a ria ti on i n th e s i z e, s h a pe , an d s ym m etr y of f em ale f in g er- l ike s lip s , o r di gi ta t i o ns o f t he s er ra t us

a n t e ri o r, h a ve a s erra te d ( s a w t oo th ) ap p ea ran c e as t h ey at t ac h t o t h e ri bs a n d i n te rg it at e w it h th e
e xt e rn al o bl iq ue . Th e in fer i o r ri bs an d co st a l m ar gi ns a re o f te n ap p are n t, e s pe c ia lly w h en t h e
a bd o m i n al m u sc l es ar e c on t ra c te d t o p u l l t h e b ell y in . T h e i n te rc o st a l m u s c u l at u re p er s e i s n ot
e vid en t n o rm al ly ; h o w ev er, i n (r are ) c a s es w h er e t h ere i s an ab s en c e or a tr op h y o f t h e i n te rc os t al
m u s c u l at u re , t h e i n te rc o s ta l s p ac es b ec o m e a p pa ren t d u rin g i n s pi ra ti on , w h en th e y ar e c on c a ve, a n d
e xp ira ti on , w h en t h ey p ro tr u de .
V a ria ti on i n th e s i z e, s h a pe , an d s ym m etr y of f em ale br eas t s e ven b et w e en t h e tw o b re as t s o f on e
p er s on i s th e ru le , n ot th e exc ep t io n . T h eir fl at t en ed s u p eri or s u r f ac es s h o w n o s h a rp de m ar c at io n
f ro m t h e an t eri or s u rf ac e o f th e t h o rac i c w al l, b u t la te ral ly a n d i n f eri or ly, t h ei r b ord e rs are w el l d ef i n ed
( F ig . S A 1 .5 ) . T h e m ed i an d ep re s s io n s e p ara ti n g t h e b re as t s is t h e in t erm am m a ry c l ef t . A v en ou s p a tt ern
o ver t h e b re as t s is of t en vi s ib l e, es p ec i al ly d u ri n g pr eg n an c y. T h e n ip p l e i s s u r rou n d e d b y t h e s l ig h tl y
ra is e d a n d c i rc u l ar p ig m e n te d a r eo l a , th e c o lo r o f w h ic h d ep en d s o n t h e w om a n 's c o m p lex io n . Th e are ol a
u s u a ll y d arke n s du r in g p reg n a n c y an d ret ai n s th e da rke n ed pi g m en t at i on t h erea f te r. T h e ar eol a i s
n o rm a ll y d ot te d w it h th e pa p u la r op en i n g s of t h e ar eo l a r gl a nds ( s eb a c eo u s g l an d s in t h e s ki n fo rm i n g
t h e a reo la ). O n oc c a s io n , on e or b o th n i pp l es are in ve rt ed ; t h i s m in o r c on g en i t al a n om a ly m ay m a ke
b re as t fe ed in g d if f i c u lt .
In m e n an d yo u n g n u l li p aro u s w o m en t h o s e w h o h ave n e ver b o rn e a via b le c h i ld w it h m od e rat e
b re as t s iz e, t h e n i pp l e li es a n ter io r t o t h e 4 th i n te rc o s ta l s p ac e, a p pr ox im a te ly 1 0 c m f ro m t h e A M L.
H o w e ver , t h e p o s it io n of n ip p l es var ies c o n s id er ab ly w it h b rea s t s i z e in w om e n , es p ec i all y m u l ti p aro u s
w om e n t h os e w h o h a ve g iv en b irt h t o vi ab le c h il dr en at le as t t w i c e. Co n s eq u en t l y, b ec au s e o f
va ri at io n s in s iz e an d s h ap e, t h e n i pp l es ar e n ot a re li ab le g u i d e to t h e 4 th i n te rc o st a l s p ac es i n ad u lt
f e m al es .

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Fi gu re S A1 . 5
P .1 1 2
Visce ra of the Thorac ic Cavity

W h e n s ec ti o n ed tra n s ver s ely , it is ap p ar en t th a t t h e t h ora c ic c av it y is ki d n ey s h a pe d : a tra n s ver s ely
ov oi d s p a c e d eep l y in d en t ed p os t er io rly b y t h e t h or ac ic v ert eb ra l c ol u m n an d t h e p os t er om e di al pa rt s of
t h e rib s ( h ea ds a n d n e c ks ) , w h i ch a rt ic u l at e w i th i t ( F ig . 1 .2 3 A ) . T h e t h ora c ic c a vit y is d i vid e d i n to th r ee
c om pa rt m en t s (F i g s . 1 .2 3 A & C ):
R ig h t an d le ft p u lm o n ar y c avi ti es , b i lat er al c o m p ar tm e n ts , w h ic h c o n ta in t h e lu n g s an d p le u ra e
(l in i n g m em b ra n es ) an d oc c u p y t h e m a jo ri ty o f th e th o rac i c c avi ty .

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Fi gur e 1 . 23. D i vi si o ns o f t ho r aci c ca vi t y an d li n in g o f p ul m o na ry c avi t i es . A . T h e CT sc a n

an d in t erp r eti ve d i ag ra m of a t ra n s vers e c ros s - s ec t io n al vie w of t h e t h or ac ic c a vit y
de m o n st ra te s th e k id n ey -l ik e s h ap e a n d d i vis i on i n to th r ee c o m p art m e n ts . ( F ro m Dea n an d
H erb e n er, 2 0 0 0 .) T h e d im e n s io n al (B ) a n d c o ro n al c r os s - s ec t io n al (C ) vie w s d em o n s tr at e th e
li n in g s of t h e p leu r al c a vi ti es an d lu n gs ( p le u rae ). T h e p ar ts o f t h e p a rie ta l p le u ra a re n am ed
af t er t h e p ort i on o f t h e w all of t h e p u lm o n ar y c avi t y th a t t h ey c o ver . E ac h lu n g i s i n ves t ed b y
th e i n n er l ay er o f a c lo s ed s ac th a t h a s be en in v ag in a te d by t h e l u n g . Th e ce rvi c al pl eu ra ,
ext en d in g a bo ve t h e r ib s , is re in f o rc ed b y an o verl yi n g f i br ou s p or ti on o f th e e n d ot h or ac ic
fa s c ia , th e s u pr ap le u ral m em b ra n e. A n o th e r p ort io n of t h e en d o th o ra c ic f as c i a, t h e
ph r en i co p le u ral f as c ia , at ta c h es t h e d ia ph r ag m at i c p a rt o f th e pa ri et al p l eu ra t o th e d i ap h ra gm .
Ins et : A fi s t i n va gi n at in g a n u n d e rin f l at ed b all oo n d em o n s tr at es t h e rel at io n s h ip o f t h e l u n g
(r ep res e n te d b y t h e f is t ) to w a ll s o f th e p l eu ra l s a c ( p ar iet al an d vi s c era l la yer s o f p leu r a) .
P .1 1 3
P .1 1 4
l
A c en t ral m ed i as t in u m, a c om p a rtm en t i n t erve n in g b et w ee n an d c om p l et el y s ep ara t in g th e tw o

p u lm on ar y c avi t ies , w h ic h c o n ta in s es s e n ti al ly a ll o t h er t h ora c ic s t ru c t u res t h e h e art , t h ora c ic
p art s of t h e g re at v es s el s , th o ra ci c p art of t h e t rac h e a, es o p h ag u s , th y m u s , an d o th e r s tru c t u re s
( e.g ., l ym p h n od es ) . It ext en d s ve rti c al ly f ro m t h e s u p eri or t h o rac i c ap ert u re to th e d i ap h ra gm an d

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an t er op o st er io rly fr om t h e t h or ac ic v ert eb ra l b od i es to th e s te rn u m .
P leurae and Lung s

T h e pu l m o n ar y ca vi t ie s ar e li n ed b y p leu r al m em b ra n es ( pl eu ra e) t h at als o ref l ec t on t o a n d c o ver t h e
e xte rn al s u rf ac e o f th e lu n g s c on t ai n ed w i th i n th e c avi ti es ( F ig . 1 .2 3 B & C) . To vis u a li z e t h e rel at io n s h ip
o f th e p l eu ra e an d lu n g s , p u s h yo u r f is t in t o a n u n de rin f l at ed b al lo on ( F ig . 1 .2 3C) . T h e i n n er p art o f t h e
b al lo on w al l ( ad j ac en t t o yo u r f is t ) , w h ic h r ep res e n ts t h e lu n g , i s c om p a rab le to th e vis c e ral pl eu ra ; t h e
re m ai n in g o u te r w a ll o f th e ba ll oo n rep re s en t s t h e p a rie ta l p le u ra. T h e c av it y b et w e en th e lay ers o f t h e
b al lo on i s an a lo go u s to th e pl eu r al c a vit y. A t yo u r w ri s t ( ro ot of t h e lu n g ) , t h e in n e r an d ou t er w al ls o f
t h e b al lo on a re c o n ti n u ou s , a s a re t h e vi s c era l a n d p a rie ta l la yer s of p leu r a, t og et h er fo rm i n g a p le u ral
s a c . N ot e t h at th e lu n g is o u ts i de of b u t s u r rou n d ed b y t h e p le u ral s ac , j u s t a s y ou r f i s t i s s u r rou n de d b y
b u t ou t s id e o f th e b a ll oo n .
T h e i n s et i n F ig u re 1 .2 3 C is a ls o h e lp f u l i n u n de rs t an d in g t h e d eve lo p m en t of t h e lu n g s an d p le u rae .
D u rin g t h e em br yon i c p eri od , t h e d eve lo pi n g lu n g s in va g in a te ( g ro w i n to ) t h e pe r ica r di o p er i to n ea l
ca n al s, t h e p ri m or di a ( b eg in n i n g s ) o f th e p l eu ra l c av it ie s ( M o ore an d Per s au d , 2 0 0 3 ) . T h e in va g in a te d
c o el om i c ep it h el iu m c o ver s t h e p ri m o rd ia o f th e l u n g s an d b ec om es th e vis c e ral pl eu r a in t h e s am e w a y
t h at th e b all oo n c ov ers yo u r f is t . T h e ep it h el iu m l in i n g th e w al ls o f t h e p er ic ar di op e rit o n eal c an al s f orm s
t h e p ar iet al p leu r a. D u rin g em br yog e n es is , t h e p le u ral c avi t ies b ec o m e s e pa rat ed f ro m th e p eri c ard ia l
a n d p e rit on e al ca vi ti es ; h ow ever , a c o n ge n it al di ap h ra g m at ic d ef e ct re s u lt s in a d ia p h rag m a ti c h ern i a
c o n n ec t in g t h e p eri to n ea l c av it y w i th o n e of t h e p le u ral c avi ti es ( u s u al ly t h e l ef t o n e) , an d t h e h ern iat i on
o f ab d om i n al vis c e ra i n to th e t h o rax ( M o ore et a l., 2 0 0 0 ).
Pl eu rae
E a c h lu n g is in v es t ed b y an d en c l os ed i n a s ero u s pl eu r al s a c th a t c o n s is t s o f tw o c o n ti n u ou s m e m b ran e s :
t h e vi s c era l p le u ra, w h ic h i n ves t s all s u rf ac e s o f th e lu n g s f orm in g th e ir s h i n y ou t er s u rf ac e, a n d t h e
p ar ie ta l p le u ra, w h ic h li n es t h e p u lm o n ar y c avi ti es ( F ig . 1 .2 3B & C) . Th e pl eu ra l ca vi t y t h e p o te n ti al
s p ac e be tw een t h e l aye rs of p le u ra c on t ai n s a c ap il la ry l aye r of se ro u s pl eu ra l f lu id , w h i c h l u b ric a te s
t h e p le u ral s u rf ac e s a n d all ow s th e l ay ers o f p l eu ra t o s lid e s m oo th l y o ver e ac h ot h er d u r in g res p i rat io n .
It s s u rf ac e te n si on a ls o pr ov id es t h e c oh e s io n th a t ke ep s th e lu n g s u rf ac e i n c on t ac t w i th t h e t h ora c ic
w al l; c on s eq u e n tl y, t h e lu n g ex pa n d s a n d fi ll s w i th a ir w h en th e th o rax exp an d s w h i le s ti ll all ow in g
s l id in g t o o c c u r, m u c h li ke a la yer o f w at er b e tw een t w o gl as s p la te s .
T h e vi sc er al pl eu ra ( pu l m o n ary p l eu ra ) c l os e ly c o ver s t h e l u n g a n d is ad h er en t to all it s s u rf ac e s ,
i n c lu d in g t h e s u rf a c es w i th i n th e h o ri z on t al an d ob l iq u e f is s u r es ; it c an n ot b e d is s e c te d f ro m t h eir
s u rf a c es ( F ig . 1 .2 4 A ) . Th e vis c e ral pl eu r a p rov id es t h e lu n g w it h a s m o ot h s li pp e ry s u rf ac e , en ab l in g it t o
m o ve f r eel y on t h e p ar iet al p leu r a. T h e vi s c era l p le u ra i s c o n t in u o u s w it h t h e p ari et al p l eu ra at th e h i lu m
o f t he lu ng, w h ere s tru c t u re s m aki n g u p t h e ro ot of t h e l u n g ( e.g ., t h e b ro n c h u s an d p u lm o n ary ves s el s )
e n te r an d le ave t h e l u n g .
T h e pa r ie t al pl eu ra li n es th e pu l m o n ary c a vi ti es , t h ere by a d h eri n g t o th e t h o rac i c w al l, t h e
m e d ias t i n u m , an d t h e d iap h r ag m . It is m o re s u b s t an t ial th a n th e vis c e ral pl eu r a, an d i n s u r ge ry a n d i n
c a da ver di s s ec t io n s , it m ay b e s e p ara te d f ro m t h e s u rf ac e s it c ove rs . T h e p ari et al p l eu ra c on s i st s o f f o u r
p ar ts :
l
l
T h e co st a l pa r t c o ver s t h e i n te rn al s u rf ac e s o f th e th o rac i c w al l.
T h e m edi a st i na l pa rt c o vers t h e l at era l as p e c ts o f t h e m e di as t in u m t h e m as s o f ti s s u es an d
o rg an s s ep ar at in g t h e p u lm o n ary c avi ti es an d t h ei r pl eu r al s a c s .
T h e di ap hr ag ma t ic p ar t c o ver s th e s u p e rio r or th o rac i c s u rf ac e o f th e di ap h ra g m on ea c h s id e o f

t h e m ed i as t in u m .
T h e ce rv ica l p le ur a e xt en d s th r ou g h t h e s u p eri or t h or ac i c a p ert u re i n to th e roo t of th e n ec k,

f or m in g a c u p - s h ap ed p le u ral d om e ove r th e ap ex o f th e l u n g (t h e p ar t e xte n d in g ab o ve t h e 1 s t r ib ) .
T h e c o s ta l p ar t o f t h e p ar iet a l p leu r a ( c os t ov ert eb ra l o r c os t al pl eu ra ) i s s ep ar at ed f rom t h e i n te rn al

s u rf a c e of t h e t h ora c ic w all ( s ter n u m , ri bs a n d c o s t al c a rt il ag es , i n ter c os t al m u s c le s a n d m em b ra n es , an d
s i d es of t h ora c ic ve rt eb rae ) b y e n do t h ora c ic f as c i a. T h is t h in , e xt rap le u ral la yer o f lo os e c o n n ec t iv e
t is s u e fo rm s a n at u ral c lea vag e p l an e f o r t h e s u rg ic a l s ep a rat io n of t h e c os t al p leu r a f ro m th e th o rac i c

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w al l ( s ee c l in ic a l c o rre lat i on [ b lu e] b ox E x tra p leu r al I n tr at h ora c ic S u rg i c al A c c es s , i n th i s c h ap te r) .

T h e m e d ias t in a l p ar t o f th e p a rie ta l p le u ra ( m e di as t in a l p le u ra) c ov ers t h e la t era l as p ec t s of t h e
m e d ias t i n u m , th e pa rt it io n b et w ee n t h e p u l m on a ry c a vit ie s . It c o n t in u es s u p er io rly i n t o t h e ro ot of t h e
n e c k as c erv ic a l p le u ra. It is c o n ti n u ou s w it h c os t al p l eu ra an t eri or ly a n d p o s te rio rl y an d w i th t h e
d i ap h rag m a t ic p leu r a in fe rio rl y. S u p eri or t o t h e r oo t o f t h e l u n g , th e m ed ia s ti n al pl eu ra is a c o n ti n u ou s
s h e et p a s s in g an t ero p os t eri or ly b et w een t h e s t ern u m a n d t h e ve rt eb ral c ol u m n . A t t h e h i lu m o f th e l u n g ,
t h e m e di as t in a l p le u ra r ef le c ts l at era ll y on t o t h e s t ru c t u res m a kin g u p th e roo t o f th e lu n g an d b ec o m es
c o n ti n u ou s w it h th e vis c e ral pl eu ra .
In f e rio r t o t h e ro ot of t h e lu n g , t h is c o n ti n u it y b et w e en p ari et al a n d vis c e ral pl eu ra is an em p ty
d o u bl e l aye r of p le u ra, t h e pu lm o n ar y l ig am e nt , ext en d i n g b et w e en t h e lu n g an d t h e m e di as t in u m ,
i m m ed i at el y an t eri or to th e e s op h a gu s ( F ig . 1 .2 6 ) . W h en th e roo t of th e lu n g is s ev ere d a n d t h e l u n g i s
re m o ved , t h is d ou b l e la yer o f pl eu r a ap p ea rs to h an g f ro m th e r oo t,
P .1 1 5
s i m il ar t o t h e m a n n er i n w h i c h t h e l arg e s l ee ve o f a Ch in e s e ro be h an g s f rom t h e f o rea rm . T o vi s u al iz e
t h e ro ot of t h e l u n g, t h e p l eu ra l s le eve s u r rou n d i n g i t , an d th e pu l m o n ary l ig a m en t h an g in g f ro m it , p u t
o n an ex tra - lar g e la b c o at an d ab d u c t y ou r u p p er l im b. Y o u r f ore arm is c om pa rab l e t o t h e ro ot of t h e
l u n g , an d th e co at s le eve r ep res e n ts t h e p le u ral s le eve s u r rou n d i n g t h e ro ot . T h e p u lm on ar y li g am e n t i s
c o m p ara b le t o t h e s l ac k o f t h e s l eev e as i t h a n gs f ro m yo u r f or ear m ; a n d you r w ri st , h a n d, a n d a b d u c ted
f i n ge rs rep re s en t th e b r an c h in g s t ru c t u res o f t h e ro ot t h e b ro n c h i a n d p u l m on a ry ve s s el s.
Fi gu re 1 . 24 . R e la t i o nsh i p o f t h or a ci c c o nt en t s an d li n in gs o f t ho r aci c ca ge . A . T h e ap i c es of
t h e lu n g s an d c er vic a l p le u ra ex te n d i n t o t h e n ec k. T h e l ef t s t er n al r ef le c ti on o f p a rie ta l p le u ra
d evi at es aw ay f ro m t h e m ed i an p la n e t ow ard t h e le ft s id e i n th e reg i on of t h e l u n g' s c ard i ac n ot c h ,
le avi n g a b are area , w h e re t h e p eri c ard i al s a c is ac c e s s ib le fo r n ee d le p u n c t u re w it h ou t tr ave rs in g
t h e lu n g or pl eu ra l c a vit y. B D. T h e s h a pe s of t h e p ari et al p l eu ra an d lu n g s d u rin g q u ie t
res p i rat io n ar e d em o n s tr at ed . Th e c os t od i ap h rag m at ic rec e s s es , n ot o c cu p i ed b y lu n g , ar e w h e re
p leu ral exu d at e a c c u m u la te s w h en t h e b od y i s erec t . O b s erve th a t t h e o u tl in e o f th e h ori z on t a l

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f is s u re in t h e ri gh t lu n g c l ear ly p ar all el s th e 4 th ri b . (R i b s are i d en t if i ed by n u m b er.)
P .1 1 6
Fi gu re 1 . 25 . D i ap hr ag m, ba se o f p ul mo n a ry ca vi t ie s a nd m ed ia st i nu m, a nd
co st o di a phr a gm at i c re ces se s. M os t of t h e d iap h r ag m at i c p l eu ra h as b een re m ov ed . A t t h is l eve l,
t h e m ed i as t in u m c o n s is t s of th e p eri c ard ia l s a c ( m i d d le m e d ias t i n u m ) a n d th e p o s te rio r
m ed i as t in u m , m ain ly c o n ta in i n g t h e e so p h ag u s an d ao rt a. T h e d ee p g ro o ve s u rro u n d in g t h e
c on v exi ty o f th e di ap h ra g m is t h e c os t o di ap h ra g m at ic re c es s , li n ed w i th p a rie ta l p le u ra. T h e
p eri c ard i u m an d c os t o m ed ia s ti n al rec es s e s an d , b et w ee n th e m , an ar ea o f pe ric a rd iu m o n ly (t h e b ar e
ar ea) li e b et w e en th e h ear t a n d t h e t h or ac ic w al l at th i s le vel .
T h e d ia p h rag m a ti c p art of t h e p ari et al pl eu ra (d i ap h ra gm at ic p le u ra) c ov ers t h e s u p eri or su r f ac e o f t h e

d i ap h rag m , e xc ep t al on g it s c os t al at ta c h m en t s (o ri g in s ) an d w h er e t h e d ia ph r ag m is f u s ed t o t h e
p e r ic a r d iu m, t h e f ib ro s er ou s m em b ran e s u r rou n d i n g t h e h e art ( Fi g . 1 .2 3B & C ). A t h in , m ore e la s ti c la yer
o f en d ot h or ac i c f a s c ia, t h e p hre n ico p le ur a l fa sci a , c on n ec t s t h e d iap h r ag m at i c p l eu ra w it h t h e m u s c u la r
f i be rs of t h e d ia p h rag m ( F ig . 1 .2 3 C ).
T h e c er vic a l p le u ra ( p le u ral c u pu l a, d o m e o f p l eu ra ) i s th e d o m e- s h ap e d c a p o f th e pl eu ra l s a c a n d is t h e
s u p er io r c on t in u a ti on o f th e c o s t al a n d m ed ia s ti n al pa rt s of th e p ari et al p l eu ra . Th e c ervi c al pl eu ra c ove rs
t h e a pe x of t h e lu n g t h at ext en d s s u p eri or ly t h ro u gh t h e s u p er io r th o ra ci c ap er tu r e in t o t h e ro ot of t h e
n e c k (F i g . 1 .2 4 A ) . Th e s u m m it of t h e c er vic a l p le u ra i s 2 3 c m s u p eri or t o t h e l eve l of t h e m e di al th i rd
o f th e c l avi c le at th e l eve l o f t h e n e c k of t h e 1 s t r ib . T h e c erv ic al p leu r a is r ein f o rc ed b y a f i br ou s
e xte n s io n of t h e en d ot h o rac i c f as c ia t h e su pra pl e ur al me m bra n e ( S ib s on f a s c ia) , w h ic h at t ac h es t o
t h e i n te rn al bo rd er o f th e 1 s t ri b an d th e tra n s ver s e p roc e s s of C7 ve rte b ra ( F ig . 1 .2 3C ).
T h e re la ti vel y ab ru p t li n es al on g w h i c h th e pa ri et al p l eu ra c h a n g es d ire c ti on a s i t p a s s es ( ref le c ts ) f ro m
o n e w a ll of t h e p leu r al c a vi ty t o a n ot h er a re t h e l in es o f pl eu ra l re f lec t io n ( F ig s . 1 .2 4 an d 1 .2 5 ) :
T h e st e rn al li ne of p le u ral ref l ec t io n is s h ar p o r ab ru p t an d oc c u r s w h ere th e c o s t al p l eu ra b e c om e s

c on t i n u ou s w i t h t h e m e d ia st i n al p l eu ra an t eri orl y.
T h e co st a l l i ne of p leu r al r ef le c ti on i s a ls o s h arp a n d o c c u rs w h er e t h e c os t al pl eu r a b ec om es

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c on t i n u ou s w i t h d i ap h ra gm at ic p le u ra i n f eri orl y.
P .1 1 7
l
T h e ve rt e bra l l i ne of p le u ral ref l ec t io n i s a m u c h ro u n d er, g ra d u al r ef le c ti on a n d o c c u rs w h e re t h e

c os t a l p leu r a b ec o m es c o n ti n u ou s w i t h t h e m ed ia s ti n al p l eu ra po s t eri orl y.
T h e ri g h t a n d l ef t s ter n al ref le c ti on s o f pl eu ra are in d ic a te d b y l in e s t h a t p as s i n fe ro m ed ia ll y f ro m th e

s t ern o c la vi c u lar jo in t s to th e A ML at t h e le vel o f th e s te rn al an g le . B et w ee n t h e l eve ls o f c o s ta l c a rti la g es
2 4 , th e p l eu ra l s a cs c o m e i n c on t ac t an d m ay even s l ig h t ly o ver la p e ac h ot h er .
T h e s t ern a l l in e o f pl eu ra l re f lec t io n on t h e ri g h t s i de pa s s es in f e rio rl y in t h e m e di an p la n e t o t h e
p o s te rio r as p ec t of t h e xi p h oi d p ro c es s ( le vel of th e 6 th c o s ta l c ar ti la g e) , w h er e it tu r n s lat er al ly ( F ig .
1 .2 4 ). T h e s t ern a l l in e o f ref le c ti on o n th e lef t s id e p as s e s in f eri or ly i n th e m ed ia n pl an e on l y to th e lev el
o f th e 4 t h c os t al c art i lag e . H ere it pa s s es t o t h e le ft m a rg in o f t h e s t ern u m a n d th e n c o n t in u es i n f eri orl y
t o t h e 6 t h c os t al c art il ag e, c r eat in g a n o t c h , w h ic h i s s h all ow er t h an t h e c a rd iac n o tc h o f th e l u n g an d
a ll ow s a pa rt of t h e p eri c ard i u m (h e art s ac ) t o b e in d i rec t c on t ac t w i th t h e an t er io r th o ra c ic w a ll . Th i s is
i m p or ta n t f o r pe ri ca rd io c en t es i s (s e e c li n ic a l c or rel at io n [b l u e] bo x, Pe ri ca rd io c en t es i s , in t h is
c h a pt er ).
T h e c o s ta l l in e o f p l eu ra l re f lec t io n p as s es o b liq u e ly a c ros s t h e 8 t h rib i n t h e M CL , t h e 1 0 t h r ib in t h e
M A L , an d th e 1 2 th ri b at it s n ec k or in f er io r to it . T h e ver te br al l in e of p leu r al r ef le c ti on p ar al lel s th e
ve rt eb ra l c ol u m n , ru n n i n g in t h e p ara vert eb ra l p l an e f ro m ver te b ral lev el T 1 t h rou g h T 1 2 .
T h e l u n gs d o n ot oc c u p y t h e p u lm o n ar y c avi ti es c o m p let el y d u ri n g e xp ira ti on ; t h u s th e p e rip h e ral
d i ap h rag m a t ic p leu r a is i n c on t ac t w i th t h e lo w e rm o s t p ar ts o f t h e c o s ta l p le u ra. T h e p o te n ti al pl eu ra l
s p ac e s h ere a re t h e co s to d ia ph ra gm at i c re ce sse s, p le u ra- l in ed g u tt er s , w h ic h s u rr ou n d t h e
u p w a rd c on v exi ty o f th e di ap h ra g m in s i de th e t h o rac i c w al l ( F ig s . 1 .2 3 C an d 1 .2 5 ) . S im i la r b u t s m a ll er
p l eu ra l rec e s s es ar e lo c at ed p os t eri or t o t h e s t er n u m w h er e th e c os t al pl eu ra is in c o n t ac t w it h th e
m e d ias t i n al p l eu ra . Th e po t en t ial p leu r al s p a c es h ere are t h e co s to m e di as ti n al re ce sse s; th e l ef t
re c es s is p o te n ti al ly l arg er (l es s oc c u p i ed ) b e c au s e o f t h e c a rd ia c n o t c h in t h e le ft lu n g . T h e i n fe ri or
b o rd ers o f t h e l u n g s m ove fa rt h er i n to th e pl eu ra l r ec es s es d u ri n g d e ep in s p ir at io n an d ret re at f r om t h em
d u ri n g exp ir at io n .
Inj uri es to t he Cerv ical Pleura and Ap ex of Lu ng

B ec au s e o f th e in f er io r s lo pe of t h e 1 s t p a ir o f r ib s an d t h e s u p eri or t h o rac i c a p ert u re t h ey f o rm , t h e
c ervi c al pl eu ra an d ap ex of t h e lu n g p ro je c t t h ro u gh t h is o p en in g i n to th e n e c k, p os t er io r to th e in f er io r
at ta c h m en t s of t h e s te rn o c lei d om a s to id m u s c l es . Co n s eq u en t ly , th e l u n g s an d p leu r al s a c s m ay b e
in j u red i n w ou n d s t o t h e b as e o f th e n ec k re s u lt in g in a p ne um o t ho r ax , t h e p res e n ce of ai r ( G. p n eu m a)
in t h e p leu r al c a vi ty. T h e c e rvi c al p l eu ra rea ch e s a re lat i vel y h ig h er l ev el i n in f an t s an d yo u n g c h i ld re n
be c au s e o f th e s h o rt n es s o f t h ei r n ec ks . C on s eq u e n tl y, t h e c erv ic al p leu r a is e s pe c ia lly vu ln e rab l e to
in j u ry d u ri n g t h e f i rs t f e w yea rs af t er b i rt h .
Inj ury to Oth er Part s of t he Pleurae

Th e pl eu ra e d es c en d i n fe ri or t o t h e c o s ta l m a rg in in t h re e reg i on s , w h ere a n ab d om i n al in c i s io n m ig h t
in a dv ert en t ly e n te r a p le u ral s ac : th e rig h t pa rt of t h e in f ra s te rn al an g le an d ri gh t an d le f t c o s to ver te br al
an g le s . Th e sm al l ar eas o f p l eu ra exp o s ed in t h e c os t ov ert eb ra l an g l es in f e rom ed ia l t o t h e 1 2 t h rib s ar e
po s t eri or t o t h e s u p er io r p ol es of t h e ki dn e ys . T h e p leu r a is i n da n g er h e re ( i.e ., a p n eu m o t h ora x m ay
oc c u r) f ro m an in c i s io n in t h e p os t er io r ab d om i n al w a ll w h en s u rg ic a l p ro c ed u res e xp os e a kid n e y, f or
ex a m p le .
Pulm onary Collapse

Th e lu n g s (m ore s pe c if i ca ll y, t h e ai r s ac s t h at c ol lec t i vel y m ak e u p th e l u n g ) a re c o m p ara b le t o a n
in f la te d ba ll oo n w h en t h ey a re d i s ten d e d. I f t h e d is t en s i on i s n ot m ai n ta in e d, t h ei r in h e ren t el as t ic i ty w il l
c au s e t h em t o c o ll ap s e ( s ec o n da ry a te lec t as i s is t h e c ol la p s e of a p re vio u s ly in f la te d l u n g ; p r i m a r y
at ele c ta s is re f ers t o t h e f ai lu re of a l u n g t o i n f la te a t b i rt h ). A n i n fl at ed b al lo on re m ai n s d is t en d ed on l y
as lo n g as it s ou t le t i s c lo s ed . N or m al lu n g s in s it u re m ai n di s te n d ed eve n w h en t h ei r ou t le t ( t h e ai rw a y)
is op e n b e c au s e t h ei r ou t er s u r f ac es ( vi sc e ral p leu r a) ad h er e to th e in n er s u rf ac e o f th e t h o rac i c w al ls
(p a rie ta l p le u ra) as a res u l t o f t h e s u rf a c e t en s io n c on s eq u e n t t o t h e p le u ral f lu i d b et w e en t h em . T h e
ela s ti c rec o il of t h e lu n g s c au s e s t h e p re s s u re i n t h e p l eu ra l c av it ies t o b e s u b - at m o s p h eri c . Th e p r es s u re
is u s u al ly a b ou t -2 m m H g ; d u ri n g in s p ir at io n , it dr op s to ab o u t - 8 m m H g .
If a p en et ra ti n g w ou n d ( h ol e) op en s t h ro u g h t h e t h or ax o r in t h e l u n gs , a ir w il l b e s u c ke d i n to t h e p leu r al
c avi ty b e c au s e o f t h e n e ga t ive p r es s u re ( F ig . B 1 .8 ) . T h e s u rf a c e te n s io n ad h eri n g vis c e ral to pa ri et al
pl eu ra ( lu n g to th o ra c ic w a ll ) w il l b e b ro ken , a n d t h e l u n g w il l c o lla p s e, ex pe ll in g m o s t o f i ts a ir b ec a u s e

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o f it s i n h er en t e la s ti c it y ( ela s ti c rec o il ) . W h en a lu n g c ol la ps e s , th e p l eu ra l c a vit y ( n or m al ly a po t en t ial

s p ac e ) b e co m e s a rea l s p ac e . T h e p l eu ra l s ac s d o n o t n orm all y c om m u n ic a te ; t h u s on e lu n g m ay be
c o ll ap s ed af t er s u r ge ry, f o r exa m p le , w it h o u t t h e ot h er lu n g c ol la ps i n g . La c era ti on o r ru p t u re o f t h e
s u rf a c e of a l u n g (a n d it s vis c er al pl eu ra ) o r p en e tra t io n o f th e th o rac i c w al l ( an d i ts p ar iet al p leu r a)
re s u lt s in h em orr h ag e a n d t h e en t ra n c e of a ir i n to th e pl eu ra l c a vit y. T h e a m ou n t of b lo od a n d a ir t h at
a c c u m u la te s de te rm i n es th e ext en t of p u lm o n ar y c ol la ps e .
Fi gu re B 1. 8
W h en t h e lu n g c o lla p s es , it oc c u p i es le s s v ol u m e w it h in t h e p u lm o n ar y c avi ty an d th e pu l m o n ary c a vi ty

d o es n ot in c r eas e i n s iz e ( i n fa c t, i t m ay d ec r eas e i n s iz e ) d u ri n g in s p ira t io n . Th i s red u c t io n i n s iz e w il l
b e e vid en t ra di og r ap h ic a ll y on t h e af f e ct ed s i de by ele vat io n of t h e d ia p h rag m a bo ve u s u a l l eve ls ,
i n te rc os t al s p ac e n a rro w i n g ( ri bs c l os e r to g et h er) , an d d is p l ac em en t o f th e m ed ia s ti n u m ( m ed i as t in a l
s h i f t; m o s t ev id en t vi a th e ai r- fi ll ed t rac h ea w i th i n it ) t o w ar d t h e a ff e c te d s i d e. In ad d it i on , t h e c ol la p s ed
l u n g w il l p ro b ab ly a p pe ar m ore de n s e ( w h it er ) s u r rou n d ed b y m o re r ad io lu c e n t ( b la c ker) ai r.
In o p en - c h es t s u r g ery, r es p ira ti on a n d l u n g in f la t io n m u s t b e m a in t ai n ed b y in t u b at in g t h e tr ac h ea w i th a
c u f f ed t u be an d u s in g a p o s it ive -p r es s u re p u m p , va ryi n g t h e p re s s u re t o a lt ern a te ly i n f lat e a n d d e fl at e
t h e l u n gs .
Pn eu moth orax, Hyd roth orax, and Hem ot hor ax

E n t ry o f air in t o t h e p le u ral c avi ty ( p n e u m ot h or a x) , re s u lt in g f rom a p en et ra ti n g w ou n d o f t h e p a rie ta l
p l eu ra f r om a b u l le t, f o r exa m p le , or f ro m ru p t u re o f a pu lm o n ary les i on i n to th e pl eu ra l c a vit y
( b ro n c h op u lm on a ry f is t u la ) , res u l ts in c o ll ap s e o f t h e l u n g (F i g . B 1 .8 ). F r ac t u red ri bs m a y al s o t ea r th e
vi s c era l p l eu ra a n d lu n g , th u s p ro d u c in g p n eu m o th o ra x. T h e ac c u m u l at io n of a s i g n if ic a n t a m o u n t o f f l u id
i n th e p l eu ra l c av it y ( hy dro t ho r a x) m a y res u l t f ro m pl eu ra l effu si o n ( es c a pe of f lu i d i n t o t h e p leu r al
c a vit y) . W i t h a c h es t w ou n d , b l oo d m ay a ls o e n te r th e pl eu r al c a vit y ( he m o th o ra x ) ( F i g. B 1 .9 ).
H e m ot h o rax r es u lt s m o re c o m m o n ly f ro m in j u ry to a m a jo r in t er c os t al or i n te rn al th o rac i c ves s e l t h an
f ro m la c era ti on o f a lu n g . If b ot h ai r an d f lu id (h e m o pn e u m ot h o r ax , if th e fl u id i s b l oo d ) a c c u m u la te in
t h e p le u ral c avi ty , an ai r f l u id le vel or i n te rf ac e ( s h a rp lin e, h or iz o n ta l re ga rd le s s of th e p at ien t 's
p o s it io n , in d ic a ti n g th e u pp er s u rf ac e o f th e f l u id ) w i ll b e s e en on a rad i og ra ph .
Th orac en tesis
S o m et im es it is n ec e s s ary t o i n s ert a h y po d erm ic n eed l e t h rou g h a n i n t erc o s ta l s p ac e i n to t h e p leu r al
c a vit y ( t ho r ace n te s i s) to ob t ai n a s am p l e of f l u id or t o r em o ve b l oo d o r p u s (F i g . B 1 .1 0 ) . To avo id

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d am ag e t o t h e i n ter c os t al n erve an d ves s e ls , t h e n ee dl e i s i n s ert ed s u p eri or to th e r ib , h ig h en o u g h to

a voi d th e c o ll at er al b ra n c h es . T h e n ee dl e p as s e s t h ro u g h th e i n t erc o s ta l m u s c l es an d c os t al p ari et al
p l eu ra i n t o t h e p leu r al c a vi ty. W h en t h e p at ie n t i s in t h e u p rig h t po s it i on , i n tra p leu r al fl u id ac c u m u lat es
i n th e c o s t od ia p h rag m a ti c rec e s s . I n s ert in g t h e n ee dl e in t o th e 9 t h in t er c os t al s pa c e in t h e m i d axi ll ary
l in e d u ri n g exp i rat io n w i ll a vo id th e in f er io r b ord er of t h e lu n g . T h e n ee dl e s h o u ld b e an g l ed u pw ard , t o
a voi d pe n et rat i n g t h e d ee p s i d e of t h e rec e s s (a th i n lay er o f d i ap h ra gm at ic p ar iet al p leu r a an d
d i ap h rag m o ver lyi n g th e l iv er) .
Fi gu re B 1. 9 . H e mo t h o ra x i n r ig ht l u ng ca vi t y.
Fi gu re B 1. 1 0. T ec hni qu e fo r t h o ra ce nt es is ( in MA L )
In serti on of a Chest Tu be
M aj o r am ou n t s of ai r, b lo od , s er ou s f lu i d , pu s o r an y c om b i n at io n of th e s e s u b s ta n c es in t h e p le u ral
c a vit y a re t yp ic a ll y rem o ve d b y p la c em e n t o f a c h es t tu b e. A s h o rt i n c is i on i s m ad e i n th e 5 t h o r 6 th
i n te rc os t al s p ac e i n th e m id ax il lar y li n e ( w h i c h i s ap p ro xim a t ely a t n i p p le l eve l) . Th e tu b e m ay b e
d i rec t ed s u p eri orl y ( to w a rd to th e c ervi c al pl eu ra or p l eu ra l c u p u la ) f o r ai r rem ova l o r in f e rio rl y (t o w ar d
t h e c o s to d iap h r ag m at i c r ec es s ) f or f l u id d rai n ag e. T h e e xtr ac o rp ore al en d of t h e tu b e ( i .e., t h e en d t h at
i s ou t s id e o f t h e b o d y) i s c on n e c ted t o a n u n de rw a te r d rai n ag e s ys t em , of t en w i th c o n tr ol led s u c t io n , to
p re ven t ai r f rom be in g s u c ked b ac k i n t o t h e p leu r al c a vi ty. R em o val of ai r al lo w s re in f la t io n o f a
c o ll ap s ed lu n g . F a il u re t o re m ov e f lu i d m ay c au s e th e l u n g to d evel op a r es is t an t f ib ro u s c ov eri n g t h at
i n h ib i ts ex pa n s io n u n les s i t i s pe el ed (l u n g d e c ort ic a t io n ).

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Th orac oscopy
T h o ra c o s co p y is a d i ag n o s ti c a n d s om e ti m es t h era p eu t ic p roc e d u re i n w h ic h t h e p le u ral c avi ty is
e xam i n ed w i th a th o rac o s c op e ( F i g. B 1 . 1 1 ). S m all in c i s io n s are m ad e in to th e p l eu ra l c av it y vi a an
i n te rc os t al s p ac e. In a d di ti on t o o b s erv at io n , bi op s i es c an b e t ak en an d s om e th o ra c ic c on d i ti on s c a n b e
t rea t ed (e .g ., di s ru p t in g ad h es i on s o r rem ovi n g pl aq u es ) .
Pleur itis (Pleuri sy)

D u rin g i n s pi ra ti on a n d e xp ira ti on , t h e s l id in g o f n orm a ll y s m o ot h , m o is t pl eu ra e m a kes n o de te c ta bl e
s o u n d d u r in g au scu lt a t io n of t h e l ung s ( li s ten i n g to b rea th s o u n ds ) ; h ow eve r, in f l am m a t io n o f th e
p l eu ra , ple ur i ti s o r pl eu ri s y , m ak es th e lu n g s u rf ac e s rou g h . T h e re s u lt in g f ric t i on ( p leu r al r u b) is
d et ec t ab l e w i th a s te th o s c op e. It s ou n d s l ike a c lu m p o f h a ir b e in g ro ll ed be tw een t h e f in ge rs . T h e
i n f lam ed s u rf ac e s o f pl eu r a m ay als o c au s e t h e p ar ie ta l an d vi s c era l l aye rs of p le u ra t o a dh e re ( p leu ral
a dh e s io n ) . Ac u t e p l eu ri ti s is m a rked b y s h ar p, s t ab b i n g p a in , es p ec i al ly o n exe rt io n , s u ch a s c li m b in g
s t ai rs , w h e n th e r at e an d d ep t h of res p i rat io n m ay be in c re as ed ev en s li g h tl y.
Fi gu re B 1. 1 1
Pleur ect omy an d Pleurod esi s

O b li te rat i on o f a pl eu ra l c a vit y b y d is e as e s u c h as p l eu ri ti s (i n f la m m at i on of p l eu ra ) o r d u rin g s u rg er y
( pl eu re ct o m y, o r exc i s io n of a p ar t o f t h e p l eu ra , fo r ex am p l e ( F ig . B 1 .1 1 ) do es n o t c a u s e ap p rec i ab l e
f u n c t io n al co n s eq u en c e s ; h o w e ver, i t m ay p ro d u c e p a in d u ri n g exe rti on . I n o t h er p ro c e d u res , a d h eren c e
o f th e p a rie ta l an d vi s c era l l aye rs of p le u ra i s in d u c ed b y c ov eri n g t h e a pp o s in g la yer s o f p leu r a w i th a n
i rri ta ti n g po w d er or s c l ero s in g ag en t ( pl eu ro de si s) . Pl eu r ec to m y a n d p l eu ro d es is a re p er fo rm e d t o
p re ven t rec u r rin g s p on t an e ou s s ec o n d ary a t ele c ta s is ( s po n t an eo u s lu n g c ol la p s e) c au s ed b y c h ro n ic
p n eu m ot h or ax o r m al ig n a n t ef f u s i on re s u lt in g f ro m lu n g d is ea s e ( A h ya e t a l., 2 0 0 1 ) .
P .1 1 8
P .1 1 9
P .1 2 0
Th e B ott om Lin e
T h e t h or ac ic c a vit y i s d i vi de d i n to t h ree c o m p ar tm e n ts : t w o b i la te ral pu l m o n ary c a vit i es th a t a re e n ti rel y
s e pa rat ed b y t h e c en t ra l m ed i as t in u m . T h e p u l m on a ry c a vit ie s are c o m p le te ly l in e d b y m e m b ran o u s
p ar ie ta l p le u ra t h at ref l ec t s o n t o t h e lu n g s at t h eir roo ts , b e c om i n g t h e v is c er al p l eu ra t h a t i n ti m at el y
i n ves t s th e lu n g s ' o u te r s u rf ac e . Th e p l eu ra l c av it y b et w ee n th e tw o la yer s of th e p leu r al s a c is em p t y,
e xc ep t f o r a l u b ric a ti n g fi lm o f p leu r al f l u id . T h e p le u ral fl u id al s o m ain t ai n s th e s u rf ac e t en s i on t h at
ke ep s th e s u rf ac e o f th e l u n g ap p li ed to th e in t ern a l s u rf a c e of t h e t h ora c ic w a ll , p reve n ti n g c ol lap s e o f
t h e o pe n res p i rat or y s ys t em , an d c a u s in g th e lu n g s to exp a n d w h en t h e th o ra x exp a n ds f o r in h a la ti on .
M o s t o f t h e p ar ie ta l p le u ra i s n a m ed f or th e s t ru c t u re s i t c o ver s : c o s ta l, m e d ias t i n al, a n d di ap h ra g m at ic .
T h e c er vic a l p le u ra e xt en d s as a p ea k or d o m e a bo ve t h e a n te rio r as p e c t o f t h e 1 s t rib a n d c l avi c le in t o
t h e ro ot of t h e n ec k . Par ie ta l p le u ra i s s e n s it iv e, b ein g i n n erva t ed by th e p h re n ic a n d i n te rc os t al n erv es .
B e c au s e t h e lu n g s d o n o t c o m p le te ly f i ll t h e p u l m on a ry c a vit ie s , an d b ec au s e o f th e pr ot ru s i on o f t h e
d i ap h rag m a n d u n d e rly in g ab d om in a l vi s c era i n to t h e in f er io r th o ra c ic ap e rtu r e, a p er ip h er al g u t te r t h e
c o s to d ia ph r ag m a ti c r ec es s is f or m ed . E xt rap u l m o n ary f l u id s ( exu d at es ) ac c u m u l at e i n th i s s pa c e w h e n
t h e t ru n k i s e rec t . A w a ren e s s o f th e ext en t of t h e lu n g s an d p le u ral c avi ti es i s i m p or ta n t f o r p h ys ic a l

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e xam i n at io n an d d et ec t io n of d is e as e.
L un gs
T h e lu n g s are th e vit al org a n s of res p i rat io n . T h eir m ai n fu n c t i on is t o o xyg e n at e th e bl oo d b y br in g i n g
in s p i red ai r in t o c l os e rel at io n w it h t h e ven o u s b lo od in t h e p u lm on a ry c ap i ll ari es . A lt h o u gh c a da ver ic
lu n g s m a y b e s h ru n ke n , fi rm o r h ar d t o t h e t ou c h , a n d d i s c ol or ed in ap p ea ran c e , h eal th y lu n g s in l ivi n g
p eo pl e ar e n or m al ly l ig h t , s of t , an d s p on g y, a n d f u l ly o c c u p y th e p u lm o n ary ca vi ti es . T h ey a re al s o e la st i c
an d re c oi l t o ap p ro xi m at el y on e t h i rd th e ir s i z e w h e n t h e t h or ac i c c a vit y i s op en e d ( F ig . 1 .2 3 C ). T h e l u n g s
ar e s ep ar at ed fr om e ac h ot h er by th e m ed ia s ti n u m , t o w h i c h th e y are at ta c h ed b y th e ro o t s o f th e
l un gs t h at is , t h e b ro n c h i ( an d as s o c ia te d b ro n c h ia l ve s s els ) , p u lm on a ry ar te rie s , s u pe rio r a n d i n f eri or
p u lm o n ar y vei n s , th e pu l m o n ary p l exu s e s o f n erv es (s y m p at h et ic , p ar as ym pa th e ti c , an d vi s c era l af f er en t
f ib er s ), a n d l ym p h a ti c ves s el s (F i g . 1 .2 6 ) . If th e r oo t i s s ec ti on e d be f ore th e ( m e di al to ) br an c h in g o f t h e
m a in ( pr im a ry) b ron ch u s a n d p u l m on ary a rt ery, i t s g e n era l ar ran g em en t i s
Pu l m on a ry a rte ry, s u p er io rm o s t o n l ef t (t h e s u p er io r lo b ar o r ep art er ia l b ron c h u s m ay b e

s u pe rio rm o s t o n t h e rig h t ) .
S u pe rio r a n d i n f eri or p u l m on a ry ve in s , a n te rio rm o s t a n d i n f eri or m os t , res p e c ti vel y.
B ron c h u s , a g ain s t an d ap p ro xi m at el y in t h e m i d dl e o f t h e p o s ter io r b ou n d ar y, w i th t h e b ro n c h ia l

ves s el s im m ed ia te ly s u rr ou n d i n g ( u s u al ly on p os t eri or as p ec t at th i s po in t ) .
M ed ia l t o t h e h il u m , t h e ro ot is en cl os e d w it h in t h e a rea o f c on t in u i t y be tw een t h e p ar ie ta l an d t h e
vi s c era l la yer s o f p leu r a t h e pl e ur al sl ee ve , or m e so pn eu m o n i u m (m es en t er y of t h e lu n g ) . T h e h il u m
of t h e lu n g i s a w e dg e- s h a pe d a rea of t h e m ed i al s u r f ac e o f e ac h lu n g, t h e p o in t at w h ic h t h e s t ru c t u res
f or m in g t h e ro ot en t er an d l eav e th e lu n g . T h e h il u m ( d oo rw a y) ca n b e li ken e d t o t h e a rea of ea rth w h ere
a p la n t 's ro ot s en t er t h e g rou n d .
T h e ho r iz o nt a l a n d o b li qu e fi ssu re s d iv id e t h e lu n gs i n to lo b es ( F i gs . 1 .2 6 a n d 1 .2 7 ) . Th e r ig h t lu n g
h as t h ree lo be s , th e lef t lu n g h as t w o . Th e rig h t lu n g is l arg er an d h eav ie r th a n th e l ef t , b u t i t i s s h o rt er
an d w i d er b ec a u s e th e rig h t d om e of th e d iap h ra g m is h i gh e r an d t h e h ea rt a n d p e ric a rd iu m b u l g e m or e
t o t h e le ft . T h e an t er io r b ord e r of t h e ri gh t lu n g i s r ela ti ve ly s t rai g h t, w h ere as t h is b ord e r of t h e le f t l u n g
h as a d e ep car di a c n o t ch, a n in d en t at io n c on s e qu e n t t o t h e d ev ia ti on o f t h e a pe x of t h e h ea rt to th e l ef t
s id e. T h i s n o t c h pr im a ril y in d e n ts t h e an t er oi n f eri or a s pe c t o f th e s u p er io r lo b e of t h e l ef t l u n g . Th i s
in d e n ta ti on o f te n c r eat es a t h i n , to n g u e- li ke p ro c es s of t h e s u p eri or l ob e , th e l i ng u l a ( L. d i m . of l in g u a,
t on g u e) , w h i c h ext en d s b el ow t h e c a rd ia c n o t c h a n d sl id e s i n an d ou t of t h e c o s to m ed i as t in al rec e s s
d u rin g i n s pi ra ti on an d e xp ira ti on ( F ig s . 1 .2 3 B , 1 . 2 4 A , an d 1 .2 6 C ) . E ac h l u n g h a s (F i g s . 1 .2 6 an d 1 .2 7 )
A n a p ex, t h e b lu n t s u p eri or e n d o f th e lu n g as c en d i n g a b ove th e lev el o f th e 1 s t ri b i n t o t h e ro ot of

th e n e c k t h at is c ov ered b y c er vic a l p le u ra.

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Fi gur e 1 . 26. M e dia st i na l s ur fac es a nd h il a o f l un gs. T h e h i lu m o f eac h l u n g i s c en t ere d i n

th e m ed ia s ti n al s u rf ac e. A t th e h il u m (B an d D) , t h e roo t of ea c h l u n g is s u rro u n d ed b y a
pl eu ra l s l eev e th a t d e s ce n d s i n f eri or to th e r oo t a s th e p u l m on a ry l ig am en t . Th e pu l m o n ary
vei n s are t h e m o s t a n t eri or a n d i n f eri or i n th e roo t , w it h t h e b ron c h i c en t ral an d p os t eri or ly
pl ac e d. I m p res s i on s ar e f orm ed in em ba lm ed lu n g s b y c on t ac t w i th a dj ac e n t s t ru c t u res .
S u pe rio r t o t h e ro ot of t h e ri g h t l u n g ( A ), a gr oo ve i s fo rm e d a s th e arc h o f t h e a z yg os ve in
c ou rs e s an t eri orl y t o en t er t h e S V C; w h e rea s in t h e le ft lu n g ( C ), a s im i la r b u t l arg er g r oo ve i s
fo rm e d su p e rio r t o t h e ro ot as t h e ao rt a ar c h es p os t eri or ly a n d d es c e n d s a s th e th o rac i c ao rta .

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Fi gur e 1 . 27. C o st a l su rfa ce s o f lu ng s. A. T h e lu n gs a re s h o w n in i s ol at io n . B . T h e h ea rt a n d

lu n g s are s h ow n i n s it u . A lt h ou g h c l ear ly d ef i n ed h ere , th e o b li q u e an d h or iz o n ta l f i ss u r es m ay
be in c o m p let e o r ab s en t in s o m e s p ec i m en s . In p a rt B , th e lef t lu n g is re tr ac t ed f rom t h e h e art
(f i b rou s p er ic ar di u m ) rev eal in g t h e p h ren i c n erve as it p as s es a n te rio r t o t h e ro ot of t h e lu n g ,
w h il e t h e va g u s n e rve ( CN X ) p as s es p o s te rio r t o t h e ro ot .
P .1 2 1
P .1 2 2
P .1 2 3
l
T h r ee s u r f ac es ( c os t al , m ed i as t in a l, an d d ia p h rag m a ti c ) .
T h r ee b o rd ers ( an t er io r, in f e rio r, a n d p o s te rio r) .
T h e l u n gs o f an em b a lm e d c a d ave r, u s u al ly f i rm t o t h e t ou c h , h av e im pr es s io n s th a t a re f o rm ed b y t h e
s t ru c t u res a dj a ce n t t o t h em , s u c h a s th e rib s ( F ig . 1 .2 7 A & B ) . T h es e m ark in g s pr ov id e c lu e s to th e
re la ti on s h i p s o f th e lu n g s ; h ow e ver , th e y are n ot vis i b le d u ri n g s u rg ery o r in f re s h c ad ave ri c o r
p o s tm o rt em s p ec i m en s .
T h e c o s ta l s u rf a ce of t h e lu n g is l arg e , s m oo th , a n d c on ve x. It is rel at ed t o t h e c os t al p leu r a, w h i c h
s e pa rat es i t f ro m t h e ri bs , c o s ta l c a rti la g es , an d t h e in n e rm o s t i n te rc os t al m u s c le s . Th e po s t eri or p ar t o f
t h e c o s ta l s u rf ac e is re lat ed t o t h e b od i es of t h e t h ora c ic ve rt eb rae an d is s o m et im e s ref er red to as t h e

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ve rt eb ra l p art of t h e c o st a l s u rf ac e .
T h e m e d ias t in a l s u rf a c e of t h e l u n g i s co n c av e b ec au s e it is rel at ed t o t h e m i dd l e m ed i as t in u m , w h ic h
c o n ta in s t h e p eri c ard i u m an d h ea rt (F i g. 1 .2 6 ). T h e m ed ia s ti n al s u r f ac e i n c lu d es t h e h il u m an d t h u s
re c ei ves t h e ro ot of t h e lu n g , a rou n d w h i c h th e pl eu ra f orm s t h e p l eu ra l s le eve . Th e pu l m o n ary l ig a m en t
h a n g s i n f eri or ly f ro m t h e p leu r al s l eev e ar ou n d th e lu n g ro ot . If em b al m ed , t h er e is a g ro ov e f or t h e
e s op h ag u s an d a c a rd ia c im p re s s io n f o r t h e h ea rt o n th e m ed ia s ti n al s u rf ac e o f th e rig h t lu n g . B ec a u s e
t w o th i rd s of t h e h ea rt l ie s to th e l ef t of t h e m id l in e , th e c a rd ia c im p re s s io n o n t h e m ed i as t in al s u rf ac e o f
t h e l ef t l u n g i s m u c h la rg er. T h i s s u r fa c e o f t h e l ef t l u n g als o f eat u re s a p rom in en t , c o n ti n u ou s g ro ov e f or
t h e a rc h of t h e ao rt a an d t h e d es c en d i n g ( t h ora c ic ) a o r t a as w ell as a s m all er g ro ov e f or t h e e s op h ag u s .
T h e d ia p h rag m a ti c s u rf ac e o f th e lu n g , w h i c h is al s o c o n c ave , fo rm s t h e b as e of th e lu n g , w h i c h res t s on
t h e d om e of t h e d ia p h rag m . T h e c o n c avi ty is d eep er in t h e ri gh t lu n g b ec a u s e of t h e h ig h e r p os it i on o f
t h e ri g h t d ia p h rag m a ti c d om e , w h i ch o ver li es th e la rg e li ver . La te ral ly a n d p o s te rio rl y, t h e d ia ph r ag m at i c
s u rf a c e is b o u n de d b y a th i n , s h arp m a rg in ( in f e rio r b or de r) th a t p ro j ec ts i n to t h e c os t od i ap h ra gm at ic
re c es s of t h e p le u ra ( F ig s . 1 .2 6 a n d 1 . 2 7 B ).
T h e a n te rio r b or de r of t h e lu n g i s w h ere th e c o s t al a n d m ed ia s ti n al s u rf ac es m e et an t eri orl y an d o ver lap
t h e h ea rt ; t h e c a rd ia c n o t c h i n d en t s th i s bo rd er o f th e lef t lu n g . T h e in f e rio r b or de r of t h e lu n g
c i rc u m s c ri b es th e di ap h ra g m at ic s u rf a c e of t h e lu n g a n d s e pa ra te s t h is s u r fa c e f ro m th e c os t al a n d
m e d ias t i n al s u r fa c es . T h e p os t er io r bo rd er of th e lu n g is w h ere t h e c o s ta l an d m e d ias t i n al s u rf a c es m ee t
p o s te rio rl y; i t i s b roa d a n d rou n d ed a n d l ie s i n th e c avi ty at t h e s i d e of t h e t h ora c ic re gi on o f th e
ve rt eb ra l c ol u m n .
Variation s in t he Lobes of th e Lun g

Oc c a s io n al ly, a n ext ra f i s s u re d iv id es a l u n g or a fi s s u re i s ab s en t . F or e xam pl e, t h e l ef t l u n g s o m et i m es
h as t h ree l ob es a n d t h e r ig h t l u n g on l y tw o. T h e m o s t c o m m o n ac c es s o ry lo b e i s t h e a z yg os l ob e,
w h ic h a p pe ars i n th e r ig h t lu n g in ap p ro xi m at el y 1 % of p eo p le. I n t h es e c as es , t h e az yg os ve in ar c h es
ove r th e ap ex o f th e rig h t lu n g an d n ot o ver t h e ri g h t h i lu m , i s ol at in g t h e m ed i al p a rt o f th e ap ex a s an
az yg o s lo be .
Ap pearance of t he Lun gs an d In halation of Carb on Part icles and Irrit an ts

Th e lu n g s are lig h t p in k i n h eal th y c h il dr en an d p eo pl e w h o ar e n on - s m o ker s a n d li ve in a c lea n
en vi ron m en t (e .g ., Pac i f ic i s lan d e rs ) . Th e l u n g s are c o m m o n ly da rk a n d m o t tl ed in m o s t a d u lt s w h o l iv e
in ei th e r u rb an o r ag ri c u lt u ra l ar eas , e s pe c ia ll y th o s e w h o s m o ke, b ec a u s e of t h e ac c u m u lat i on of c a rb on
an d d u s t p ar ti c les i n th e a ir a n d irr it an t s in t ob ac c o th a t a re i n h al ed . S m ok er's c o u g h r es u lt s f ro m th e
in h a lat i on of t h es e i rri ta n t s. H ow ever , th e lu n g s are c ap ab le of ac c u m u lat i n g a c on s id e rab l e am o u n t o f
c arb o n w it h o u t b ei n g a d vers e ly a f f ec te d . Lym ph f ro m t h e lu n g s c ar rie s s pe c ia l d u s t c el ls
(p h a go c yt es ) th a t r em o ve c ar b on f ro m th e ga s -e xc h an g i n g s u r f ac es a n d d ep o s it it in t h e in a c ti ve
c on n ec t i ve t is s u e, w h ic h s u p p ort s t h e lu n g o r in ly m p h n od es re c ei vin g ly m p h fr om t h e l u n g s.
Au scu ltation of t he Lun gs and Per cussi on of t he Thor ax

Au scu lt a t io n o f t he lu ng s (l is t en i n g to th e ir s o u n d s w it h a s t et h os c o pe ) a n d per cu ssi o n o f t he t h or a x
(t ap p i n g t h e t h or ax o ver t h e l u n gs w it h th e fi n g ers t o d et ec t s ou n d s in t h e l u n g s ) ( F ig . B 1 .1 2A ) ar e
im p o rt an t t ec h n i q u es of p h ys i c al e xam in a ti on . A u s c u l ta ti on a s se s s es ai rf lo w t h ro u gh t h e t rac h e ob ro n c h ia l
tr ee i n to th e l ob e s o f th e lu n g . Pe rc u s s io n h elp s es t a bl is h w h eth e r t h e u n d erl yin g t is s u e s a re a ir f i ll ed
(r es on a n t s o u n d ), f l u id f il le d ( d u ll s ou n d ) , or s o li d (f l at s ou n d ) . A n a w a ren e s s o f n orm al a n at om y,
pa rt ic u l arl y t h e p roj ec t i on of t h e l u n gs a n d t h e p o rti on s t h at ar e ov erl ap p ed b y bo n e w it h as s o ci at ed
m u s c le s ( e. g., t h e s c a pu l a) en a b le t h e ex am i n er t o k n ow w h ere fl at an d re so n an t s ou n d s s h o u ld b e
exp ec t ed ( F ig . B 1 .1 2 B ) . A u s c u lt at io n an d p erc u s s i on s h o u ld al w a ys in c l u de th e r oo t o f th e n e c k w h e re
th e a p ic es o f th e l u n g s are l oc a te d . W h en c l in i c ia n s r ef er t o a u s c u lt at in g t h e b as e o f t h e l u n g , th e y
are n o t u s u all y re fe rri n g t o it s d i ap h ra g m at ic s u rf a c e or a n at om ic al b as e. T h ey are u s u a ll y ref e rri n g t o
th e i n f ero p os t eri or pa rt of t h e in f er io r lo b e. T o au s c u l t at e th i s are a, t h e c li n ic i an a pp l ies a s te th o s c op e t o
th e p o s te rio r t h or ac ic w al l at th e lev el o f th e 1 0 th t h or ac ic v ert eb ra .

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Fi gu re B 1. 1 2. P er cus si o n o f th e l un gs. A . B im a n u al p e rc u s s io n is s h ow n . B . A re as of f l at n es s
( yel lo w ) an d res o n an c e a re s h o w n .
Lu ng Can cer an d Mediasti nal Nerves

L u n g c an c er i n vo lvi n g a p h ren i c n erve m ay r es u lt in p ar al ys is o f t h e h e m id i ap h ra gm . B ec au s e o f th e
i n ti m at e r ela ti on s h i p of t h e rec u r ren t lar yn g ea l n erv e t o t h e ap ex of th e lu n g ( F ig . 1 .2 7 B ) , th i s n erv e m ay
b e i n vo lve d i n ap ic a l l u n g c a n c ers . T h is i n vol vem en t u su a ll y re s u lt s i n h oa rs en e s s o w i n g to pa ra lys i s of a
vo c al f ol d ( c o rd ) b ec a u s e t h e rec u r ren t la ryn g ea l n er ve s u p p li es al l b u t o n e o f t h e l ary n g eal m u s c le s ( s ee
Ch a p te r 8 ) .
P .1 2 4
Th e B ott om Lin e
T h e l u n gs a re t h e vi ta l o rg an s o f r es p ira ti on i n w h i c h v en o u s b l oo d e xc h an g e s o xyg e n an d c arb o n di ox id e
w it h a t id al ai rf lo w . A ir an d bl o od are de li ver ed to eac h l u n g v ia i t s r oo t, c o n s is t in g o f a pu l m o n ary a rt ery
a n d v ein a n d a m ai n b ron c h u s a n d t h ei r b ran c h e s /t ri b u ta rie s t h a t en t er t h e l u n g at i t s h i lu m . B ot h lu n g s
a re p yra m i da l, h a vin g an a p ex, a b a s e, t h ree s u r fa c es , a n d t h ree b ord er s . Th e rig h t lu n g h as t h ree lo be s
t h at are s ep ara t ed by h ori z on t al an d ob l iq u e f i s s u res ; th e lef t lu n g h as t w o lo be s , s ep ar at ed by an
o b li qu e fi s s u re, a n d fe at u res a m ark ed c ard i ac n ot c h in i ts a n te rio r b or de r ow in g t o t h e as ym m et ri c al
p l ac em e n t o f th e h e art .
Trac hea and Bronc hi

B eg in n i n g at th e l a r y n x, t h e w a ll s of th e ai rw a y are s u pp o rt ed by h ors e s h oe - o r C- s h ap ed ri n g s o f h yal in e
c ar ti la ge . Th e s u b- l aryn g e al a ir w ay c o n s t it u te s th e t r ac he o bro n chi a l t re e . Th e t r a c h e a, l oc a te d w it h i n
t h e s u p eri or m e d ias t i n u m , c on s t it u t es th e tr u n k of t h e t ree. ( T h e t rac h e a w i ll be de s c rib e d i n gr eat er
d et ai l w i th t h e s u p er io r m ed ia s t in u m, l at er i n th i s c h a p te r.) It b i fu r c at es at t h e le vel o f th e tra n s ver s e
t h ora c ic p la n e ( or s t er n al a n g le) in t o m ai n ( p ri m ar y) b r on c h i , on e t o e ac h lu n g , p as s i n g in f ero la t era lly to
en t er t h e l u n gs a t t h e h i la ( s i n gu l ar = h il u m ) ( F i g. 1 . 2 8 B ).
Th e ri ght m ai n br o nc hu s is w i d er, s h o rt er, a n d r u n s m ore vert i ca ll y t h an t h e le ft m a in b ro n c h u s a s

it pa s s es d ire c tl y t o t h e h il u m o f t h e l u n g.
Th e le ft m a i n bro n ch us p as s e s in f ero la t era lly , in f er io r to th e arc h o f t h e a or ta a n d an t eri or t o t h e

es op h a g u s a n d t h o rac i c ao rta , to rea c h th e h il u m of t h e lu n g .
W i th in t h e lu n g s , t h e b ron c h i b ran c h i n a c on s t an t f as h i on t o f or m th e roo t s o f th e tra c h eo b ron c h i al tre e,

as c o m p on e n ts o f t h e ro ot o f e ac h lu n g ( c on s i s ti n g of b ran c h e s o f th e pu l m o n ary a rt ery a n d vei n s a s w el l
as t h e b ro n c h i) . E ac h m a in b ro n c h u s d i vid e s i n t o l o ba r br o nch i ( s ec o n d ary b ro n c h i) , t w o on t h e le f t an d
t h ree o n th e rig h t , ea ch o f w h i ch s u p p li es a l ob e o f th e lu n g . E ac h l ob ar b r on c h u s d ivi d es in t o s e ver al
se gm en t al bro n chi ( te rt ia ry b ron ch i ) th a t s u p p ly t h e b ro n c h op u l m on a ry s eg m en t s ( F i gs . 1 .2 8 a n d 1 .2 9 ) .
P .1 2 5

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Fi gu re 1 . 28 . T r a che o br o nch ia l t r ee an d bro n cho p ul m o na ry s egm e nt s. A , C , an d D. T h e

b ron c h o p u lm on ar y s eg m en ts ar e d em o n s tr at ed af t er i n je c ti on o f a d if f ere n t c o lo r la te x in t o e ac h
s eg m e n ta l b ro n c h u s. B . Th e rig h t m ai n b ron c h u s i s m ore vert i c al a n d s h o rt er t h an t h e l ef t m ain
b ron c h u s . A l th o u g h n ot ap p ar en t h e re, t h e ri g h t m a in b ro n c h u s gi ves o f f t h e r ig h t s u p e rio r lo b ar
( lo be ) b ro n c h u s b ef or e en t eri n g th e h i lu m o f th e lu n g . T h e lo b ar b ro n c h i d iv id e i n to s eg m en t al
b ron c h i ( c ol ore d) , e ac h of w h i c h s erv es a b ro n c h op u lm on a ry s eg m e n t o f t h e s a m e n a m e ( an d c ol or ).
T h e br o nc ho pu lm o n ar y se gm en ts a r e

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Py ram id al - sh a p ed s eg m en t s of t h e lu n g, w it h th e ir a p ic es f ac i n g th e l u n g roo t a n d th e ir b as e s at t h e
p le u ral s u rf ac e.
T h e la rg es t s u bd i vis i on s o f a lo b e.
S ep ar at ed f rom ad j ac en t s eg m en t s b y c on n e c ti ve t is s u e se p ta .
S u p p li ed in d ep en d en t l y b y a s eg m e n ta l b ro n c h u s a n d a t ert ia ry b ra n ch o f th e pu l m o n ary a rt ery .
N a m ed ac c o rd in g t o t h e s eg m en t a l b ron c h i s u p pl yi n g t h em .
D rai n ed b y in t ers e gm en t al p a rt s o f th e pu l m o n ary v ein s t h at li e in t h e c o n n ec t ive ti s s u e b et w ee n

an d d ra in ad j ac e n t s eg m e n ts .
S u rg ic a ll y res e c ta b le.
U s u al ly 1 8 2 0 in n u m b er (1 0 i n th e r ig h t lu n g ; 8 1 0 in t h e l ef t l u n g , de pe n d in g on t h e
c om b in in g o f s e g m en t s ).
B e yon d t h e d ire c t b ra n c h es of t h e lo b ar b ro n c h i th a t i s , b eyo n d t h e s e gm en t al b ro n c h i ( F ig . 1 .2 8 B )

are f r om 2 0 t o 2 5 g en e rat io n s of b ra n c h es th a t e ven t u al ly e n d i n t er mi n al bro n ch io l es (F i g . 1 .2 9 ) .
E a c h ter m in a l b ro n c h io le g i ves ri s e t o s ev era l g en er at io n s of re sp ir at o r y bro n ch io l e s, an d ea c h
re s p ira to ry b ro n c h io le pr ovi d es 2 1 1 a l veo l a r du ct s, ea c h of w h i c h gi ves r is e t o 5 6 al ve o la r s acs
l in e d b y a lve ol i. T h e pu lm o n ar y al ve o l us i s th e ba s ic s t ru c t u ral u n it of g as ex ch a n g e in t h e l u n g. N ew
a lve ol i c o n ti n u e t o d eve lo p u n t i l ab o u t a ge 8 yea rs , b y w h i c h t i m e t h ere a re a pp r oxi m at el y 3 0 0 m i ll io n
a lve ol i.
P .1 2 6
As piration of For eig n B odies

B ec au s e t h e r ig h t b ro n c h u s is w id er a n d s h o rt er a n d r u n s m ore vert i c all y t h an t h e le f t b ro n c h u s , fo re ig n
m at eri al (e .g ., a f or ei gn b o dy or f o od ) is m o re l ike ly t o e n te r an d lo d ge in i t o r on e o f it s br an c h es . A
po t en t ial h az a rd en c ou n ter ed b y d en t is t s i s an as p i rat ed f or ei gn b o dy , s u c h a s a p ie c e of t oo th o r f il li n g
m at eri al , th a t i s li kel y to en t er t h e ri g h t m a in b ro n c h u s . To c rea te a s t eri le e n vir on m e n t a n d a vo id
as p ir at io n o f f ore ig n ob j ec t s , d en t is t s m ay i n s ert a t h in ru b b er da m in t o t h e o ral c avi t y d u rin g
pr oc e du r es .
Bron chos copy

A s a br on c h o s c op e p ro c ee ds d o w n th e tr ac h ea to en t er a m ain b ro n c h u s , a ke el -l ike rid g e, t h e ca r in a ( L .
kee l of a b o at ) i s ob s er ved b et w ee n th e ori f ic es o f th e m ai n b ro n c h i ( F ig . B 1 .1 3 ). A c ar ti la g in o u s
pr oj ec t io n of t h e la s t t ra c h eal rin g , t h e c ar in a n o rm a ll y li es i n a s ag it t al p l an e a n d h a s a f ai rl y de f in i te
ed g e. If th e tr ac h eo b ron c h i al lym ph n o d es in t h e an g l e b et w ee n th e m ai n b r on c h i a re e n lar g ed be c au s e
c an c er c e ll s h a ve m et as t as iz e d f r om a br on c h o ge n ic c ar c in o m a, f o r exa m p le , th e c a ri n a is d is t o rt ed ,
w id e n ed po s t eri orl y, a n d i m m o b ile . H en c e , m or ph o lo g ic a l c h an g es i n th e ca ri n a ar e im p o rt an t di ag n o s ti c
s ig n s to b ron c h o s c op i s ts i n a s s is t in g w i t h t h e d i ff e ren t ia l d ia g n os i s of res p i rat or y d is ea s e.
Th e m u c ou s m e m b ran e co ve rin g t h e c ar in a i s on e o f th e m os t s en s it i ve ar eas o f th e t ra c h eo br on c h i al
tr ee an d i s a s s oc i at ed w i th t h e c o u gh r ef le x. F or e xam pl e, w h en c h il d ren as p i rat e a p e an u t , th e y c h ok e
an d c ou g h . O n c e t h e p ean u t p as s es t h e c a rin a , c ou g h i n g u s u a ll y s to p s . If t h e c h o ki n g v ic t im i s i n ve rte d
to m ak e u s e of g ra vit y t o e xp el t h e f o rei gn b o d y (p o s tu r al d ra in a g e of t h e lu n g s ) , lu n g s ec r et io n s p a s s in g
th e c a ri n a al s o c a u se c ou g h in g , w h ic h as s i s ts t h e ex p ell at io n .

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Fi gu re B 1. 1 3
Lu ng Resection s
K n o w l ed g e of t h e an a t om y o f th e br on c h o p u lm o n ary s eg m en t s is es s e n ti al f o r p rec i s e in t er p ret at io n of
ra d io g rap h s an d o th e r m ed ic a l i m ag es o f th e l u n g s . K n ow le dg e o f th e s e s eg m en t s is a ls o es s en t ia l f or
s u rg i c al r es ec t io n of d is e as ed s eg m e n ts . B r on c h i al a n d p u l m o n ary d i s ord e rs s u c h a s tu m ors o r ab s c es s e s
( c ol le c ti on s o f pu s ) of t en l oc a li z e in a b ro n c h o pu l m o n ary s e g m en t , w h i c h m ay b e s u rg i c al ly re s ec t ed .
D u rin g t rea tm en t of lu n g c an c e r, t h e s u rg eo n m ay r em o ve a w h ol e lu n g ( pn eu mo n ec to m y) , a l ob e
( l o bec to m y ), o r a b ro n c h op u l m on a ry s eg m e n t ( se gm e n t ec to m y) .
S egm en tal Atelectasis

B l oc ka g e of a s e g m en t al br on c h u s , as b y a n as p ira t ed ob j ec t , w il l p re ven t ai r f rom rea ch i n g th e
b ro n c h op u l m on a ry s e gm en t i t s u p p li es . T h e a ir w it h in t h e b lo c ked s eg m e n t w ill g rad u a lly be ab s or be d
i n to th e bl oo d , an d t h e s eg m en t w i ll c ol la ps e . A s e g m en t al c o ll ap s e d o es n ot req u i re c o m p en s at i n g s p a ce
( ai r) in t h e p le u ral c avi ty t o be rea liz ed be c au s e a d ja c en t s e g m en t s w il l e xp an d to c om pe n s at e f or th e
re d u c ed vol u m e o f th e c o ll ap s ed s eg m e n t.
P .1 2 7

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Fi gu re 1 . 29 . I nt e rn al st ru ct ur e a nd o r gan i za ti o n o f l un gs. W it h in t h e lu n g s , t h e b ro n c h i an d
p u lm o n ar y art er ies a re p ai red a n d b ra n c h in u n is o n . S eg m e n ta l ( te rt iar y) br an c h es s u p p ly t h e
b ron c h o p u lm on ar y s eg m en ts , t h e s m a lle s t r es ec t ab le u n it s of t h e lu n g s . E ac h i n tr as eg m e n ta l
p u lm o n ar y art er y, c arr yin g p o orl y ox yg en a ted b lo o d, e n d s i n a c ap i ll ary p l exu s i n t h e w al ls of t h e
al veo la r s ac s an d a lve ol i, w h ere o xyg en a n d c a rb on d i oxi d e ar e exc h a n g ed . Th e pu l m o n ary vei n s
ar is e f ro m t h e p u lm o n ary c ap il la rie s an d dr ai n to w ar d a n d th e n c o u rs e w it h in t h e s ep t a b et w e en
ad j ac e n t s eg m e n ts , c a rryi n g w el l- o xyg en a te d b l oo d t o t h e h e art . B ro n c h ia l ar te rie s a re d i s tri b u te d
al on g an d s u p p ly t h e b ro n c h ia l t ree . Th e ir d is t a lm o s t b ra n c h es s u p pl y c ap i ll ary b e ds d ra in e d b y t h e
p u lm o n ar y vei n s , s u c h as th o s e o f t h e v is c er al p l eu ra ( e ven t h ou g h t h is s m al l a m ou n t o f b l oo d i s
p oo rly oxy ge n at ed ) .
P .1 2 8
P .1 2 9
Vasc ulature of the Lungs and P leurae

E a c h lu n g h as a l arg e p u l m on a ry a rt ery s u p p ly in g b lo od t o it an d t w o p u l m o n ary v ein s d ra in i n g b l oo d
f ro m it ( F ig . 1 .3 0 ) . T h e ri gh t a n d le ft p ul m o na ry a rt e ri e s ari s e f ro m th e pu l m o n ary t ru n k a t t h e l eve l
o f th e s t er n al a n g le a n d c a rry p o orl y o xyg en a te d ( ve n ou s ) bl oo d to th e lu n g s f or o xyg en a t io n .
( T h ey a re u s u al ly c o lo re d b l u e, li ke v ein s , i n an at o m ic a l i llu s t ra ti on s .) E a ch p u l m on a ry a rt ery b ec o m es
p ar t o f th e r oo t o f th e c o rre s po n d in g l u n g a n d g i ves o ff i ts f i rs t b ra n c h to th e su p e rio r lo b e b ef o re
e n te rin g t h e h il u m . W i t h in t h e lu n g , ea c h art er y d es c en d s p os t ero la te ral to th e m ai n br on c h u s an d
d i vid es i n to lo b ar an d se gm en t al ar t er ie s. Co n s eq u en t ly , an ar te ria l b ra n c h g o es t o ea c h lo be an d
b ro n c h op u l m on a ry s e gm en t o f th e lu n g , u s u al ly o n th e an t eri or a s p ec t o f th e co rre s p on d in g b ro n c h u s .
T h e a rte ri es an d b ron c h i are pa ir ed in t h e lu n g , b ra n c h in g s im u l t an eo u s ly a n d r u n n in g p ara ll el c o u rs e s.
T h e pu l mo n ar y ve i ns, t w o on ea c h s id e, c a rry w el l- ox yg en at ed ( art eri al ) b l oo d f r om t h e l u n gs t o
t h e l ef t a tr iu m o f t h e h e art . ( Th e y ar e c om m on l y c ol or ed red or p u r pl e, l ike art eri es , i n an at o m ic a l
i ll u s tr at io n s .) B e gi n n in g i n t h e p u l m on a ry c a pi ll ari es , t h e ve in s u n it e i n to la rg er a n d l arg e r ves s e ls . T h e

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p u l m on a ry ve in s ru n i n de p en d en t ly o f th e a rt eri es an d b ro n c h i, c o u rs in g b et w e en an d rec e ivi n g bl o od

f ro m ad j ac e n t s eg m en t s a s th e y ru n to w a rd th e h il u m . Th e vei n s fr om t h e vi s c era l p le u ra d ra in i n to th e
p u l m on a ry ve in s , a n d t h e ve in s f ro m th e pa ri et al p l eu ra j o in s ys t em i c vei n s in ad j ac e n t p ar ts o f t h e
t h or ac i c w al l.
T h e br o nc hi al ar t er i es s u p p ly b l oo d fo r n u t rit i on o f t h e s t ru c t u res m a kin g u p th e roo t o f th e lu n g s , t h e
s u p p or ti n g t i s s u es of t h e lu n g s , a n d t h e vi s c era l p le u ra ( F ig . 1 .3 1 A ) . T h e t w o l ef t br on c h i al a rt eri es
u s u a ll y ari s e d ir ec tl y f ro m th e th o ra c ic ao rt a. T h e s in g l e ri gh t b ro n c h ial art er y m ay ari s e d ire c tl y f ro m
t h e a ort a. M o s t c o m m o n ly i t a ris e s in d ir ec tl y, ei t h er b y w a y of t h e p ro xim al p a rt o f on e o f th e u pp e r
p o s te rio r in t er c os t al a rt eri es ( u s u al ly t h e ri g h t 3 rd p o st er io r in t er co s t al a rt ery ) o r f rom a c om m on t ru n k
w it h th e l ef t s u pe ri or b ro n c h ia l ar te ry.
T h e s m a ll br on c h i al a rt eri es p ro vid e b ra n c h es t o t h e u p pe r es o p h ag u s an d th e n ty pi c al ly p a s s a lo n g t h e
p o s te rio r as p ec t s of t h e m a in b ro n c h i, s u p p lyi n g th e m an d th e ir b ra n c h es as f a r di s t all y as t h e
re s p ira to ry b ro n c h io le s . (H ow e ver , s ee t h e va ria ti on s h o w n i n F i g s . 1 .5 3 an d 1 .5 9 , d ra w n f ro m a c ad a ver
d i s se c ti on . ) T h e d is t al m o s t b ra n c h es of t h e b ron c h i al art er ies a n as t om o s e w i t h b r an c h es o f t h e p u l m on a ry
a rt eri es in t h e w a ll s of t h e b ron c h i ol es an d i n t h e v is c er al p l eu ra . Th e p a rie ta l p le u ra i s s u pp l ie d b y t h e
a rt eri es th a t s u p p ly th e t h o rac i c w al l ( s ee A rt er ies o f th e T h o rac i c W a ll, i n th i s c h ap t er) .
T h e br o nc hi al ve in s ( F ig . 1 .3 1 B ) d rai n on l y p art of t h e b lo od s u p p li ed to th e lu n g s by th e b r on c h i al
a rt eri es , p rim ari ly
P .1 3 0
t h at d is t rib u t ed t o o r n ear th e m ore pr oxi m a l p art of t h e ro ot s of t h e lu n g s . T h e re m ai n d er o f t h e b l oo d i s
d ra in e d b y t h e p u lm on a ry vei n s , s p ec if i c al ly t h at ret u rn i n g fr om t h e vi s c era l p le u ra, t h e m o re p e rip h er al
re g io n s o f th e lu n g , an d t h e d is t al c om p o n en t s o f th e roo t o f th e lu n g . T h e ri gh t b ron c h i al vei n dr ai n s
i n to th e az yg o s vei n a n d th e l ef t br on c h i al v ein d ra in s i n to th e ac c es s o ry h em iaz y g os vei n or t h e l ef t
s u p er io r in t erc o s t al v ein . B r on c h i al v ein s a ls o r ec ei ve s o m e b lo o d f ro m es o p h ag ea l ve in s .
Fi gu re 1 . 30 . P u lm o n ar y ci rc ul at i o n. A l th o u g h t h e i n tr ap u lm on a ry re lat i on s h i ps a re ac c u r at el y
d em o n s tr at ed , th e s ep ara t io n o f th e ves s el s of t h e ro ot of t h e lu n g h as b ee n exa gg e rat ed in t h e h i la r
reg i on t o s h o w t h em as t h ey e n te r an d le ave th e lu n g . N ot e t h at t h e rig h t p u lm o n ar y art er y pa s s es
u n d er t h e ar c h of th e ao rt a to rea c h th e rig h t lu n g an d t h at th e l ef t pu l m o n ary a rt ery l ie s c om p l et ely
t o t h e le ft o f t h e a rc h .

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Fi gu re 1 . 31 . B ro n chi a l a rt e ri e s an d vei n s. A. T h e b ro n c h ia l ar te rie s s u p p l y th e s u pp o rt in g ti s s u es

of t h e lu n gs a n d v is c er al p l eu ra . Lef t b ron ch i al art er ies a ris e fr om t h e s u p eri o r th o rac i c ao rt a, b u t
t h e or ig in o f t h e r ig h t b ro n c h ia l a rt ery i s vari ab l e; in or d er o f f re q u en c y, i t m a y ari s e ( 1 ) fr om a
ri gh t p os t eri or in t erc o s ta l a rte ry ( u s u al ly t h e 3 r d) , ( 2 ) fr om a c om m o n t ru n k s h ar ed w it h t h e le f t
s u p eri or b ro n c h ia l a rt ery, o r ( 3 ) d i rec t ly f r om t h e ao rt a. B . Th e br on c h i al v ein s d ra in t h e m o re
p rox im a l c a pi ll ary be d s s u p p li ed b y t h e b ron c h i al art er ies ; t h e res t is d ra in ed b y t h e p u lm o n ar y
vei n s . T h e ri gh t b ron c h i al vei n dr ai n s i n t o t h e az y go s vei n an d th e lef t b ron c h i al vei n dr ai n s i n t o t h e
ac c e s so ry h e m ia z yg os v ein o r t h e le ft s u p eri or i n t erc o s ta l ve in .
T h e p u lm on a ry ly m p h at ic p le xu s es c o m m u n i ca t e f ree ly ( F ig . 1 .3 2 ) . T h e su pe rf i ci al ( s u b pl eu ra l)
l ym ph at i c pl ex us lie s de ep to t h e vis c e ral p leu r a an d d rai n s th e lu n g p are n c h ym a ( t is s u e ) a n d v is c era l
p l eu ra . Lym ph a ti c ves s e ls f ro m th i s s u pe rf ic i al pl exu s d ra in i n to th e bro n cho p ul m on a ry l ym ph n o de s
( h il ar l ym p h n o de s ) i n th e h il u m of t h e lu n g .
T h e de e p l ym ph a ti c pl ex u s is l oc at ed i n t h e s u b m u c o s a o f t h e b ro n c h i a n d i n th e p e rib ro n c h ia l
c o n n ec t ive ti s s u e. It is la rg el y c on c e rn ed w i th d ra in i n g t h e s t ru c t u res t h at f orm th e r oo t o f th e l u n g .
L ym p h a ti c ves s el s f rom t h i s d e ep pl exu s d ra in i n it ia ll y in t o t h e pu lm o n ar y l ym ph n o des , lo c at ed al on g
t h e l ob ar b r on c h i . Lym ph a ti c ves s e ls f ro m th e s e n od e s c o n t in u e t o f o ll ow t h e b ro n c h i a n d p u l m on a ry
ve s s el s t o t h e h i lu m o f th e l u n g , w h e re t h ey al s o d ra in i n to th e br on c h o p u lm o n ary (h i la r) lym p h n o d es .
F ro m t h em , l ym p h f ro m bo t h t h e s u p er f ic i al a n d d e ep lym p h a ti c p lex u s es d rai n s to th e s u pe r io r an d
i nf er io r tr a che o br o nch ia l l ym ph no de s, s u p eri or an d in f er io r to th e bi f u rc at i on o f t h e t rac h e a an d
m a in b ro n c h i, r es p ec t ive ly. T h e ri g h t l u n g d r ain s p ri m ar il y th r ou g h t h e res p ec t i ve s et s of n o de s on t h e
ri g h t s i d e, an d t h e s u p eri or l ob e o f th e lef t lu n g d rai n s p rim a ri ly t h ro u gh r es p ec t ive n od es o f t h e l ef t
s i d e. M an y, b u t n ot al l, o f t h e l ym p h at ic s f ro m t h e lo w e r lo b e of t h e le f t l u n g, h o w e ver, d r ain t o t h e ri g h t
s u p er io r tr ac h eo b ron ch i al n od es ; t h e ly m p h t h en c o n t in u es t o f o ll ow t h e ri g h t- s i de pa t h w ay .
L ym p h f ro m th e tr ac h eo b ron c h i al lym ph n o d es p as s es t o t h e ri g h t an d l ef t b ro n c h om ed ia s ti n al lym p h
t r u n ks . T h es e t ru n k s u s u a ll y t erm i n at e o n eac h s i de at th e v en ou s a n g les ( j u n c ti on s o f t h e s u b c l avi an an d
i n te rn al ju g u l ar v ein s ) ; h ow eve r, th e rig h t b ron c h o m ed i as t in a l t ru n k m a y f irs t m er ge w it h o th e r
l ym p h at i c t ru n k s , c o n ve rg in g h ere to f orm t h e s h o rt ri ght l ym pha t i c d uct . T h e le f t b ro n c h om e d ias t i n al
t ru n k m a y t erm i n at e i n th e t h o ra ci c duct . L ym p h f ro m th e pa ri eta l p l eu ra d r ain s i n to th e lym ph n o d es of
t h e t h or ac ic w al l ( in t erc o s ta l, p a ras t ern a l, m e d ias t i n al, a n d ph r en ic ) . A f ew l ym p h a ti c ves s el s f rom t h e
c e rvi ca l p ar ie ta l p le u ra d ra in in t o t h e a xil la ry l ym p h n od e s .
P .1 3 1

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Fi gu re 1 . 32 . L ym pha t ic d ra in a ge o f l un gs. T h e ly m p h at ic ve s s els o rig i n at e in s u p er f ic i al

s u b pl eu r al a n d d e ep lym ph a ti c p lex u s es . A ll lym ph f ro m t h e lu n g l eav es al on g th e roo t of th e lu n g
an d d rai n s to t h e in f er io r or s u p e rio r t rac h e ob ro n c h ia l ly m p h n od es . T h e i n fe rio r l ob e o f b o th l u n g s
d rai n to th e c en t ral ly p l ac ed in f e rio r t rac h e ob ro n c h ia l ( c ari n al ) n o d es , w h i c h p rim a ri ly d ra in t o t h e
ri gh t s id e . Th e o t h er l ob es o f e ac h lu n g d ra in p ri m ari ly t o th e i p s il at era l s u p eri or t ra c h eo br on c h i al
ly m p h n od es . F ro m h er e th e lym ph t ra vers e s a var ia bl e n u m b er of p ara tr ac h ea l n o d es an d en t ers t h e
b ron c h o m e di as t in a l t ru n ks .
Pulm onary Em bolism

Ob s t ru c t io n of a p u l m on a ry ar te ry b y a b l oo d c l ot ( em b o lu s ) is a c o m m o n c a u s e o f m orb i di t y (s i c kn es s )
an d m or ta li ty (d ea th ) . A n em bo lu s i n a p u lm o n ar y art er y f orm s w h en a b l oo d c l ot , f at g lo bu l e, o r ai r
bu b b l e tr ave ls in t h e b lo o d t o t h e l u n gs f ro m a l eg vei n , f or e xam pl e, a f ter a c om po u n d f rac t u re. T h e
em b o lu s p as s es t h ro u gh t h e ri g h t s i de of t h e h ea rt t o a lu n g t h rou g h a p u l m on a ry a rte ry. It m a y b lo c k a
pu l m o n ary a rt ery pu lm o na r y em bo l i sm (P E ) or o n e o f it s b r an c h es . T h e p u lm on a ry ar te rie s c a rry
all of t h e b lo od t h at h as b een r etu r n ed to th e rig h t h ea rt v ia t h e ve n a c av al s y s te m . Co n se q u en t ly, t h e
im m e d ia te r es u lt of P E is p art ia l o r c om pl et e o bs t ru c t io n of b lo od f lo w t o t h e l u n g . T h e b l oc ka g e res u l t s
in a l u n g o r a s e c to r of l u n g t h at is v en t il at ed w it h ai r b u t n o t p e rf u s ed w i th b lo od .
W h en a la rg e em b o lu s o cc l u d es a p u l m on a ry ar te ry, t h e p at ie n t s u f f er s a c u te res p ir at or y di s t res s
be c au s e o f a m a jo r d ec re as e i n th e o xyg e n at io n of b lo od , o w in g t o b lo c ka ge of b lo od f lo w t h ro u gh t h e
lu n g . Co n vers e ly, t h e r ig h t s i d e of t h e h ea rt m ay b ec o m e a c u te ly d i lat ed b ec a u s e th e vol u m e o f bl o od
arr ivi n g f r om t h e s ys t em i c c irc u i t c a n n ot b e p u s h ed th r ou g h th e pu l m o n ary ci rc u i t ( ac u t e c o r p u lm o n al e) .
In eit h er c as e, d ea th m a y o c cu r in a f ew m in u t es . A m e d iu m - s iz e em b o lu s m ay bl oc k an art er y s u p pl yi n g
a b ro n ch o p u lm on ar y s eg m e n t, p ro d u c in g a p u lm on ar y in f a rc t, a n are a o f n e c rot i c ( d ea d) l u n g t is s u e .
In ph y s ic a lly ac t ive pe op l e, a c o ll at era l c ir c u la ti on a n in d i rec t , ac c es s o ry b l oo d s u p p ly of t en e xis t s
an d d evel op s f u rt h er w h en t h ere i s a PE s o th a t i n f arc t io n is n o t a s l ik ely to oc c u r, o r at le as t n ot b e as
de vas t at i n g. A n a s to m o s es w i th b ra n c h es of t h e b ro n ch ial art er ies a bo u n d in t h e re gi on o f th e t er m in a l
br on c h i ol es . In il l p eo p le w it h im pa ire d ci rc u l at io n in t h e lu n g , s u c h as c h ro n ic c o n g es ti on , P E c om m on l y
res u l ts i n l u n g in f ar c ti on . W h en an a rea of vi s c eral p leu r a is a ls o de p riv ed of b lo od , it b ec o m es i n fl am e d
(p l eu ri ti s) a n d irri t at es or b e c om e s f u s e d t o t h e s e n s it ive pa ri et al p l eu ra , res u l ti n g i n p ain . P ai n f rom t h e
pa ri et al p l eu ra i s ref e rred t o t h e c u t an eo u s d is t rib u t io n of t h e in t er c os t al n e rve s t o th e t h o rac i c w al l, o r,
in t h e c as e o f in f er io r n erv es , to t h e an t eri or ab d om i n al w al l.
Lymph atic Dr ain ag e after Pleur al Ad hesion

If th e p a rie ta l an d vi s c era l l aye rs of p le u ra a dh e re ( p le u ral ad h es i on ) , th e lym ph a t ic ves s e ls in t h e l u n g
an d vis c e ral p leu r a m a y dr ai n i n t o t h e ax ill ar y lym p h n o d es . T h e p res e n c e of c ar b on p art i c les i n th e se

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n o d es is p res u m pt i ve ev id en c e o f p leu r al a d h es io n .
B ronc hogenic Carci noma

T h e t erm b r on c h o ge n ic c ar c in o m a o n c e w a s a s p ec if i c de s ig n at io n f or c a n c er a ris i n g i n th e
b ro n c h u s u s u a lly s qu a m o u s - ( oa t) o r s m al l- c el l c a rc in o m a ( c an c e r) b u t n o w t h e t erm r ef ers t o a n y
l u n g c a n c er. L u ng ca n cer is m a in l y c au s ed b y c i ga ret t e s m o kin g ; m os t c an c e rs ari s e in t h e m u c o s a o f
t h e l arg e b ro n c h i a n d p ro d u c e a p er s is t en t , pr od u c t ive c ou g h or h e m o pt ys i s (s p i tt in g o f b l oo d) . M al ig n a n t
( c an c e r) ce ll s c an b e d et ec t ed in t h e s p u tu m ( s a liv a- b orn e m at t er) .
T h e p ri m ar y tu m or, o b s erve d rad io lo g ic a ll y as an e n la rg in g lu n g m a s s , m et as t as i z es ear ly t o t h e
b ro n c h op u l m on a ry ( h il ar ) l ym p h n od e s a n d s u b s e qu e n tl y t o o th e r th o ra c ic ly m p h n o d es . Co m m o n s it es of
h e m at og e n ou s m et a st a s es (s p re ad in g t h ro u gh t h e b lo o d) o f c a n c er c el ls f ro m a b ro n c h og en i c c arc i n om a
a re t h e b rai n , b on e s , lu n g s , an d s u p rar en al (a d ren a l) g la n ds . T h e t u m o r c ell s p rob a bl y en t er t h e s y s tem ic
c i rc u la ti on b y i n vad i n g t h e w al l of a s i n u s oi d or v en u le in a l u n g a n d are t ra n s po rt ed t h rou g h t h e
p u l m on a ry ve in s , l ef t h e art , an d ao rt a t o t h es e s t ru c t u res . O f t en t h e ly m p h n o d es s u p eri or t o th e
c l a vi c le t h e s u p rac l avi c u la r lym ph n o d es a re e n lar ge d w h en b ro n c h og en i c c arc i n om a d eve lo ps o w i n g
t o m eta s t as es o f c a n c er c el ls f ro m t h e tu m or. C on s eq u e n tl y, t h e s u p rac l avi c u la r ly m p h n od es ar e c al le d
s e n ti n el l ym p h n od e s b e c au s e t h ei r en l arg em en t a le rt s t h e p h ys i c ia n to th e p o s s ib il it y o f m al ig n an t
d i s eas e i n th e th o rac i c an d / or a b do m i n al o rg an s .
P .1 3 2
Ner ves of the Lungs and Pleurae

T h e n erv es of t h e lu n g s an d vi s c era l p le u ra a re d er ive d f ro m t h e p u lm o n ar y p lex u s es an t eri or an d
( m ai n ly) p os t er io r to th e roo t s o f th e lu n g s ( Fi g . 1 .3 3 ) . Th e s e n erv e n et w o rks c o n ta in p ar as ym p a th e ti c
f ib er s f r om t h e va gu s ne rv es ( CN X ) an d s ym p a th e ti c fi b ers f ro m t h e s ym p at h et i c t ru n ks . T h e
pa ra sy mp at he t ic g an gl io n c el l s ( ce ll bo d ie s o f p os t s yn ap t ic p ar as ym p a th e ti c n eu ro n s ) a re i n th e
p u lm o n ar y p lex u s es an d al on g t h e b ran c h e s o f th e br on c h i al t re e. T h e sym pa t he t ic g an gl io n c el l s (c e ll
b od i es of p os t s yn a pt i c s y m p at h et ic n eu r on s ) are in t h e p ara vert eb r al s ym p at h et ic g an g li a o f t h e
s ym p a th e ti c t ru n k s . T h e p a ras y m p at h et ic f ib er s f r om t h e va g u s n e rve s a re m ot or t o t h e s m o ot h m u s c l e of
t h e b ron c h i al tre e ( b ron c h o c on s t ri c to r) , in h i b it ory to th e pu l m o n ary v es s el s (va s od i la to r) , an d s ec re to ry
t o t h e g la n ds o f t h e b ro n c h ia l t ree (s e c ret om ot or) . R e f lex ive vis c e ral af f ere n t f ib e rs of CN X ar e
d is t ri bu t ed t o t h e:
B ron c h i al m u c os a , pr ob a bl y in a s s oc i at io n w it h t ac t il e s en s at i on f or co u g h ref l exe s .
B ron c h i al m u s c le s, p o s s ib l y in vo lv ed in s t ret c h rec e pt i on .
In te ral veo la r c o n n ec ti ve t i ss u e , in a ss o c ia ti on w it h H er in g - B reu er ref le xes ( a m e c h an i s m th a t t en d s

to li m it res p i rat o ry exc u r s io n s ).
Pu l m on a ry a rte rie s , s erv in g p res s o r rec e pt o rs (r ec ep t or s s e n s it ive to b lo od p res s u re ).
Pu l m on a ry ve in s , s er vin g c h em ore c ep to rs ( r ec e p to rs s en s i ti ve t o b lo o d g as l eve ls ) .
V is c e ral af f ere n t f ib e rs m ed i at in g n oc i c ep t ive i m p u ls e s (i m p u ls e s g e n era te d i n res p on s e to p ain f u l or

in j u ri ou s s t im u li) f ro m th e vis c e ral pl eu r a an d b ro n c h i ac c o m p an y t h e s ym pa t h eti c f ib er s , w h ere as t h os e
f ro m th e t ra c h ea a c c om p a n y th e p ara s ym p at h et ic f i be rs of t h e va gu s . T h e s y m p at h et ic f ib er s a re
in h i b it or y to th e br on c h i al m u s c le ( b ro n c h od il at or ), m ot or t o th e p u l m on a ry ve s s el s ( va s oc o n s tr ic t or ), a n d
in h i b it or y to th e alv eo la r gl an d s o f t h e b ro n c h ia l t ree ty p e II s ec re to ry e pi t h eli al c ell s of t h e al veo li
( F ig . 1 .2 9 ) .
T h e n erv es of t h e p ari et al pl eu ra d eri ve f ro m th e in t erc o s ta l a n d p h re n ic n er ves . T h e c o s ta l p le u ra a n d
t h e p eri ph e ral p art of t h e d ia ph r ag m a ti c pl eu ra are su pp l ied b y t h e i nt er co st a l n er ve s. T h ey m e di at e
t h e s en s at i on s of t ou c h a n d p a in . T h e c en t ra l p art of t h e d ia p h rag m a ti c p leu r a an d t h e m ed i as t in a l p le u ra
ar e s u p pl ie d b y t h e ph re ni c ne r ves (F i g s . 1 .2 5 an d 1 .2 7 B ) .
Pleur al Pain
T h e vi s c era l p le u ra i s in s en s i ti ve t o p a in b ec a u s e it rec e ive s n o n er ves of g en e ral s en s at i on . T h e p ari et al
p l eu ra ( p ar ti c u la rly t h e c o s ta l p ar t) is e xtr em e ly s en s i t ive to pa in . T h e p ar iet a l p leu r a i s r ic h l y s u pp l ie d
b y b ra n c h es of t h e in t er c os t al an d ph ren i c n e rve s . I rri ta ti on o f t h e p a rie ta l p le u ra m a y p ro du c e lo c al p a in
o r ref e rred p ai n p roj ec t ed t o d er m at om es s u p pl ie d b y t h e s a m e s p in a l ( p os t eri or r oo t) g an g li a a n d
s e gm en t s o f th e sp i n al c ord . Irr it at io n of t h e c os t al an d p eri p h era l p art s of t h e d ia p h rag m a ti c p leu r a
re s u lt s in l oc al p ai n a n d ref er red p ai n t o th e d e rm at o m es of t h e t h or ac ic a n d a b do m i n al w al ls . Irr it at io n

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o f th e m ed ia s ti n al a n d c en t ral di ap h ra g m at ic a rea s o f p ari et al p l eu ra res u l ts i n r ef err ed p ain t o t h e ro o t

o f th e n e c k an d ov er t h e s h o u ld er ( C3 C5 d erm a to m es ) .
P .1 3 3
Fi gur e 1. 33. N e rve s o f l u ng s an d vi sce ra l p le ur a . T h e r ig h t a n d lef t p u lm o n ary pl exu s e s , an t eri or

an d po s t eri or t o t h e ro o ts o f t h e l u n gs , r ec ei ve s ym pa t h et ic c on t ri b u ti on s f ro m th e rig h t an d le ft
sy m p at h et ic t ru n ks a n d p ar as ym pa th e ti c c on t ri bu t i on s f ro m th e rig h t an d le ft va gu s n e rves ( CN X ) .
Af t er c o n t rib u t in g t o t h e p os t eri or pu l m o n ary p l exu s , t h e va g i c on t i n u e in f er io rly an d be c om e p art of
th e e s op h ag e al p l exu s , o f te n l os i n g th e ir i de n ti t y an d th e n ref o rm i n g a s an t eri or a n d p o s te rio r va g al
tru n k s . B ran c h e s o f th e pu l m o n ary p l exu s e s a c c om p a n y p u lm o n ar y art er ies a n d e s pe c ia ll y b ron c h i to
an d w it h i n th e l u n g s .
S urface An atomy of th e Pleu rae and Lun gs

T h e c er vic a l p le u rae an d ap ic e s of t h e lu n g s p as s t h rou g h t h e s u p eri or t h o rac i c ap ert u re i n t o t h e
s upr ac la vi cu la r fo s sa e, w h ic h ar e lo c at ed p os t eri or a n d s u pe rio r t o t h e c la vi c les a n d l at era l t o t h e
t en d o n s o f th e s te rn oc l ei do m a st o id m u s c le s (F i g . S A1 . 6 ). T h e a n te rio r b or de rs of t h e l u n gs l ie a d ja c en t to
t h e a n ter io r li n e o f r ef le c ti on o f t h e p ar iet a l p le u ra b et w e en th e 2 n d a n d 4 th c o s ta l c ar ti la ge s . H ere th e
m a rg in o f th e l ef t pl eu r al r ef le ct i on m o ves l at era ll y an d t h en in f er io rly at t h e c a rd ia c n ot c h to rea c h t h e
6 t h c os t al c art il ag e. T h e a n te rio r b o rd er o f t h e l ef t l u n g is m o re d ee pl y in d e n te d b y i ts c a rd ia c n o t c h . O n

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t h e ri g h t s i de , th e pl eu ra l re f lec t i on c on t i n u es in f er io rly fr om t h e 4 t h to th e 6 th c o s ta l c a rti la g e,

p ar al lel ed c lo s el y b y th e an t eri or b o rd er o f th e r ig h t l u n g . B ot h p leu r al r ef le c ti on s a n d a n te rio r l u n g
b o rd ers p as s l at era ll y at th e 6 th c o s ta l c ar ti la ge s . Th e pl eu ra l re f lec t i on s re ac h th e MC L a t t h e le vel of
t h e 8 t h c os t al c art il ag e, t h e 1 0 t h ri b a t t h e M A L, a n d th e 1 2 t h ri b a t t h e S L ; h o w e ver, t h e i n f eri or
m a rg in s o f th e l u n g s rea c h t h e M CL at th e lev el o f th e 6 t h ri b , th e M A L at th e 8 th ri b , an d th e sc a p u la r
l in e a t t h e 1 0 t h ri b, p ro c ee di n g to w a rd th e s p i n ou s p ro c es s of T 1 0 ver te br a. T h ey t h en p ro c eed t ow a rd
t h e s p in o u s p roc e s s o f T1 2 v ert eb ra . Th u s t h e p ar iet al p leu r a g en er al ly e xte n d s a p pr ox im a te ly t w o rib s
i n f eri or t o t h e l u n g .
T h e o b liq u e f i s s u re o f t h e l u n g s ext en d s f rom t h e l eve l o f t h e s p in o u s p roc e s s of T 2 v ert eb ra po s t eri orl y
t o t h e 6 t h c os t al c art il ag e a n te rio rl y, w h i c h c oi n c id es ap p ro xi m at el y w i th t h e m e di al bo rd er o f th e s c ap u la
w h en t h e u p pe r li m b is el eva te d a b ove th e h ead ( c au s i n g t h e i n fe ri or a n gl e t o ro t at e la te ral ly ). T h e
h o riz on t al f i s s u re o f t h e r ig h t l u n g ext en d s f rom th e o b li q u e f is s u re alo n g th e 4 th ri b an d c os t al c a rt il ag e
a n te rio rl y .
Fi gu re S A1 . 6
P .1 3 4
P .1 3 5
Th e B ott om Lin e
T h e t rac h e ob ro n c h ia l t ree is d is t in g u i s h ed gr os s l y b y c art il ag e i n it s w al ls . T h e b i fu r c at io n of th e tr ac h ea
( at t h e le vel of th e s te rn al an g le ) i s as ym m et ric a l: th e rig h t m ai n b ron c h u s i s m ore vert i c al a n d o f
g re at er c a lib e r th a n th e lef t . T h e b ron c h i an d p u lm o n ar y art er ies c o u rs e a n d b ra n c h to g et h er: th e m ai n
b ro n c h i/ ar te rie s eac h s er ve a l u n g , s ec o n d- o rd er l ob ar br an c h es s u p p ly t h e t w o to th r ee l ob es , a n d t h i rd o rd er s e gm en t al b ra n c h es s u p p ly t h e 8 1 0 b ro n c h o pu l m o n ary s e g m en t s of ea c h l u n g . Th e
b ro n c h op u l m on a ry s e gm en t i s th e s m al les t res e c ta b le d i vis i on o f t h e l u n g . Th e pu l m o n ary v ein s r u n
i n d ep en d en t in t ers e g m en t al c o u rs e s, d r ain i n g ad j ac en t b ron c h o p u lm o n ar y s eg m en t s . T h e s t ru c tu r es of
t h e ro ot of t h e l u n g a n d s u p p o rti n g ti s s u es ( an d p art of t h e es o p h ag u s ) a re s u p p li ed b y b ron c h i al
a rt eri es . T h e ly m p h at ic d rai n ag e o f th e l u n g s fo l lo w s a m o s tl y p red i c ta b le c o u rs e, w it h m os t of t h e ri g h t
l u n g a n d th e s u p e rio r lo b e of t h e l ef t l u n g f o ll ow in g ip s i la te ral pa th w ays t o t h e ri g h t l ym p h a ti c t ru n k a n d
t h or ac i c d u c t . H ow eve r, m u c h o f t h e d ra in a ge f rom t h e l ef t i n f eri or l ob e pa s s es t o t h e rig h t . N er ve f ib e rs
o f th e p u l m on a ry p l exu s es a re a u to n om i c ( br on c h i oc o n s tri c t ive , vas o in h i b it ory , an d s ec re to m o to r) an d
re f lex ive vis c e ral af f ere n t.

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M ed ias tinu m
T h e m e dia s t i nu m ( M od . L . m i dd l e s ep t u m ) , oc c u p ie d b y t h e m a s s of t is s u e b et w e en t h e tw o p u lm on a ry
c a vit ie s , is t h e c en t ra l c om pa rt m en t of t h e t h ora c ic c av it y ( F ig . 1 .3 4 ) . It is c ov ered o n eac h s i de by
m e d ias t i n al p l eu ra a n d c on t ai n s a ll th e th o rac i c vis c e ra a n d s t ru c t u res e xc ep t t h e l u n g s . Th e m ed ia s ti n u m
e xte n d s f r om t h e s u p eri or th o rac i c ap er tu re to th e di ap h ra g m in f er io rly a n d fr om t h e s t ern u m a n d c os t al
c a rt ila g es an t er io rly t o t h e b o di es o f t h e t h or ac i c v ert eb ra e p os t eri or ly. U n l ike th e r ig id s t ru c t u re
o b s erve d i n th e em b al m ed c ad a ver , th e m ed ia s ti n u m in l ivi n g pe op l e is a h i g h ly m o b il e re gi on , b e ca u s e i t
c o n s is t s pr im a ri ly o f h o ll ow (l iq u i d - o r ai r- f ill ed ) vis c e ral s tr u c tu re s u n it ed on l y b y lo os e c on n ec t i ve
t is s u e , of t en in f i lt rat ed w it h fa t. T h e m aj or s t ru c t u res i n th e m ed ia s ti n u m ar e al s o s u rr ou n d ed b y b lo od
a n d l ym p h a ti c ves s el s , lym p h n o d es , n er ves , a n d f a t.
T h e l oo s en es s o f t h e c o n n ec t ive ti s s u e an d t h e el as t ic i ty o f th e lu n g s an d p ari et al pl eu ra on ea c h s id e o f
t h e m e di as t in u m en ab l e it to ac c o m m o da t e m ov em e n t a s w el l as vo lu m e an d p res s u r e c h an g es i n th e
t h or ac i c c a vit y s u c h a s th o s e re s u lt in g f ro m m ov em e n ts o f t h e d ia p h rag m , t h o rac i c w al l, a n d
t ra c h eob ro n c h ia l t ree du r in g res p i rat i on , c o n tra c ti on ( b ea ti n g ) o f th e h e art an d p u ls a ti on s o f t h e g re at
a rt eri es , an d p as s a ge of in g e st ed s u b s t an c es t h ro u gh t h e es o p h ag u s . Co n n ec t ive ti s s u e h ere be c om e s
m o re f i b rou s a n d r ig id w i t h a g e; h en c e t h e m e di as t in a l s t ru c t u res b ec o m e l es s m ob i le .
T h e m e d ias t in u m is ar ti f ic ia ll y d iv id ed in t o s u p er io r an d in f e rio r p ar ts f or pu r po s es o f d e s cr ip t io n . Th e
s u p er io r m ed i as t in u m ex te n d s i n f eri or ly f ro m t h e s u p eri or t h or ac i c a p ert u re t o t h e h o riz on t al p l an e t h at
i n c lu d es t h e s t ern a l an g l e an t er io rly a n d pa s s es ap p ro xim at ely th r ou g h th e ju n c t io n ( IV di s c ) o f th e T4
a n d T 5 ve rte b rae p o s te ri orl y, o ft en r ef err ed to as t h e tr a nsv er se t h o ra ci c pl an e ( F ig . 1 .3 4 ) . T h e
i nf er io r me di a st in um b et w e en t h is p la n e an d t h e d ia ph r ag m i s f u rth e r s u b d ivi d ed by th e
p er ic ar d iu m i n to an t eri or , m id d le , an d p os t eri or p a rt s . Th e p e ric a rd iu m a n d i t s c o n t en t s ( t h e h ea rt a n d
ro o ts o f i ts g re at ves s el s ) co n s t it u te th e m i ddl e m e di as ti nu m . S om e s t ru c t u re s , s u c h a s th e e s op h ag u s ,
p as s v ert ic a ll y th r ou g h th e m ed i as t in u m a n d t h ere f ore li e in m o re t h an o n e m e di as t in a l c o m p art m e n t.
Fi gu re 1 . 34 . S ub div i si on s a nd l ev el s o f me di a st in um . T h e s u b di vi s io n s of th e m ed ia s t in u m ar e
d em o n s tr at ed as if t h e p ers o n w e re in t h e s u p in e p os it i on . T h e l evel of t h e vi s c era r ela t ive t o th e
s u b di vi s io n s as d ef in e d b y t h or ac i c c a g e la n d m ark s d e pe n d s o n t h e in d iv id u al 's p os i t io n b e c au s e t h e
s of t ti s s u e o f t h e m e d ias t in u m s ag s w i th t h e p u ll of g rav it y.
P .1 3 6
Levels of the V iscera Relati ve to t he Mediastin al Divis ions

Th e di vi s io n b e tw een t h e s u p eri or a n d th e i n f eri or m ed ia s ti n u m ( th e tra n s ver s e th o ra c ic p la n e) is d ef in e d
in t erm s o f bo n y b od y w al l s t ru c tu r es an d ar e m o s tl y in d ep e n de n t o f gr avi ta ti on a l e ff e c ts . T h e l evel of
th e v is c er a re lat i ve t o t h e s u b d ivi s io n s of t h e m ed i as t in u m d ep en d s o n th e p o s it io n of t h e p ers o n (i .e.,
gr avi ty ). W h en a p e rs on i s s u pi n e o r w h en a c ad ave r is b ei n g di s s ec t ed , th e vis c e ra a re p os i t io n ed h ig h er
(m ore s u pe rio r) rel at iv e to t h e s u b di vi s io n s o f th e m ed ia s ti n u m t h an w h e n th e p e rs on i s u p r ig h t ( F i gs .
1 .3 4 an d B 1 .1 4A ) . In ot h er w or ds , g ra vi ty p u l ls t h e vi s ce ra d o w n w a rd w h e n w e ar e ve rti c al . A n at om i c al
de s c rip t io n s tr ad it io n al ly d e s c rib e t h e l eve l of t h e vi s c era as if t h e p ers o n w er e in t h e s u p in e
po s it i on t h at is , l yi n g i n be d o r o n th e o p era ti n g or d i ss e c ti on t ab l e. In t h is p os i ti on , t h e a bd o m i n al
vis c e ra s p rea d h ori z on t a lly , p u sh i n g th e m ed ia s ti n al s tru c t u re s su p e rio rl y. H o w ev er, w h e n th e in d iv id u al
is s t an d in g or s it ti n g erec t , t h e le vel s of th e vis c e ra a re as s h o w n i n F i g u re B 1 .1 4 B . T h i s o c c u rs b ec au s e

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t h e s o ft s t ru c tu r es in t h e m e di as t in u m (e s pe c ia ll y th e p e ric a rd iu m a n d it s c o n t en t s ), t h e h ea rt an d g rea t
ve s s el s , a n d th e a b d om i n al vis c e ra s u p p ort i n g t h em s a g i n f eri or ly u n d er t h e i n f lu e n ce of g rav it y.
In t h e s u p in e po s it i on , t h e:
A rc h o f t h e a ort a l ie s s u p e rio r t o t h e tr an s ve rs e t h or ac ic p l an e.
B if u r c at io n o f th e tr ac h ea is tr an s ec t ed b y t h e t ran s ve rs e t h or ac ic p l an e.
Ce n tra l t en d o n o f th e di ap h ra g m (o r t h e d ia ph r ag m a ti c su rf ac e o r in f e rio r ex ten t o f t h e h ea rt ) l ie s

at t h e le vel of th e xip h i s te rn al ju n c t io n an d ve rte b ra T 9 .
W h en s t an d in g o r s it ti n g u pr ig h t , th e :
A rc h o f t h e a ort a i s tra n s ec t ed b y th e tr an s ve rs e t h ora c ic p la n e.
T rac h e al b i f u rc at io n li es in f e rio r t o t h e tr an s ve rs e t h or ac ic p l an e.
Ce n tra l t en d o n o f th e di ap h ra g m m ay f a ll to th e l eve l o f t h e m id d le o f th e x ip h o id p roc e s s a n d th e

T 9 T 1 0 IV d is c .
T h is v ert ic a l m o vem e n t o f m ed ia s ti n al s tr u c tu re s m u s t b e c o n s id er ed d u rin g p h ys ic a l a n d r ad io lo g ic a l

e xam i n at io n s in t h e er ec t a n d s u pi n e p os i ti on s. I n a d d it io n , w h en l yin g o n on e' s s id e, t h e m e di as t in u m
s a gs t ow ar d t h e l ow e r s id e u n d e r th e pu l l o f g r avi ty .
Mediast inoscop y and Med ias tin al Biop sies

U s in g a n en d os c o pe (m e d i as ti n o sco pe ) , su rg eon s c a n s ee m u c h o f t h e m e d ias t i n u m an d c on d u c t m in o r
s u rg i c al p r oc ed u re s . Th e y in s e rt t h e e n do s c op e t h ro u g h a s m a ll i n c is i on a t t h e ro ot of t h e n ec k, j u s t
s u p er io r to th e ju g u l ar n o tc h o f th e m an u b ri u m , in t o t h e p o te n ti al s p a c e an t eri or to th e t ra c h ea. D u ri n g
m e di ast i n o s c o p y, s u r ge on s c an v iew or b i op s y m e di as t in a l l ym p h n od e s t o d e te rm in e if c an c e r c ell s
h a ve m e ta s ta s iz e d t o t h em f ro m a b ro n c h o ge n ic c ar c in o m a, f o r exa m p le . Th e m ed ia s ti n u m c an a ls o b e
e xp lo red an d b io p s ies t ak en th r ou g h an a n te rio r t h ora c ot o m y ( rem o vi n g p a rt o f a c os t a l c art i lag e ; s e e
c l in i c al c o rre la ti on [ b lu e] b ox T h o rac o to m y, I n te rc os t al S pa c e In c i s io n s , R ib E xc i s io n , an d B on e
G ra ft i n g, i n th i s c h ap te r) .
Fi gu re B 1. 1 4
Wideni ng of the Mediast inu m

R a d io lo gi s t s a n d em er ge n c y p h ys ic i an s s o m et im e s ob s er ve w i d en in g o f t h e m ed ia s ti n u m w h en v iew in g
c h e s t ra d io gr ap h s (S a u erl an d , 1 9 9 9 ) . A n y s t ru c t u re in t h e m e d ias t i n u m m ay c o n t rib u t e t o p at h ol og i c al
w id en i n g . It i s of t en ob s er ved af t er t ra u m a re s u lt in g f ro m a h ea d -o n c ol li s io n , f or e xam p l e, w h i c h
p ro d u c es h em o rrh a g e in t o t h e m e d ias t i n u m f rom l ac e rat ed g rea t ve s s el s s u c h a s t h e a or ta o r S V C.
F r e q u e n t ly , m a li g n an t lym ph o m a ( c a n ce r of l ym p h at i c t is s u e ) p ro d u c es m a s si ve e n la rg em e n t o f
m e d ias t i n al l ym p h n o de s an d w i de n in g of t h e m e di as t in u m . E n lar ge m en t ( h yp ert ro p h y) o f th e h ear t
( o cc u r rin g w it h co n g es t iv e h ear t f a ilu r e) is a c o m m o n c au s e o f w id en i n g of t h e in f er io r m ed i as t in u m .
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Th e B ott om Lin e
T h e m e d ias t in u m is t h e c en t ral c om p a rt m en t of t h e th o ra c ic c av it y an d c on t ai n s al l t h ora c ic vi s c era
e xc ep t t h e l u n g s . Oc c u p yi n g s tru c t u re s a re h o ll ow (f l u id or air fi ll ed ) , an d al th o u g h c on t ai n ed b et w ee n
b o n y f orm at io n s an t eri orl y an d p o st er io rly , li e b et w ee n p n e u m at ic p ac k in g , in f l at ed to c on s t an t ly
c h a n gi n g vol u m es o n eac h s i d e. T h u s t h e m e d ia st i n u m is a p l iab l e, d yn a m ic s t ru c t u re t h at is m o ved b y
s t ru c t u res c o n ta in e d w it h in i t ( th e h ear t) an d s u rr ou n d in g i t ( th e d iap h ra g m an d ot h er m ov em en t s of
re s p ira ti on ) as w ell as t h e ef f ec t of g ra vit y a n d b o dy po s it io n . T h e s u p eri or m ed ia s ti n u m ( ab ov e th e
t ra n s vers e th o rac i c pl an e ) i s oc c u p ie d b y t h e t ra ch ea a n d u p p er p a rts o f th e g r eat ves s e ls ; th e m id d le
p ar t ( m o s t) o f t h e i n fe ri or m e d ias t in u m is oc c u p i ed b y th e h ear t; an d m o s t o f t h e p o s te rio r m ed i as t in u m
i s oc c u p ie d b y s t ru c t u res ve rt ic a lly tra ver s in g al l o r m u c h of t h e t h ora x.
Pe ricard ium
T h e m id d l e m ed i as t in u m i n c lu d es t h e p eri c ard i u m , h ea rt , an d ro ot s of it s g rea t ve s s els ( F ig . 1 .3 4 )
a s c en d in g ao rt a, p u lm on a ry t ru n k, a n d S V C pa s s in g t o an d f ro m th e h ear t. T h e pe r ica r di u m is a
f ib ro s ero u s m em b r an e t h at c ov ers t h e h ea rt a n d t h e b eg i n n in g of i ts g re at ves s el s (F i g s . 1 .2 7 B an d
1 .3 5 ) . T h e p eri c ard i u m is a c l os e d s a c c o m p o se d of tw o l aye rs . T h e to u g h ext er n al l aye r, t h e f ib ro u s
p e ri c a rd i u m, is c o n ti n u ou s w it h (b l en d s w it h ) th e c en t ral te n do n of t h e d ia ph r ag m ( F ig . 1 .2 5 ) . T h e
in t er n al s u r fa c e o f t h e f i br ou s p eri c ard i u m is l in ed w it h a g li s te n in g s ero u s m em b ra n e, t h e pa ri e ta l la ye r
o f se ro u s per i car di um . T h is l aye r is re fl ec t ed on t o t h e h e art at th e gr eat
P .1 3 8
ves s e ls a or ta , p u lm o n ary tru n k an d vei n s , an d s u p eri or a n d i n f eri or ven a e c ava e a s th e vi sce ra l
l ay er o f s er o us pe ri ca rd iu m . Th e s e ro u s p e ric a rd iu m i s c om p o s ed m ai n ly o f m es o th e li u m , a s in g l e la yer
of f l at te n ed c ell s f orm in g an ep i th e li u m th a t l in e s b o th t h e i n te rn al s u rf ac e o f th e f i b rou s p er ic ar d iu m an d
t h e ext er n al s u r fa c e o f t h e h ea rt .
Fi gur e 1. 35. P e ri ca rdi u m a nd he a rt . A. T h e h e art oc c u p ie s th e m id d le m ed ia s ti n u m an d i s

en c lo s ed b y th e pe ric a rd iu m , c om p o s ed of t w o p a rt s. T h e t o u gh , o u t er f ib ro u s p eri c ard i u m s ta b ili z es
th e h e art an d h el p s p r even t it f ro m ov erd il at in g . W it h in t h e f ib ro u s p eri c ard i u m is a c o ll ap s ed
sa c , th e s ero u s pe ric a rd iu m . Th e em b ryo n ic h e art in va g in a te s t h e w al l of t h e s er ou s s ac ( B) an d
so o n p ra c t ic al ly o b li te rat es t h e p eri c ar di al c avi ty ( C ) , lea vi n g o n ly a p ot en t ia l s p ac e b et w e en t h e
lay ers o f s e rou s p er ic a rd iu m . C an d D . T h e c o n t in u it y o f th e f i b rou s p er ic ar d iu m w i t h t h e c e n tr al
ten d o n of t h e d ia ph r ag m c on s t i tu t es t h e p eri c ard i ac o ph r en ic l ig a m en t .

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Fi gu re 1 . 36 . D e ve lo pm e nt o f he ar t a nd p er ic ar di um . Th e lo n g it u di n al , em b ry on i c h ear t t u b e
in v ag in a te s th e d o u b le- l aye red p eri c ard i al s a c (s o m ew h at li ke p la c in g a w ie n er in a h ot - do g bu n ) .
T h e p rim ord i al h e art t u be th e n l oo p s v en t ral ly , br in g in g t h e p rim ord i al art eri al an d ven o u s
en d s of t h e h ea rt to g et h er an d c re at in g t h e p rim o rd i al t ra n s vers e pe ric a rd ia l s i n u s ( T ) be tw een
t h em . W it h gr ow th o f t h e e m b ryo , th e v ein s e xp an d an d s p rea d a p art , in f e rio rl y an d la te ral ly . Th e
p eri c ard i u m ref l ec t ed aro u n d th e m fo rm s t h e b o u n da ri es of t h e ob l iq u e p er ic ar di al s in u s . I V C,
in f e rio r ve n a c ava ; S V C , su p e rio r ve n a c av a.
T h e fi br o us pe r ica r di um is
Co n ti n u ou s s u p er io rly w it h t h e tu n i c a a dv en t it ia o f th e gr eat ves s e ls en t er in g an d le avi n g th e h e art

an d w it h th e p re tr ac h ea l l aye r of d eep c er vic a l f as c i a.
A t ta c h ed an t eri or ly t o t h e p os t er io r s u rf ac e o f th e st er n u m b y th e s te rn op er ic a rd ia l li g am e n ts , w h ic h
ar e h ig h l y var ia bl e i n t h ei r d eve lo p m en t .
B ou n d p o s te rio rly by lo os e c o n n ec t ive ti s s u e t o s t ru c tu r es in t h e p os t er io r m ed i as t in u m .
Co n ti n u ou s i n f eri orl y w i t h t h e c e n tra l t en d o n o f th e di ap h ra g m (F i g . 1 .3 5 C & D) .
T h e i n f eri or w all ( fl oo r) of t h e f ib ro u s p eri c ard i al s a c is f ir m ly a tt ac h e d a n d c on f lu e n t ( p ar ti al ly b le n d ed )

c e n tra ll y w i th t h e c en t ra l t en d on o f th e d i ap h ra g m . Th e s it e of c o n ti n u it y h a s b ee n ref er red t o as t h e
pe r ica r di aco p hr en ic l i ga me nt ; h ow eve r, th e f ib ro u s p e ric a rd iu m a n d c e n tr al t en d o n are n ot tw o
s e pa rat e s t ru c t u res t h at f u s ed to g et h er s ec o n d ari ly , n or a re t h ey s ep a rab l e b y d is s ec t io n . A s a re s u lt of
t h e a tt ac h m e n ts j u s t d e s c rib ed , t h e h ea rt is rel at iv el y w el l t et h ere d i n p lac e in s i de th i s fi b ro u s s a c . Th e
p er ic ar d iu m i s i n f lu e n c ed by m ov em en t s of t h e h ea rt an d g rea t ve s s els , t h e s t ern u m , an d di ap h ra g m .
T h e f i br ou s p eri c ard i u m p rot ec t s t h e h ear t a ga in s t s u d de n ove rf il li n g be c au s e i t i s s o u n yi eld i n g a n d
c l os e ly re la te d t o t h e g re at v es s el s th a t p i erc e i t s u p er io rly . Th e a s c en d in g a ort a c a rri es th e p eri c ard iu m
s u p er io rly b e yon d t h e h ea rt t o th e l eve l o f t h e s t ern a l a n gl e.
T h e pe ri ca r dia l cav it y i s th e po t en t ial s p ac e b et w e en op p o s in g la yers o f th e p a rie ta l a n d vi s c era l l aye rs
o f se ro u s p e ric a rd iu m . I t n o rm a lly c on t ai n s a th i n f il m of f lu i d t h a t en a b les t h e h ea rt to m ov e an d b ea t i n
a fr ic t io n le s s e n vir on m e n t.
T h e vi s c era l l aye r of s er ou s p eri c ard i u m m ak es u p th e e p ic ar di u m, t h e ou ter m os t of t h ree la yers o f th e
h e art w a ll . I t ex te n d s o n t o t h e b eg in n i n g o f th e gr eat ve s se ls , b ec o m i n g c o n ti n u ou s w it h th e pa rie ta l
l aye r of s er ou s p eri c ar di u m , ( 1 ) w h ere th e a or ta an d p u lm o n ary tru n k lea ve t h e h ea rt an d ( 2 ) w h ere t h e
S V C, IV C , an d pu l m o n ary vei n s e n te r th e h ear t. T h e t ra n s vers e p e ric a rd ia l s in u s l ie s b e tw een t h es e t w o
g ro u p s of ves s e ls an d t h e re fl ec t io n s of s ero u s p eri c ard i u m aro u n d th e m , an d t h e ref l ec t io n of th e s ero u s
p er ic ar d iu m a rou n d t h e s ec o n d g ro u p of ve s s els d ef i n es th e ob li q u e p eri c ard i al si n u s . T h e p eri c ard i al
s i n u s es f orm du r in g d eve lo pm en t o f th e h ear t a s a c on s eq u e n c e of t h e f ol d in g of t h e p ri m or di al h ear t
t u b e. A s th e h ear t t u b e f ol d s , i t s v en o u s e n d m ove s po s t ero s u pe ri orl y ( F ig . 1 .3 6 ) s o t h at th e ven o u s en d
o f th e t u b e l ies
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a dj a c en t t o th e a rt eri al e n d , s ep ara te d o n l y by th e t r an sve r se pe ri ca r dia l sin us , a t ran s ve rs el y ru n n i n g

p as s a g e in t h e p eri c ar di al s ac b et w ee n th e o ri gi n s of t h e af f er en t an d th e ef f ere n t g rea t v es s el s (F i g .
1 .3 7 ). T h u s th e tr an s ve rs e s in u s i s po s te ri or t o t h e i n tra p eri c ard i al p a rt s o f th e pu l m o n ary t ru n k a n d
a s c en d in g ao rt a an d a n te rio r t o t h e S V C an d s u p eri or t o t h e a tr ia o f th e h ear t.
A s t h e vei n s of t h e h ea rt d e vel op an d ex pa n d , a p eri c ard i al r ef le c ti on s u rr ou n d i n g t h em f o rm s t h e
o bl i qu e pe ri ca rdi a l si n us, a w i de po c ket - li ke re c es s in t h e p er ic ar di al c avi ty po s t eri or t o t h e b as e
( p os t er io r as p ec t ) o f th e h ear t, f o rm ed b y t h e le f t at ri u m ( F ig . 1 .4 2C & D) . T h e ob l iq u e s i n u s is b ou n d ed
l at era ll y b y th e pe ri ca rd ia l re f lec t i on s s u rro u n d in g t h e p u lm o n ar y vei n s an d IV C an d p os t eri or ly b y t h e
p er ic ar d iu m o verl yi n g t h e a n te rio r as p e c t o f t h e e so p h ag u s . T h e ob l iq u e s i n u s c an b e en t ere d i n f eri or ly
a n d w il l ad m i t s e ver al f i n g ers ; h ow eve r, th e y c an n o t p a s s a ro u n d a n y of t h es e s t ru c t u res b ec a u s e t h e
s i n u s is a b li n d s ac ( c u l- d e- s ac ) .
T h e a rte ri al s u p p ly o f th e pe ric a rd iu m ( F i g. 1 . 3 8 ) i s m ai n ly f ro m a s l en d er b ra n c h of t h e in t er n al t h o rac i c
a rt ery, t h e pe r ica r di aco p hr en ic a rt e ry , th a t o f te n a c c om pa n ie s o r at le as t p ara ll els t h e p h ren i c n erv e
t o t h e d ia p h rag m . S m all er c o n tr ib u t io n s of b lo od c om e f rom th e :
Fi gu re 1 . 37 . I nt e ri o r o f pe ri ca rd ia l s ac . T o rem o ve t h e h e art f rom t h e s a c , th e e ig h t ves s el s

p ier c in g t h e s ac w e re s ev ere d. T h e o b li qu e pe ric a rd ia l s i n u s i s c irc u m s c rib ed b y f iv e vei n s . T h e
s u p eri or v en a c a va ( S V C) , p u lm o n ary tru n k , an d es p ec i al ly t h e ao rt a h a ve i n tra p eri c ard i al p o rt io n s .
T h e p eak o f th e pe ric a rd ia l s a c o c c u rs at t h e ju n ct i on o f t h e a s ce n d in g ao rt a an d t h e ar c h o f th e
ao rt a. T h e t ran s v ers e p er ic a rd ia l s in u s i s b o u n d ed an t eri or ly b y t h e s er ou s p eri c ard i u m c ov eri n g t h e
p os t eri or as p ec t of th e p u lm o n ary tru n k an d as c en d i n g a or ta , po s t eri orl y b y t h at c ove rin g t h e S V C,
an d in f e rio rl y b y th e vis c e ral pe ric a rd iu m c o ve rin g t h e at ri a of t h e h ea rt . I V C, in f e rio r ve n a c ava .

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Fi gu re 1 . 38 . A r te r ia l s uppl y a nd v en o us dr ai n age o f per i car di um . T h e ar te rie s o f th e

p eri c ard i u m d eri ve p ri m ari ly fr om t h e i n te rn al th o rac i c art er ies w it h m in o r c o n tri b u ti on s f ro m it s
m u s c u lo p h ren i c b ran c h a n d t h e t h or ac ic a ort a. T h e v ein s a re t rib u t ar ies o f th e b ra c h io c ep h al ic ve in s .
M u s c u lo p h ren i c a rt ery , a t erm i n al br an c h of t h e in ter n al t h o rac i c art er y.
B ro n c h ia l, es o p h ag ea l, a n d s u p er io r p h ren i c a rt eri es , b ra n ch es of t h e th o ra c ic ao rt a.
Co ro n ary a rt eri es ( vis c e ral lay er o f s e rou s p er ic a rd iu m o n ly) , t h e f ir s t b ra n c h es of t h e ao rt a.
T h e ve n ou s d ra in ag e o f th e pe ric a rd iu m is f rom th e :
Pe ric a rd ia c op h re n ic ve in s , t rib u t ar ies o f t h e b ra c h io c ep h al ic ( or i n t ern a l t h ora c ic ) vei n s .
V ar iab l e t rib u t ari es o f t h e a z yg os ve n ou s s ys t em ( d is c u s s e d l at er i n th i s c h ap te r) .
T h e n er ve s u p p ly o f th e pe ric a rd iu m i s f rom t h e:
Ph r en i c n e rves ( C3 C5 ) , pr im a ry s o u rc e o f s e n s ory fi b ers ; p ai n s e n s at io n s c on ve yed b y t h es e

n er ves ar e c om m on l y ref e rre d t o t h e s ki n (C 3 C5 d er m at om es ) o f th e ip s il at era l s u p ra c la vic u l ar
re gi on ( t op of t h e s h o u ld er o f th e s a m e s i de ) .
V ag u s n er ves, f u n c t io n u n c e rt ai n .
S ym p a th e ti c tru n k s , vas o m ot o r.
P .1 4 0
T h e i n n erva t io n o f th e pe ric a rd iu m b y t h e p h re n ic n er ves ( th e y ar e s om a ti c n o t v is c er al n erv es ,
d es p i te th ei r l oc at i on ) an d t h e c ou rs e of t h es e s o m at ic n er ves b et w e en t h e h ear t a n d t h e l u n g s m ake
l it tl e s en s e u n les s t h e d eve lo p m en t of t h e f ib ro u s pe ri c ard iu m is c on s i d ere d. It is s p l it or s e pa rat ed f ro m
t h e d ev elo p in g b od y w all b y th e de vel op i n g p l eu ra l c av it ie s, w h ic h e xte n d t o ac c om m od a te t h e r ap id l y
g ro w i n g l u n g s . Th e lu n g s d evel op w it h in t h e p eri c ard i op er it on e al c a n al s th a t ru n o n bo t h s id es o f t h e
f o reg u t , c on n e ct i n g t h e t h or ac ic a n d a b do m i n al c a vi ti es on e ac h s id e o f th e s e p tu m t ra n s vers u m . Th e
c a n al s ( p ri m or di al p leu r al c a vit i es ) a re t o o s m a ll t o a c c om m od at e t h e ra p id g row th o f th e l u n g s , an d t h ey
b eg i n to in va d e th e m es en c h y m e o f t h e b o dy w al l p o s te rio rly , la te ral ly, a n d an t eri orl y, s p li t ti n g i t i n to

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t w o la yers : an o u te r la yer th a t b ec o m es t h e d ef in i t ive th o rac i c w al l ( ri b s a n d in t erc o s ta l m u s c l es ) an d an

i n n er o r d eep la yer (t h e p l eu ro pe ric a rd ia l m e m b ran e s ) t h at c on t ai n s th e ph r en i c n e rve s a n d fo rm t h e
f i br ou s p eri c ar di u m ( M oo re an d P ers a u d, 2 0 0 3 ). T h u s t h e p eri c ard i al s a c ca n b e a s o u rc e o f p a in j u s t a s
t h e ri b ca g e or pa ri et al p l eu ra c a n b e, al th o u g h th a t p ai n te n d s t o be ref er red to d erm a t om e s o f th e bo d y
w al l a rea s fr om w h ic h w e m or e c om m on l y rec e ive s en s at io n .
Su rgical S ign ificance of th e Tr an sverse Per icar dial S inu s

Th e tra n s ver s e p eri c ard i al s i n u s is es p ec i al ly i m p or ta n t t o c a rd ia c s u r ge on s . A f t er t h e p eri c ard i al s ac is
op en e d a n te rio rl y, a f i n ge r c an b e p as s e d t h ro u g h t h e t ra n s vers e pe ric a rd ia l s i n u s p o s te rio r t o t h e ao rt a
an d p u lm o n ary tru n k (F i g . B 1 .1 5 ) . B y pa s s in g a s u rg i c al cl am p o r p la c in g a l ig at u re a ro u n d t h es e v es s el s ,
in s er ti n g t h e t u b es of a co ro n ary by p as s m ac h i n e, a n d t h en t ig h t en i n g t h e l ig at u re, s u r ge on s c a n s t o p o r
di ver t t h e c i rc u la ti on o f b l oo d in t h es e l arg e a rt eri es w h i le p er f orm in g c ard i ac s u rg er y, s u c h as c or on a r y
art ery by pa s s g raf t in g .
F igu re B1 . 15
Expos ure of th e IVC and SV C

A ft er pa s s in g t h rou g h t h e d ia ph r ag m , t h e en t ir e th o ra c ic p art o f t h e IV C ( ap p ro xi m at el y 2 c m ) is
en c lo s ed b y t h e p eri c ard i u m . Con s e q u en t ly, t h e p er ic ar di al s ac m u s t be op en e d t o e xp os e t h e s u p er io r
pa rt of t h e IV C. T h e s am e is t ru e f o r th e ter m in a l p ar t o f t h e S V C, w h ic h i s p a rt ly i n s id e a n d p ar tl y
ou t s id e t h e p er ic ar di al s ac .
Peri card iti s, Pericard ial Rub, and Peri card ial Effu sion
Th e pe ric a rd iu m m ay b e i n vol ve d i n s ever al d i s eas e pr oc e ss e s . In f la m m at i on o f t h e p er ic ar di u m
(p er ic ar di ti s) u s u al ly ca u s es c h es t p ai n . It m a y al s o m a ke t h e s er ou s p eri c ar di u m ro u g h . Us u a ll y th e
s m oo th o p p os i n g l aye rs of s er ou s p eri c ard i u m m a ke n o d e te ct a bl e s o u n d d u ri n g au s c u lt at i on , b u t i n
pe ric a rd it i s f ri c t io n o f th e rou g h e n ed s u rf ac es s o u n d s l ik e th e ru s t le o f s i lk w h en l is t en in g w it h a
s te th o s c op e o ver t h e l ef t st er n al b o rd er a n d u p p er rib s ( pe ri ca rdi a l fr ic ti o n r ub) . A c h ro n ic a ll y
in f la m ed a n d t h ic k en ed p eri c ard i u m m ay ac t u all y c al c if y, s e rio u s ly h am p er in g c ard i ac ef f i ci en c y
(S a u erl an d , 1 9 9 9 ) . S om e in f l am m a t ory d i s eas e s pr od u c e pe ri ca r dia l effu si o n ( p as s a ge of f lu i d f r om
pe ric a rd ia l c a pi ll ari es i n to th e p e ric a rd ia l c av it y, o r an ac c u m u lat i on of p u s ) . A s a res u l t, t h e h e art
be c om e s c om p re s s ed (u n a b le t o e xp an d an d f il l f u l ly) an d i n ef f ec t ive . N on - in f l am m at ory pe ric a rd ia l
ef f u s io n s of t en oc c u r w it h co ng est i ve he ar t fa i lu re , in a d eq u ac y o w i n g to a h ea rt t h at f ai ls t o p u m p ou t
bl oo d at th e s a m e r at e th a t i t r ec ei ves i t ( i.e ., th a t f a il s t o m ai n ta in b lo od c i rc u la ti on ) .
Cardi ac Tamp ona de

Th e fi b rou s p er ic a rd iu m i s a to u g h , in e las t i c , cl os e d s a c th a t c o n ta in s t h e h ea rt , n orm al ly t h e o n ly
oc c u p an t ot h er t h a n a th i n lu b ri c at in g la yer of p eri c ard i al f l u id . If ex ten s i ve p e ric a rd ia l ef f u s io n exi s t s,
th e c o m p ro m is e d v ol u m e o f t h e s a c d o es n o t al lo w f u l l ex pa n s io n of t h e h ea rt, l im it in g th e am o u n t o f
bl oo d th e h ear t c an r ec ei ve, w h ic h in t u rn re du c e s c ard i ac ou t p u t. T h i s p h e n om e n on , ca r d i ac
ta m po na d e ( h ear t c o m p res s i on ) , is a p o te n ti al ly l et h al c on d it io n b ec au s e h ear t vo lu m e is i n c rea s in g ly
c om p ro m i s ed by th e f l u id ou t s i de th e h e art b u t i n s id e t h e p er ic ar di al c avi ty .
B lo od in t h e p eri c ar di al c avi ty , h em o pe ri ca rd iu m , li kew is e p ro d u c es c ard i ac t am p o n ad e. H e m op e r ic a rd iu m
m ay r es u lt f ro m pe rf or at io n of a w eak en ed ar ea o f h ear t m u s c l e ow in g t o a p re vio u s m y o ca rd ia l
in fa rc t i o n ( M I) o r h ea rt at ta c k, f ro m b lee di n g in t o t h e p eri c ar di al c avi ty a f te r c ard i ac o pe rat io n s , o r

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f ro m s t ab w o u n ds . T h i s s i t u at io n i s es p ec i al ly l et h al b e ca u s e o f t h e h i g h p re s s u re i n vol ve d a n d t h e
ra p id it y w it h w h i c h t h e f l u id ac c u m u l at es . T h e h ea rt is in c r eas i n g ly c o m p res s e d a n d c i rc u la t io n f a il s . Th e
ve in s o f t h e f a c e an d n ec k b ec o m e e n g org ed b ec a u s e of t h e b ac ku p o f b l oo d , be g in n i n g w h ere t h e S V C
e n te rs th e p e ric a rd iu m .
In p a ti en t s w it h p n eu m o th o ra x a ir o r g as in t h e p le u ral c avi t y t h e ai r m a y d is s ec t al on g c on n e c ti ve
t is s u e pl an e s a n d en te r t h e p eri c ard i al s a c , pr od u c i n g a pn e um o pe ri ca rd iu m , w h ic h c a n be
d em on s t rat ed ra d io gr ap h ic a ll y ( S au erl an d , 1 9 9 9 ) .
Pericardi oc en tesis
D rai n ag e o f f lu id f ro m t h e p eri c ard i al c a vit y, p er ic ar d i o c en t esi s, i s u s u al ly n e c es s ary to rel iev e c ar di ac
t am po n ad e. T o rem o ve t h e ex c es s f lu i d, a w i de - bo re n e ed le m ay b e i n s ert ed t h rou g h t h e le f t 5 t h or 6 t h
i n te rc os t al s p ac e n e ar t h e s t ern u m . T h is a p pr oa c h t o t h e p er ic a rd ia l s ac i s p o s s ib le b ec au s e t h e c a rd ia c
n o tc h i n th e l ef t lu n g an d t h e s h al lo w er n ot c h in t h e le ft p le u ral s ac le ave s pa rt of th e pe ri ca rd ia l s a c
e xp os ed th e b a re a rea o f th e pe ric a rd iu m ( F i gs . 1 .2 4 A a n d 1 .2 5 ) . T h e p e ric a rd ia l s ac m a y al s o b e
re ac h e d b y e n ter in g t h e in f ra s te rn al an g le an d p as s in g t h e n ee dl e s u p er op os t er io rly ( F i g. B 1 . 1 6 ). A t th i s
s i te , th e n e ed le avo id s t h e lu n g an d p le u rae an d en t ers t h e p eri c ar di al c avi ty ; h o w ev er, c a re m u s t b e
t ak en n ot to p u n c tu r e th e in t ern a l t h or ac ic a rt ery o r it s t erm i n al br an c h es . In a c u te c ard ia c ta m p on a d e
f ro m h em op eri c ar di u m , an e m erg e n c y th o ra c ot om y m ay b e p e rf orm ed (t h e t h or ax i s rap i dl y op e n ed ) s o
t h at th e p eri c ard ia l s a c m ay b e i n c is ed t o i m m ed i at el y rel ie ve t h e t am p on ad e an d es t ab l is h s t as is o f th e
h e m or r h ag e ( s t op th e es c ap e o f b lo od ) f r om t h e h ea rt (s e e c li n ic a l c or rel at io n [b l u e] b ox
T h or ac ot o m y, In t erc o s t al S p a ce In c is i on s , R i b E xc is i on , a n d B o n e G raf t in g , in t h is c h a p te r) .
Fi gu re B 1. 1 6
P .1 4 1
Th e B ott om Lin e
T h e p er ic ar di u m i s a f ib ro s ero u s sa c , in v ag in a te d b y t h e h e art an d ro ot s of t h e g rea t ve s s els , t h at
e n c lo s es th e se ro u s c a vi ty s u r rou n d i n g t h e h e art . T h e f ib ro u s pe ric a rd iu m i s in e las t i c, a t ta c h ed an t eri orl y
a n d i n f eri or ly t o t h e s t ern u m a n d d i ap h ra g m , an d b len d s w i t h th e a d ven t it ia of t h e g rea t ve s s els a s th e y
e n te r or l ea ve t h e s ac . T h u s it h ol d s t h e h e art in i ts m i d dl e m e di as t in a l p o s it io n an d li m it s exp a n s io n
( f il li n g ) o f t h e h e art . If f lu i d o r a t u m o r oc c u p i es th e pe ri ca rd ia l s p ac e , th e ca p ac i ty o f th e h eart is
c o m p ro m is e d. T h e s e rou s p er ic ar di u m l in es t h e f ib ro u s p eri c ard i u m an d th e ext eri or of t h e h ea rt. T h i s
g l is t en in g l u br ic a te d s u rf a c e al lo w s t h e h ea rt ( a tt ac h e d o n ly b y i ts a f fe ren t an d ef f er en t ves s el s an d
re la te d r ef le c ti on s o f s e rou s m em b ra n e) t h e f re e m o vem en t r eq u ir ed fo r i ts w r in g in g - ou t
c o n tr ac t io n m ot io n s . T h e p ari et al lay er o f t h e s e rou s p er ic ar di u m i s s e n s it ive . Pa in im p u ls es c o n du c t ed
f ro m it b y t h e s om a t ic p h ren i c n erve s res u l t i n r ef er red p ai n s e n s at io n s .
He art and Gre at V essels

T h e he ar t , s li gh t l y la rg er t h an a c l en c h ed f i st , i s a d ou b le , s elf - ad j u s t in g , s u c t io n a n d pr es s u re p u m p ,
t h e p art s of w h i c h w o rk in u n i s on t o p ro p el b l oo d t o all p art s of t h e b od y. T h e ri g h t s i d e of t h e h ea rt
( rig h t h ear t) re ce iv es p oo rly o xyg e n at ed (v en o u s ) b lo o d f ro m t h e b od y t h ro u gh t h e S V C a n d IV C a n d
p u m p s it th ro u g h th e pu l m o n ary t ru n k t o th e l u n g s fo r o xyg en a ti on ( F ig . 1 .3 9 A ) . T h e le f t s i de of t h e h ea rt
( lef t h ea rt) re c eiv es w e ll- o xyg en a t ed (a rt eri al ) b lo o d f ro m t h e lu n g s t h rou g h t h e p u lm o n ar y vei n s an d

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p u m p s it in t o t h e a or ta f o r d is t ri bu t i on t o t h e b od y.
T h e h ea rt h as f ou r c h a m b ers : r ig ht an d le ft at r ia an d ri gh t a n d le ft ven t ri cl es . Th e a t ria are r ec ei vin g
c h a m b ers t h at pu m p b l oo d i n t o t h e ven t ri c le s ( t h e d is c h a rg in g c h am be rs ) . Th e sy n c h ron ou s p u m p in g
a c ti on s o f t h e h e art 's t w o at rio ven t ri c u la r ( AV ) p u m p s (r ig h t an d lef t c h am b e rs ) c o n s t it u te th e c ar d i ac
c y c l e ( F ig . 1 .3 9 B F ). T h e c yc l e b eg i n s w it h a p eri od o f v en t ric u l ar e lo n g at io n a n d fi ll in g ( di as to l e) a n d
e n ds w it h a p eri od o f v en t ric u l ar s h o rt en in g a n d e m p ty in g (s y st o l e) . T w o h ear t s o u n d s a re h e ard w i th a
s t et h os c o p e: a lu b s o u n d a s th e b l oo d i s tr an s f err ed ( su c k ed ) f r om t h e at ri a i n to th e ven t ric l es a n d a du b
s o u n d a s th e ven t ri cl es ex p el b l oo d f ro m t h e h ea rt . T h e h e art s ou n d s a re p ro du c e d b y t h e s n a pp i n g s h u t
o f th e o n ew ay va lv es th a t n o rm a ll y kee p b l oo d fr om f l ow in g b ac kw ard d u rin g c o n tr ac t io n s o f th e h ear t.
P .1 4 2
Fi gu re 1 . 39 . C a rd ia c cyc le . Th e c ard i ac c yc le de s c rib e s t h e c o m p le te m ove m en t of t h e h ea rt or

h ea rt be at an d in c l u de s th e p e rio d fr om t h e b eg i n n in g of o n e h ea rt be at to th e be gi n n in g o f t h e n e xt
on e . Th e c yc le c o n s is t s of d ia s to le (v en t ric u l ar r ela xa ti on an d f i lli n g ) a n d sy s to le (v en t ric u l ar
c on t ra c ti on a n d e m p ty in g ) . Th e rig h t h ear t ( b lu e s i d e) is t h e p u m p f o r t h e p u lm o n ar y c irc u i t; t h e le f t
h ea rt ( re d s i d e) is t h e p u m p fo r t h e s ys t em i c c irc u i t.
T h e w all of ea c h h ear t c h a m b er c o n s is t s o f th r ee l aye rs (F i g . 1 .3 5 ) :
E n d o car di u m , a t h in i n t ern a l la yer ( e n do t h eli u m an d s u b en d o th el ia l c o n n ec t ive ti s s u e) or l in i n g

m e m b ran e o f th e h ear t t h at al s o c ov ers i ts va lve s .
M y o ca rd iu m , a th ic k, h e lic a l m i d d le l aye r c om p o s ed of c ar d iac m u sc l e.
E p i ca rdi u m, a th i n ext ern a l l aye r ( m es o th e liu m ) f o rm e d b y t h e vi s c era l la yer of s ero u s

p er i c ar d i u m .

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T h e w all s of t h e h ea rt c o n s is t m o s tl y of t h ic k m yoc a rd iu m , e s p ec ia ll y in t h e ve n tri c le s .

W h en t h e ven t ri c le s c o n t rac t , th e y p rod u c e a w ri n g in g m o ti on b ec a u s e of t h e d ou b l e h el ic a l or ien t a ti on o f
t h e c ar d iac m u s c l e f ib e rs (T o rren t - Gu a s p et a l., 2 0 0 1 ) ( F ig . 1 .4 0 A ) .
P .1 4 3
P .1 4 4
T h is m o t io n in i ti al ly ej e ct s t h e b lo od f ro m th e v en t ric l es as t h e o u te r ( ba s al ) s p ir al c o n t rac t s , f irs t
n a rro w i n g a n d t h en s h o rt en in g t h e h ea rt , red u c in g t h e vo lu m e of t h e ven t ri c u la r c h am b e rs . Con t i n u ed
s e qu e n ti al c on t rac t io n of t h e i n n er ( ap ic a l) s p ira l e lo n ga te s th e h e art , f ol lo w e d b y w id en i n g as th e
m y oc a rd iu m b ri ef ly rel axe s , in c re as in g t h e vo lu m e of t h e c h am b e rs to d raw b l oo d fr om t h e a tri a. T h e
m u s c l e f ib e rs are an c h or ed to th e fib ro u s sk el e to n o f t h e he ar t (F i g . 1 .4 0 B ) . Th i s is a c o m p le x
f ra m ew ork of d en s e c o ll ag en f o rm in g f o u r fi bro u s ri ng s ( L. a n u li f i b ros i ) t h at s u rro u n d th e ori f ic es o f
t h e va lve s , a ri g h t a n d l ef t f ib ro u s t r ig o ne (f o rm e d b y c o n n ec t io n s be tw een ri n g s ), a n d th e m em b ra n ou s
p ar ts o f th e i n te rat ri al an d in t erv en t ric u l ar s e pt a . Th e f i b rou s s ke le to n of t h e h ea rt:

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Fi gu re 1 . 40 A r ra nge m en t o f t he my o ca rdi um a nd t he f ib ro u s sk el et o n o f h ea rt . A . T h e h e li c al
( do u b le s p i ral ) a rra n g em e n t o f t h e m y oc a rd iu m . ( M od i f ied f ro m T orr en t -G u as p et al ., 2 0 0 1 ) . 1 . W h e n
t h e s u p erf ic i al m yo c ard i u m is in c i s ed al on g t h e an t er io r in t erv en t ric u l ar g ro ov e ( da s h ed red l in e) an d
p eel ed b ac k s t art i n g a t i ts o rig i n fr om t h e f i br ou s ri n g o f th e pu l m o n ary a rt ery ( P A ), t h e t h ic k d o u b le
s p ira ls o f t h e v en tr ic u l ar m y oc a rd ia l b an d are rev eal ed (2 ). It c an b e s e en th a t a ba n d of n ea rly
h or iz o n ta l f ib e rs f orm s a n ou t er b a s al s p i ral (d a rk b row n ) t h a t c o m p ris e s t h e o u t er w a ll of t h e rig h t
ven t ri c le ( ri g h t s e gm en t ; rs ) an d ex te rn al la yer o f th e o u t er w a ll of t h e le f t ve n tr ic le (l ef t s eg m en t ;

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ls ) . 3 . A f t er t h e le ft ve n tri c le h as b een ro t at ed to b rin g t h e in t er ven t ri c u lar s ep tu m a n te ri orl y, it c an

b e s ee n t h at t h e m yo c ard i u m t h en ab ru p t ly t u rn s m o re ve rt ic a ll y, d es c en d in g t o t h e ap e x
( de s c en d in g s eg m e n t; d s ) a n d t h en a s c en d s (a s c en d in g s eg m e n t; as ) t o i n s ert on t o t h e f ib r ou s ri n g
of t h e ao rt a ( A o) . T h e d s an d as f or m th e de ep er a p ic al s p ira l ( li g h t b ro w n ) , w h i c h co m p ri s es t h e
in t er n al l aye r of t h e o u te r w a ll o f th e l ef t ven t ri c le, w h il e t h e c ris s - c ro s s in g as a n d d s f ib e rs m ake u p
t h e in t erv en t ric u l ar s e pt u m . T h u s t h e s ep tu m , li ke t h e ou t er w al l o f t h e l ef t ven t ri cl e, i s als o d ou b le
la yer ed . 4 an d 5 . T h e ven t ri c u la r m yo c ard i al b a n d i s pr og re s s ive ly u n w rap p ed . 6 . It is c o m p let el y
u n c oi le d a n d i t s s e g m en t s are i d en t if i ed . Th e s eq u en t ia l c on t ra c ti on o f th e m yoc a rd ia l b an d en a b les
t h e ven t ri c les t o f u n c t io n as p ara ll el , s u c kin g an d p ro p ell in g p u m p s ; o n c on t ra c ti on , t h e ve n tr ic l es d o
n ot m er el y c ol la ps e i n w a rd b u t ra th e r w ri n g th e m s el ves o u t. a pm , an t eri or p a pi ll ar y m u s c le s ; p g 1
an d p g 2 , po s t eri or i n te rve n tr ic u la r g ro ove ; p p m , p o st er io r p ap il la ry m u s c l es . B . T h e i s ol at ed f ib ro u s
s kel et on i s c om p o s ed of f ou r f i b rou s r in g s (o r t w o rin g s an d t w o c o ro n et s ) , e ac h en c i rc li n g a
va lve ; t w o tr ig on e s ; a n d t h e m e m b ra n ou s p or ti on s o f t h e i n te rat ri al , in t erve n tr ic u l ar, a n d
at ri ove n tr ic u l ar s ep t a.
K ee p s t h e o ri fi c es o f t h e A V an d s em i lu n a r va lve s pa te n t a n d p re ven t s t h em f ro m b ein g o verl y

d is t en d ed b y an i n c rea s ed vo lu m e o f b lo od p u m p in g th r ou g h t h em .
l
l
Pr ovi d es at t ac h m e n ts f or th e l ea f let s an d c u s p s of th e val ves .

Pr ovi d es at t ac h m e n t f o r th e m yoc a rd iu m , w h ic h , w h en u n c o il ed , f orm s a c on t in u o u s ve nt ri cu la r
m yo ca rd ia l b an d th at o ri g in at es p ri m ar il y f rom t h e f i br ou s ri n g of th e p u lm o n ary val ve a n d i n s ert s
p ri m ari ly i n t o t h e f ib ro u s rin g o f t h e a ort i c v al ve ( To rre n t- G u as p et al ., 2 0 0 1 ) (F i g . 1 .4 0A ).
F or m s an el ec t ri ca l i n s u lat o r, b y s ep ara t in g th e m yen t er ic al ly co n d u c te d im p u ls e s of t h e at ri a

an d ve n tr ic l es s o t h at th e y c on t ra c t i n de pe n d en t ly a n d b y s u r rou n d i n g a n d p r ovi d in g p as s ag e f o r t h e
in i t ial p art of t h e A V b u n dl e o f t h e c o n d u ct i n g s y s tem of th e h ear t ( d is c u s s ed l at er i n t h i s c h a p te r) .
T h e h ea rt an d ro ot s of t h e g rea t ve s s els w it h in t h e p eri c ard i al sa c are rel at ed an t eri or ly t o t h e s t ern u m ,

c o s ta l c ar ti la g es , an d an t er io r en d s of t h e 3 rd 5 t h ri bs o n th e lef t s id e ( F ig . 1 .4 1 ) . T h e h ea rt an d
p er ic ar d ial s ac ar e s it u at ed o bl iq u e ly, a pp r oxi m at el y t w o t h i rd s t o th e l ef t an d on e t h i rd to th e r ig h t of
t h e m e di an p l an e ( F ig s . 1 .4 1 a n d 1 . 4 2A ). If yo u tu r n you r fa c e t o t h e le f t a bo u t 4 5 w i th o u t ro t at in g
yo u r s h o u ld er s , t h e r ot at io n of yo u r h ea d a p pr oxi m a te s t h at o f t h e h ea rt rel at ive to th e tru n k. E xt ern a ll y,
t h e a tri a a re d em a rc at ed f ro m th e ven t ri c les b y t h e co r o n a ry or a t ri o ve nt r icu l ar gro o v e ( L. s u l c u s ),
a n d t h e ri g h t a n d l ef t ven t ri c les a re d em a rc at ed f ro m ea c h o t h er b y a n t er i o r a n d po s te r io r
i nt e rv en tr i cul a r (I V) gr o o ve s ( F ig s . 1 .4 2 B & D ) . Th e h ear t a pp e ars t rap ez oi da l f ro m an a n te rio r or
p o s te rio r vi ew ( F ig . 1 .4 2A ) , b u t i n th r ee d i m en s i on s it is s h a pe d l ik e a t ip p ed - ov er p yra m id w it h an ap ex
( d ir ec te d a n t eri orl y an d t o t h e l ef t) , a b a s e ( op p os i te th e a p ex, f ac i n g m os t ly po s t eri orl y) , an d f ou r s i d es .
T h e a pe x o f t he h ea r t ( F ig . 1 .4 2 B ) :
l
l
Is f or m ed b y th e in f er ol at era l p art o f t h e l ef t v en t ric l e.

L ies p o s te rio r t o t h e le f t 5 t h in t erc o s ta l s p ac e in ad u l ts , u s u a ll y ap p ro xim a t ely 9 c m ( a h a n d 's
b rea d th ) f ro m th e m ed ia n pl an e .
R em ai n s m ot io n le s s t h ro u g h ou t th e c ard i ac c yc le .
Is w h e re t h e s o u n ds o f m it ral val ve c l os u r e are m ax im a l ( ap ex bea t); t h e ap e x u n d erl ies t h e s it e

w h e re t h e h ea rt be at m ay be au s c u lt at ed o n th e t h o rac i c w al l.
T h e ba se o f t h e he a rt ( Fi g . 1 .4 2 C & D ) :
Is t h e h ea rt' s po s t eri or a s p ec t ( o pp o s it e t h e ap e x) .
Is f or m ed m ai n ly by th e l ef t at riu m , w it h a l es s er c o n t rib u t io n by th e r ig h t at riu m .
F ac e s p o s te rio rl y t ow a rd th e bo d ie s o f ver te br ae T 6 T 9 an d i s s e p ara te d f ro m t h em b y t h e

p eri c ard i u m , o bl iq u e p er ic a rd ia l s in u s , e s op h ag u s , a n d a ort a.

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E xt en d s s u p eri or ly t o t h e b if u rc a ti on o f th e pu l m o n ary t ru n k a n d in f eri or ly t o t h e c o ro n ary g ro ov e.
R ec e ive s th e pu l m o n ary v ein s o n th e rig h t an d le ft s id e s o f it s lef t at ri al p o rt io n a n d th e s u p e rio r

an d i n fe ri or ve n ae c a vae at th e s u p e rio r an d i n fe rio r en d s o f i t s r ig h t a tr ia l p or ti on .
T h e f o u r s u rf ac e s o f th e h e art ( F ig . 1 .4 4 A D ) a re t h e:
A nt er i o r (s te rn o co st a l) su r fa ce, f o rm e d m a in l y b y t h e rig h t ven t ri c le .
D ia ph ra gm at i c (i nfe r io r ) su rfa ce , f orm ed m ai n ly b y t h e l ef t v en t ric l e an d p ar tl y b y th e rig h t

ve n tri c le ; i t i s rel at ed m ai n ly t o th e c e n tr al t en d o n of th e d iap h ra g m .
l
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R ig ht pul m o na ry s ur fac e, f o rm ed m a in l y b y th e rig h t at riu m .

L e ft p ul mo n a ry su rf ace , f or m ed m ai n ly by t h e l ef t ven t ri cl e; it f or m s th e c a rd ia c im p re s s io n of th e
le f t l u n g.
T h e h ea rt ap p ear s tra p ez o id al in b ot h an t er io r (F i g . 1 .4 2A & B ) an d p os t er io r vie w s ( F ig . 1 .4 2 C & D) . It s

f o u r b ord e rs are t h e:
R ig ht bo rd er (s l ig h t ly c o n vex ), f o rm ed b y t h e ri g h t at ri u m an d ex te n di n g be tw een t h e S V C a n d t h e
IVC.
In fe ri o r bo r de r ( ob l iq u e, n e arl y ver ti c al ), f o rm ed m a in l y b y th e rig h t ven t ri c le a n d s l ig h t ly b y t h e

le f t ve n tr ic l e.
L e ft b or de r ( n ea rly h ori z on t al ) , f orm ed m ai n ly b y t h e l ef t v en t ric l e an d s li g h tl y b y t h e le ft au r ic l e.
Su pe ri o r bo r de r, f o rm ed b y t h e ri gh t an d l ef t a tr ia a n d a u ri c les i n an an t eri or vie w ; th e as c en d i n g

ao rt a a n d p u l m on a ry t ru n k em erg e f ro m t h is b or de r an d t h e S V C en t ers i ts ri g h t s i de . Po s te rio r t o
t h e ao rt a an d p u lm on a ry t ru n k an d a n te rio r t o t h e S V C, th i s b ord e r f orm s t h e i n f eri or b o u n d ary o f
t h e tr an s ve rs e p er ic ar di al s in u s .
T h e pu l mo n ar y t ru nk , ap p ro xim at ely 5 c m lo n g a n d 3 c m w id e, i s th e art eri al c on t in u a ti on o f th e r ig h t

ve n tr ic l e an d d iv id es in t o rig h t an d le ft p u lm o n ar y art er ies . T h e p u l m on a ry t ru n k a n d a rt eri es c on d u c t
p o orl y o xyg en a te d b l oo d t o t h e l u n g s f o r ox yg en a ti on ( F ig . 1 .3 9 A ) .
P .1 4 5

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Fi gu re 1 . 41 . P e ri ca rd ia l s ac i n r el a ti o n t o st er nu m a nd ph re n ic n er ve s. Th i s d is s ec t io n exp o s es
t h e p eri c ard i al s a c po s te ri or t o t h e b od y o f th e s ter n u m f rom ju s t s u p eri or t o t h e s t ern a l a n gl e t o t h e
le vel of t h e xip h i s te rn al jo in t . T h e p eri c ar di al s ac li es ap p ro xim at el y on e t h i rd t o th e r ig h t o f th e
m i ds t er n al l in e a n d tw o t h ird s t o t h e le f t.
Position al Abnor maliti es of the Hear t

A bn o rm a l f o ld in g o f t h e em b ryo n ic h ea rt m ay c a u se th e po s it io n of t h e h ea rt to be c om p l et ely reve rs ed
s o t h at th e a p ex i s d i rec t ed t o t h e ri gh t in s t ea d o f th e lef t de x tr o c a rd ia ( Mo or e an d Pe rs au d , 2 0 0 3 ) .
Th i s c on g en i ta l a n om a ly i s th e m os t c om m on p os i t io n al a b n orm ali t y of t h e h ea rt, b u t it is s t il l re lat i vel y
u n c om m on . D ext ro c ard i a is a ss o c ia te d w it h m i rro r im a g e p os i ti on i n g o f th e gr eat ve s se ls a n d t h e a rc h of
th e a or ta . Th i s an o m al y m a y be p art of a g en e ral tr an s p os i ti on o f th e th o rac i c an d ab d om in al vi s ce ra
(s i tu s i n ver s u s) , o r t h e tr an s p os i ti on m ay a ff e c t o n ly t h e h ea rt (i s ol at ed d ext ro c ard i a) . In d ext ro c ard i a
w it h s it u s in v ers u s , t h e in c i d en c e o f ac c om pa n yi n g c a rd ia c d e f ec ts i s lo w , an d t h e h ea rt u s u a ll y f u n c ti on s
n orm all y. In i s ol at ed d ext ro c ard i a, h ow eve r, t h e c on g en i t al a n om aly is c om pl ic a te d b y s e vere c ard i ac
an o m al ies , s u c h a s t ra n s p os i ti on o f t h e g re at art eri es . F o r a d is c u s s i on o f t h e p ro g n os i s a n d tre at m en t of
de xt roc a rd ia , s ee B e h rm an e t a l. ( 2 0 0 0 ) .
Percu ssion of th e Heart

Pe r cus s io n d ef in e s t h e d en s i t y an d s iz e of th e h ear t. T h e c l as s ic a l p er c u ss i on t ec h n i q u e is t o c re at e
vib ra ti on b y t ap p in g t h e c h es t w i th a fi n g er w h il e li s te n in g an d f eel in g f or di f f ere n c es in s o u n dw ave
c on d u c t io n . Per c u s si on i s p erf or m ed at t h e 3 rd , 4 t h , an d 5 th i n te rc os t al s p ac es f ro m t h e le ft an t er io r
axi ll ary l in e to th e rig h t an t eri or a xi lla ry l in e ( F i g. B 1 . 1 7 ) N o rm a ll y, t h e p erc u s s i on n o te c h a n g es f rom
res o n an c e t o d u l ln es s ( b ec a u se of t h e p res e n ce of t h e h ea rt) a pp ro xi m at el y 6 c m la te ral to th e lef t
bo rd er o f th e s te rn u m .

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Fi gu re B 1. 1 7. Ar e as o f fl a tn es s an d re so n an ce.
P .1 4 6

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Fi gu re 1 . 42 . S ha pe , o ri en t at i o n, su rf a ce s, an d bo r der s o f he ar t . A an d B. T h e s t ern o c os t al
s u rf ac e of th e h ear t a n d t h e re la ti on s h i p o f th e gr eat ve ss e ls ar e s h ow n . T h e ven t ri c les d o m in a te th i s
s u rf ac e (t w o th i rd s rig h t ven t ri c le , on e t h ir d l ef t ven t ri cl e) . T h e en t ir e ri gh t au r ic le an d m u c h of t h e
ri gh t at ri u m are vis i b le, b u t on l y a s m a ll pa rt of t h e le ft au r ic l e is s ee n . C a nd D . Th e pu l m o n ary
( lef t ) an d d iap h ra g m at ic ( i n fe rio r) s u rf ac e s a n d th e b a s e of t h e h ea rt are s h o w n a s w el l as t h e
rel at io n s h ip o f t h e g re at ves s el s .
P .1 4 7
R ight At rium
T h e ri g h t a tr iu m f o rm s th e rig h t b ord er of t h e h ea rt a n d r ec ei ves ve n ou s b lo od f ro m t h e S V C, IV C, a n d
c o ro n ary s i n u s (F i g . 1 .4 2 B & D ). T h e e ar- l ike r i ght a ur icl e is a c o n ic a l m u s c u la r p ou c h t h at p roj ec t s
f ro m t h is c h am be r li ke a n ad d -o n ro om , i n c rea s in g th e c ap ac i ty of th e at riu m as it ov erl ap s th e as c en d i n g
a ort a .
T h e i n te rio r o f t h e ri g h t a tr iu m ( F ig . 1 .4 3A & B ) h a s a:
S m o ot h , th i n - w a lle d , po s t eri or p ar t ( t h e si nu s ve na ru m ) o n w h ic h t h e ve n ae c a vae (S V C a n d I VC )

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an d c o ron a ry s i n u s o p en , b ri n g in g p oo rly o xy ge n at ed b lo od in t o t h e h e art .

l
R o u g h , m u s c u la r an t eri or w al l c o m p os ed o f p e c ti n at e m u s c l es (L . m u s c u l i p ec t in a ti ).
R i gh t A V ori f ic e t h ro u g h w h ic h t h e ri g h t a tr iu m d is c h a rg es t h e p oo rly oxy ge n at ed b lo od it h as

re c eiv ed in t o t h e ri g h t ve n tr ic le .
T h e s m o ot h an d ro u g h pa rt s of th e at ria l w all are s ep ara t ed ext ern a ll y b y a s h al lo w ve rt ic a l g ro ove , th e

s ul cus t e rm i na li s o r t erm i n al gr oo ve ( F ig . 1 .4 2 C ), a n d in t ern a ll y b y a ve rti c al rid g e, t h e cr i st a
t e rm i n a li s o r t erm i n al c res t (F i g . 1 .4 3A ). T h e S V C o p en s in t o t h e s u p er io r p art of t h e ri gh t at ri u m at th e
l eve l o f t h e ri g h t 3 rd c o s ta l c ar ti la g e. T h e IV C op e n s i n t o t h e in f er io r p art of t h e ri g h t a tri u m al m o s t i n
l in e w it h th e S V C at ap p rox im a te ly t h e l eve l of t h e 5 t h c os t al c a rt il ag e. T h e o pe ni n g o f t h e co r o na ry
s in us, a s h ort ve n ou s t ru n k re c eiv in g m o st o f t h e c a rd iac v ein s , i s be tw een t h e ri g h t A V o rif i c e an d t h e
IV C o ri f ic e. T h e i nt e ra t ri a l se pt um s ep ar at in g t h e at ri a h as an o va l, t h u m b p rin t - s iz e d ep r es s io n , th e
o v al fo ssa ( L. f o s s a ov ali s ) , w h ic h i s a re m n an t of t h e o va l fo r a me n ( L . fo ra m en o val e) an d it s val ve i n
t h e f et u s .
Embry ology of t he Righ t At riu m

Un d e rs ta n d in g t h e d evel op m e n t o f th e r ig h t at riu m m ake s i t s a d u lt an a to m y ea s ie r to le arn an d
rem e m b er ( M oo re a n d P ers a u d , 2 0 0 3 ) . Th e pr im o rd ia l a tri u m is r ep res e n te d i n th e a d u lt b y th e r ig h t
au ri c le . T h e d e fi n it i ve at ri u m is en l ar ge d b y i n c or po ra ti on o f m os t of t h e em b ry on i c ven o us s in u s ( L .
s in u s ven o s u s ) . Th e c oro n ar y s in u s is a ls o a d eri vat iv e of t h is ve n ou s s i n u s . Th e p a rt o f th e ven o u s s in u s
in c o rp ora t ed in t o t h e p rim ord i al at riu m b e c om e s t h e s m o o th - w a ll ed s in u s ve n aru m o f th e a d u lt rig h t
at riu m ( F i g. 1 . 4 5A ) i n to w h i c h all th e vei n s d r ain , i n c lu d i n g t h e c o ro n ary s i n u s . Th e li n e of f u s io n of t h e
pr im o rd ia l a tr iu m ( th e ad u lt au r ic le ) a n d th e s i n u s ven a ru m ( th e de ri vat iv e of t h e ven ou s s in u s ) is
in d ic a te d i n t ern a ll y by th e c r is t a t erm i n al is a n d e xte rn al ly by t h e s u l c u s te rm in a li s . Th e s in u a tri al (S A )
n od e ( d is c u s s ed l at er i n t h i s c h a p te r) i s lo c at ed j u s t i n f r on t of t h e op en i n g of t h e S V C at th e su p e rio r
en d of t h e c ris t a t er m in a li s t h at i s , in t h e b or d er b et w e en th e pr im o rd ia l a tri u m an d t h e s in u s
ven o s u s ; h e n c e it s n am e .
B ef or e b irt h , t h e val ve o f th e IV C d ire c ts m o s t o f th e o xyg e n at ed bl o od ret u rn i n g f r om t h e p la c en t a in
th e u m b ili c al vei n an d IV C t ow a rd th e ova l f o ram e n in t h e in t er at ria l s ep t u m , t h ro u gh w h ic h it p as s es
in t o t h e le f t a tr iu m . T h e o val f ora m en h a s a f lap - li ke v al ve t h at pe rm i ts a r ig h t to lef t s h u n t o f bl oo d bu t
pr eve n ts a l ef t to rig h t s h u n t. A t b irt h , w h e n th e b a by ta kes i ts f ir s t b re at h , th e l u n g s exp an d w i t h a ir
an d p res s u re in t h e rig h t h ea rt f a ll s b e lo w th a t i n th e lef t h ea rt. C on s eq u e n tl y, t h e ov al f o ram en c lo s es
fo r i ts f ir s t a n d l as t ti m e, a n d i t s v al ve u s u al ly f u s e s w it h t h e in t era tr ia l s ep t u m . T h e c lo s ed ov al f o ram en
is rep r es en t ed in t h e p os t n at a l in t er at ria l s ep t u m b y t h e d ep res s e d o val f os s a . Th e b o rde r o f t he o va l
f o s sa ( L. l im b u s f os s a e o val is ) s u rro u n d s t h e f o s s a. T h e f lo or o f th e fo s s a i s f o rm e d b y t h e va lv e of t h e
ova l f o ram e n . Th e ru d im e n ta ry I VC v al ve , a s em il u n ar c re s c en t of ti s s u e, h a s n o f u n c ti on a f te r bi rt h ; i t
var ies c o n s id er ab ly i n s iz e a n d is oc c a s io n al ly a bs e n t.
R ight Ve ntricle
T h e ri g h t ve n tr ic l e f orm s th e l ar ge s t p ar t o f t h e a n te rio r s u rf a c e of t h e h ea rt , a s m al l p ar t o f th e
d i ap h rag m a t ic s u rf ac e , an d al m os t t h e en t ire in f er io r b ord er of th e h ear t ( F ig . 1 .4 2 B ) . S u p eri or ly i t
t ap er s in t o an a rt eri al c o n e, t h e co n us a rt e ri o su s ( in f u n d ib u l u m ) , w h ic h l ead s i n to th e pu l m o n ary t ru n k
( F ig . 1 .4 4 ) . T h e i n te rio r of t h e ri g h t ve n tr ic l e h as ir reg u l ar m u s c u l ar e lev at io n s (t r ab ecu la e c ar ne ae) . A
t h ic k m u s c u la r rid g e, t h e su pr av en tr i cul a r cr est , s e pa rat es t h e ri d ge d m u s c u la r w al l o f th e i n f lo w p ar t
o f th e c h a m b er f ro m t h e s m o ot h w al l o f th e c o n u s art er io s u s , or o u tf l ow pa rt . Th e in f lo w p ar t o f t h e
ve n tr ic l e rec e ive s
P .1 4 8
b l oo d f ro m t h e ri gh t at ri u m th rou g h t h e ri gh t A V (t r ic uspi d) o r i fi ce ( F ig . 1 .4 5 A ) , l oc at ed p os t er io r to
t h e b od y o f th e s ter n u m at th e lev el o f th e 4 th a n d 5 t h in t er co s t al s p a c es . T h e rig h t A V ori f ic e i s
s u rr ou n d ed b y o n e of t h e f ib ro u s rin g s o f t h e f i br ou s s ke let o n o f th e h ear t ( d is c u s s ed ea rli er i n th i s
c h a pt er ). T h e f i br ou s ri n g keep s t h e c al ib er of th e ori f ic e c o n s t an t (l arg e e n ou g h t o ad m it th e t ip s o f
t h ree f in g ers ) , re s is t in g t h e d il at io n t h a t m i g h t o th e rw i s e res u l t f r om b lo o d b ei n g fo rc e d t h ro u g h i t a t
va ryi n g pr es s u re s.

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Fi gu re 1 . 43 . R i gh t a tr i um o f h e ar t. A . Th e s m oo t h -w al led p ar t o f t h e a tr iu m , t h e s i n u s v en ar u m ,
is d er ive d f ro m ab s o rp t io n o f th e ven o u s s in u s of t h e em br yon i c h ear t. A l l o f t h e ve n ou s s t ru c t u res
en t eri n g th e r ig h t at riu m ( s u p er io r an d in f er io r ven a c ava e an d c o ron a ry s i n u s ) o p en in t o t h e s i n u s
ven a ru m . T h e ro u g h - w al le d p a rt o f th e at riu m i s d eri ved f ro m th e p r im o rd ia l at ri u m . T h e s h al lo w
ov al f o s s a i s t h e s i te of f u s io n of th e em b ry on i c v al ve o f t h e o val f ora m en w it h th e i n t era tri al
s e p t u m . B . T h e in fl ow f rom t h e s u p er io r ven a c ava (S V C) is d i rec t ed to w a rd th e rig h t at rio ve n tri c u la r
or if ic e , w h er eas b l oo d f ro m t h e in f e rio r ve n a c av a ( I V C) i s d ire c te d t ow ar d t h e o val fo s s a, a s it w as
b ef or e b irt h .
T h e t ri cu spi d va l ve ( F i g. 1 . 4 5 ) g u ar d s t h e ri g h t A V o rif i c e. T h e b as es o f t h e v alv e c u s p s are a tt a ch ed to

t h e f ib r ou s ri n g a ro u n d t h e o rif i c e. B ec a u s e th e f ib ro u s r in g m a in t ai n s t h e c a li be r of t h e o rif i c e, th e
a tt ac h e d v al ve c u s p s c on t ac t eac h o th e r in t h e s am e w a y w i th e ac h h ea rtb e at . Te n din o us c o rds ( L .
c h o rd ae t en d i n eae ) a tt a ch t o t h e f re e ed g es an d ve n tr ic u l ar s u rf a c es of t h e an t er io r, p os t eri or , an d
s e pt al c u s p s, m u c h lik e t h e c or ds a tt ac h i n g t o a p ara c h u te (F i g . 1 .4 4 ) . T h e t en d i n ou s c o rd s a ri s e f rom
t h e a pi c es of p ap i ll ary m u s c les , w h ic h ar e c on i c al m u s c u la r p roj ec t i on s w i th b a s es at ta c h ed to t h e
ve n tr ic u l ar w all . T h e p ap il la ry m u s c l es b eg in t o c o n tr ac t be f ore c on t rac t io n of t h e ri g h t ve n tr ic le ,
t ig h t en i n g t h e t en d in o u s c or ds a n d d ra w i n g t h e c u s p s t og et h er. B e c au s e t h e c o rd s are a t ta c h ed to
a dj a c en t s i d es of t w o c u s ps , t h ey p re ven t s ep ar at io n of t h e c u s p s a n d th e ir i n vers i on w h en t en s io n is
a pp l ie d t o t h e t en d in o u s c or ds a n d m ain t a in ed t h rou gh o u t v en t ric u l ar c o n tr ac t io n (s y s to le) th a t i s , th e
c u s p s of t h e t ric u s p i d v alv e ar e p reve n te d f r om p ro la ps i n g (b e in g d rive n in t o t h e ri g h t a tri u m ) as
ve n tr ic u l ar p re s s u re ri s es . T h u s r eg u rg it at i on o f b l oo d ( b ac k w ar d f l ow o f b lo od ) fr om t h e ri g h t v en tr ic l e
b ac k in t o t h e ri g h t at ri u m is b l oc ke d b y t h e va lv e c u s ps .
T h re e p ap il la ry m u s c l es in t h e ri g h t ve n tr ic le c orr es p on d t o t h e c u s p s of th e tr ic u s p id va lve :
T h e a nt er i o r pa pi ll a ry m us cl e, t h e l arg es t an d m o s t p ro m in e n t o f th e t h re e, ar is es f ro m t h e
an t er io r w a ll o f th e rig h t ven t ri c le; it s t en d in o u s c ord s at t ac h t o t h e an t er io r an d p os t eri or c u s p s o f
t h e tr ic u s p id va lv e.
T h e po st e ri o r pa pi l la r y mu scl e , s m al ler th a n t h e a n te rio r m u s c l e, m a y c on s i s t o f se ver al p a rt s; i t

ar is es f ro m t h e in f e rio r w a ll of th e rig h t ven t ri c le, a n d it s te n di n ou s c o rd s at ta c h to th e p o s te ri or
an d s ep t al c u s ps o f th e t ri c u s p id val ve.
T h e se pt al pa pi ll a ry m us cl e ar is es f ro m t h e in t er ven t ri c u lar s ep tu m , an d it s te n di n ou s c o rd s
at t ac h t o t h e an t er io r an d s ep t al c u s p s of t h e t ric u s p i d v alv e.

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P .1 4 9
Fi gu re 1 . 44 . I nt e ri o r o f r igh t v en t ri cl e o f he ar t . A. T h e en t ra n c e to th e ven t ri c le, t h e ri g h t

at ri ove n tr ic u l ar o rif i c e, is s i tu a te d i n f eri or ly a n d p o s te rio rl y. T h e s m o ot h fu n n e l- s h ap e d o u tf l ow tra c t
of t h e c h am be r, t h e c on u s a rt eri os u s , li es s u p eri or ly a n d l ea ds t o t h e p u l m on a ry o rif i c e, t h e exi t t o
t h e p u lm o n ary tru n k , w h er e t h e ven t ri c u la r as p ec t of t h e c u s p s o f th e tri c u s p id va lve a re s h o w n .
T en d in o u s c ord s ex te n d f ro m t h e p ap il la ry m u s c l es t o t h e c u s p s o f th e tri c u s p id va lve . B . T h e in f l ow
of b lo o d e n te rs th e c h a m b er f ro m i ts p os t er io r an d in f e rio r as p ec t , f lo w i n g a n t eri orl y an d t o t h e le f t
( to w a rd th e a p ex) ; th e o u t f lo w of b lo od t o t h e p u lm on a ry t ru n k le ave s s u pe rio rl y an d p os t eri or ly.
T h e i nt e rv en tr i cul a r se pt um (IV S), co m p o s ed of m u s c u la r an d m e m b ran o u s p art s , is a s t ro n g ,

o b li qu e ly p l ac ed p art i ti on b et w e en t h e rig h t an d le f t ve n tr ic l es (F i g s . 1 .4 2 A an d 1 .4 4 ) , f orm in g p art of
t h e w a ll s of ea c h . B ec au s e of th e m u c h h ig h er b l oo d pr es s u re i n th e lef t ven t ri c le, t h e m u sc u l ar p a rt o f
t h e IV S , w h i c h f orm s t h e m aj ori t y of t h e s ep t u m , h as t h e t h ic kn e s s o f th e rem a in d er of th e w al l o f th e
l ef t v en t ric l e ( tw o t o t h re e ti m es a s t h i c k as t h e w a ll o f th e rig h t ven t ri c le) an d b u lg e s i n t o t h e c avi t y of
t h e ri g h t ve n tr ic l e. S u p eri orl y an d p o s ter io rly , a t h in m e m b ran e , pa rt of th e f ib ro u s s k ele to n of t h e h ea rt
( F ig . 1 .4 0 ) , f o rm s t h e m u c h s m al le r m em br an o u s p a rt o f th e IV S . On t h e ri g h t s i de , th e s ep ta l c u s p of
t h e t ric u s p i d v al ve is a tt ac h e d t o t h e m id d le o f th i s m em b ra n ou s p ar t o f th e f i b rou s s ke le to n (F i g . 1 .4 4 ) .
T h is m e an s t h at in f er io r to th e c u s p t h e m e m b ran e is an i n te rven t ri c u la r s ep t u m , b u t s u p eri or to th e cu s p
i t i s an at ri ove n tr ic u l ar s ep t u m , s ep a rat in g t h e ri gh t at ri u m f ro m th e l ef t ven t ri c le.
T h e se pt o m ar gi na l t r ab ec u la ( m od er at o r b an d) is a c u rv ed m u s c u la r b u n d le t h at tr ave rs es t h e ri gh t
ve n tr ic u l ar c h a m b er f ro m th e in f er io r p art of t h e IV S to th e ba s e o f t h e a n te rio r p ap i lla ry m u s c l e. T h is
t ra be c u la i s im p o rt an t be c au s e i t c a rri es p art of t h e r igh t b ra nch o f t h e A V bun dl e, a pa rt of th e
c o n d u c ti n g s y s te m of t h e h ea rt t o t h e a n te rio r p ap il la ry m u s c l e ( s ee Co n d u c ti n g S y s te m of t h e
H e art , in t h is c h a p ter ). T h i s s h o rt c u t a c ros s t h e c h am be r s eem s t o fa c il it at e c o n du c t i on t im e ,
a ll ow in g c oo rd in a te d c o n t rac t io n of t h e an t eri or pa p il la ry m u s c l e.
T h e ri g h t a tr iu m c o n tr ac t s w h en t h e ri gh t ven t ri c le is em p t y an d re la xed ; th u s b lo od i s f o rc ed t h ro u gh
t h is o rif i c e in t o th e r ig h t v en t ric l e, p u s h in g t h e c u s p s of t h e tr ic u s p id va lve as id e l ik e c u rt ai n s . Th e in f lo w
o f bl oo d in t o t h e ri g h t ve n tr ic le (i n f lo w t rac t ) en t ers p os t eri or ly; a n d w h en th e ven t ri c le c o n tr ac t s , th e
o u tf l ow of b lo od in t o t h e p u l m on a ry t ru n k ( o u tf lo w t ra c t) le ave s s u p e rio rl y an d to t h e le ft

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P .1 5 0
( F ig . 1 .4 4 B ) . Co n s eq u en t ly , th e bl oo d ta kes a U - s h ap e d p at h t h rou g h t h e ri g h t ve n tr ic le , c h an g in g
d i rec t io n ab ou t 1 4 0 . T h i s c h a n g e in d ir ec t io n is ac c o m m o da t ed by th e s u p ra ven t ri c u la r c res t, w h i c h
d ef l ec t s th e i n c om in g f lo w in t o t h e m a in c a vit y o f t h e v en t ric l e, an d t h e ou tg o in g f lo w in t o t h e c o n u s
a rt eri os u s t ow ard t h e p u lm o n ary ori f ic e. T h e i n f lo w ( A V ) o rif i c e an d o u tf l ow ( p u l m on a ry) or if ic e are
a pp r oxi m at el y 2 c m ap a rt .
Fi gu re 1 . 45 . V a lv es o f he a rt an d gre a t ve ss el s. A . T h e c o ro n ary v al ves ar e s h ow n in s it u . A V ,

at r i ove n tr ic u l a r. B . At t h e b eg in n i n g o f d ias t o le ( ve n tr ic u la r re lax at io n an d f il li n g) , t h e ao rt ic an d
p u lm o n ar y val ves a re c l os ed ; s h or tl y t h erea f te r, t h e tr ic u s p id an d m i tr al val ves o pe n (a ls o s h ow n i n
F ig . 1 .3 9 ) . C . S h ort l y af t er s ys t ol e ( ven t ri c u la r c on t ra c ti on an d e m p tyi n g ) b e gi n s , th e tr ic u s p id an d
m i tra l va lv es c lo s e an d t h e ao rt ic an d p u lm on a ry va lve s op en .
T h e pu l mo n ar y va l ve ( F i gs . 1 .4 4 a n d 1 .4 5 ) a t t h e a p ex o f t h e c o n u s a rt eri os u s i s a t t h e l eve l o f t h e l ef t
3 r d c o s ta l c ar ti la g e. T h e s em i lu n a r val ves ( p u lm on a ry an d ao rt ic ) ar e d is c u s s ed la te r in t h is c h a pt er ,
a f te r di s c u s s io n of t h e h ea rt c h a m b ers .
Septal Defects
At rial S ep tal Defects
A c o n g en i ta l an o m a ly o f t h e i n te rat ri al se p tu m , u s u a ll y in c o m p le te c lo s u re o f t h e o val f ora m en , i s an
at r ia l s ept a l de fe ct (A S D ). A p ro b e- s iz e p a te n c y is p res e n t i n th e s u p e rio r p art o f t h e o val f os s a i n
1 5 2 5 % o f a d u lt s (M o ore an d Pe rs au d , 2 0 0 3 ) . T h es e s m a ll op en i n g s , by t h em s elv es , c au s e n o
h em o d yn am i c ab n or m al it ie s an d are , th e ref o re, o f n o c li n ic a l s ig n i f ic an c e an d s h ou l d n o t be c on s id e red
fo rm s o f A SD s . Cl in i ca ll y s ig n i f ic an t A S Ds va ry w i d el y in s iz e an d lo c at io n an d m a y oc c u r a s p a rt o f m o re
c om p l ex c o n ge n it a l h ear t d is e as e. L ar ge A S Ds al lo w o xyg en a te d b l oo d f r om t h e l u n gs t o b e s h u n t ed f ro m
th e l ef t at riu m th ro u g h th e AS D in t o t h e ri g h t a tr iu m , c a u s in g en l arg em en t o f th e rig h t at riu m an d
ven t ri c le a n d d i la ti on o f t h e p u lm on a ry t ru n k ( F ig B 1 .1 8 A ) . T h is le f t t o ri g h t s h u n t of b lo od o verl oa d s t h e
pu l m o n ary v as c u l ar s ys t em , r es u lt i n g i n h yp ert ro p h y of t h e rig h t at ri u m an d ven t ri c le a n d p u l m o n ary
ar t er i es .
Vent ricu lar Sept al Defect s

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T h e m e m b ran o u s p art of t h e IV S d eve lo ps s e pa rat el y f ro m th e m u s c u la r p art an d h as a c o m p le x

e m b ryo lo gi c al ori g in ( M oo re a n d P ers a u d , 2 0 0 3 ) . C on s e qu e n tl y, t h is p ar t is t h e c o m m o n si t e of
v en tr i cul a r se pt al de fect s ( V S D s) , a lt h ou g h d ef ec t s al s o o c c u r in t h e m u s c u l ar p ar t ( F ig . B 1 .1 8 B ) .
V S D s r an k f i rs t o n al l li s t s o f c ard i ac d ef ec t s . Is ol at ed V S Ds a c c ou n t fo r a pp ro xi m at el y 2 5 % o f a ll f o rm s
o f co n g en i ta l h ea rt di s ea s e. T h e s iz e o f th e de f ec t v ari es f ro m 1 to 2 5 m m . A V S D c a u s es a le f t t o ri g h t
s h u n t of b lo od t h ro u gh t h e d ef ec t . A la rg e s h u n t in c re as es p u lm on a ry b lo od f lo w , w h ic h c au s e s s e ver e
p u l m on a ry d is e as e ( h yp er te n s io n , or i n c rea s ed bl oo d p res s u re ) a n d m ay c a u se c ard i ac f ai lu re . Th e m u c h
l es s c om m on V S D i n th e m u s c u la r p art of t h e s ep t u m f req u en t l y c lo s es s p on t an e ou s ly du r in g c h il d h oo d
( Cre as y a n d R es n ik , 1 9 9 9 ) .
Fi gu re B 1. 1 8. Se pt al de fec ts . A . A n at ri al s e pt al d ef ec t is s h o w n . B . A ve n tri c u la r s ep t al d e fe c t i s
s h ow n .
P .1 5 1
Left Atrium
T h e le ft at ri u m f or m s m os t of t h e b as e o f th e h e art ( F ig . 1 .4 2 C & D ) . T h e va lve les s p a irs o f r ig h t a n d lef t
p u lm o n ar y vei n s en t er t h e s m o ot h - w al le d a tr iu m ( F ig . 1 .4 6 ) . In t h e em br yo, t h er e is o n ly o n e c o m m on
p u lm o n ar y vei n , j u st as t h ere is a s i n g le p u l m on a ry t ru n k. T h e w all of t h is ve in an d f ou r of it s t rib u t ari es
w e re i n co rp o rat ed in t o th e w al l o f t h e l ef t a tr iu m , i n th e sa m e w ay t h at th e s in u s ve n os u s w a s
in c o rp or at ed in t o t h e ri g h t a tr iu m . T h e p ar t o f t h e w al l d eri ved f ro m th e em b ry on i c p u l m on a ry v ein i s
s m o ot h w al le d . Th e t u b u la r, m u s c u l ar l ef t a ur ic le , it s w a ll t ra b ec u la te d w it h p ec t in a te m u s c les , f o rm s
t h e s u p eri or p ar t o f th e l ef t bo rd er o f th e h ear t a n d o ver lap s t h e ro ot of t h e p u lm on ar y tr u n k ( Fi g . 1 .4 2 A
& B ) . It rep re s en t s th e r em a in s of t h e l ef t p a rt o f th e p r im o rd ia l at ri u m ( Mo o re an d P ers a u d, 2 0 0 3 ). A
s em i lu n a r d ep res s i on i n th e i n t era tri al s ep tu m in d ic a te s th e f l oo r of t h e o val fo s s a ( F ig . 1 .4 6A ) ; th e
s u rro u n d in g ri dg e i s th e val ve o f th e o va l f os s a (L . va lvu l ae f o ram en ov ale ) .
T h e in t eri o r of t h e le ft at ri u m h as
A l ar ge r s m o ot h -w al le d p ar t a n d a s m al le r m u s c u la r au ri c le c on t ai n in g p ec t in at e m u s cl es .
F ou r p u l m on a ry ve in s ( tw o s u p er io r an d tw o i n f eri or) en t er in g it s s m oo t h po s te ri or w all ( F ig .

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1 .4 6 A C ).
l
A s li g h tl y th i c ker w al l t h an t h at of t h e ri gh t at ri u m .
A n in t er at ria l s ep t u m t h at s l op e s p o s te rio rl y an d t o t h e ri gh t .
A le ft A V or if ic e t h ro u g h w h i ch t h e l ef t a tr iu m d i s c h arg es t h e o xyg en a te d b l oo d i t r ec ei ves f ro m t h e

p u lm on ar y vei n s in t o t h e l ef t v en t ric l e ( F ig . 1 .4 6 B ) .
St roke or Cerebrovascu lar Accident

Th r om b i ( c l ot s ) f o rm o n th e w al ls o f t h e l ef t a tr iu m i n c ert ai n typ e s o f h ear t d i s eas e . If t h es e th ro m b i
de ta c h or p i ec es b rea k o ff o f t h em , th e y p as s in t o t h e s ys t em ic c ir cu lat i on an d o c c lu d e p eri p h era l
art eri es . O c c lu s i on o f an ar te ry s u p p lyi n g t h e b ra in re s u lt s in a s tr o k e o r cer e bro v as cul a r ac ci den t
(C VA ) , w h ic h m ay af f ec t vis i on , c o g n it io n , or t h e m o t or f u n c t io n of p art s of t h e b od y p re vi ou s ly
c on t ro lle d by t h e n o w - d am a g ed (i s c h em i c ) a rea of t h e b rai n .
Fi gu re 1 . 46 . I nt e ri o r o f l eft a tr i um a n d ven t ri cl e o f he a rt . A. T h e f ea tu r es of t h e in t er n al
as p ec t s of t h e le f t a tri u m an d t h e i n fl ow tr ac t o f th e lef t ven t ri c le a re s h o w n . A V , at ri ov en t ric u l ar. B .
T h e p at te rn of b lo od f lo w t h ro u g h t h e l ef t s i d e of t h e h ea rt is d em o n s tr at ed . C . T h e h e art in p ar ts A
an d B w a s i n c is e d v ert ic a ll y al on g it s le f t b or d er an d t h en t ran s ve rs el y ac r os s t h e s u p eri or p a rt o f it s
b as e, p a s s in g b et w ee n t h e s u p er io r an d t h e in f er io r le f t p u lm on a ry vei n s .
P .1 5 2
Left Ventric le
T h e l ef t v en t ric l e f or m s th e ap ex o f t h e h e art , n ea rly all it s le ft ( p u lm o n ary ) s u r fa c e an d b or d er, an d
m o s t o f th e di ap h ra g m at ic s u rf a c e ( F ig s . 1 .4 2 an d 1 .4 7 ) . B ec a u s e ar te ria l p res s u r e is m u c h h i g h er in t h e
s ys t em ic t h an in t h e p u lm on a ry c ir c u lat i on , t h e le f t ve n tr ic l e p erf o rm s m o re w o rk t h an t h e ri g h t ve n tr ic l e.
T h e i n te rio r o f t h e l ef t v en t ric l e h as ( F ig . 1 .4 7 )
l
l
W a ll s th a t a re t w o to th r ee t im e s as th i c k as t h at of t h e ri g h t ve n tr ic le .
W a ll s th a t a re m o s tl y c o vere d w it h a m e s h of tr ab ec u l ae c a rn ea e t h at a re f i n er a n d m o re n u m ero u s
t h an t h os e o f th e r ig h t ven t ric l e.

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A c on i c al ca vi ty t h at is l on g er th a n th a t o f t h e r ig h t v en t ric l e.
A n t eri or a n d p o s te rio r p ap i ll ary m u sc l es t h at are lar ge r t h an t h os e i n th e r ig h t ven t ric l e.
A s m o ot h -w al le d, n o n - m u s c u la r, s u p ero an t eri or , ou t f lo w p art , t h e a o rt i c v es ti bu l e, l ead i n g t o t h e

ao rt ic o rif i c e an d ao rt ic va lv e.
A d ou b le - lea f let m i tr al v alv e th a t g u a rd s th e l ef t A V o ri fi c e ( F ig s . 1 .4 5 a n d 1 .4 7 A ).
A n ao r t ic o r i fic e t h at li es in i ts ri g h t p o st er os u p er io r p art an d is s u rr ou n d ed b y a f i br ou s ri n g to
w h i c h th e rig h t , p os t eri or , an d lef t c u s p s o f th e ao rti c val ve a re a tt ac h e d; t h e as c e n di n g ao rta
b eg in s a t t h e ao rt ic o rif i c e.
T h e m i tr a l va l ve h a s tw o c u s p s , an t eri or an d p os t eri or . T h e a d je c ti ve m i t ral de riv es f ro m th e v al ve' s

re s em b l an c e t o a bi s h op ' s m it er ( h ea dd r es s ) . Th e m it ral val ve i s lo c at ed p os t eri or t o t h e s t er n u m at th e
l eve l o f t h e 4 t h c os t al c art il ag e. E a c h of it s c u s p s r ec ei ves t en d in o u s c or ds f ro m m o re t h an o n e p ap il la ry
m u s c l e. T h es e m u s c les a n d t h ei r c or ds s u p p or t t h e m i tr al v al ve, al lo w i n g th e c u s p s t o re s is t th e p re s s u re
d ev elo p ed d u rin g c o n tra c t io n s ( p u m p in g ) of t h e l ef t v en tr ic l e.
P .1 5 3
T h e t en d in o u s c or ds b ec o m e t au t j u s t b ef o re a n d d u ri n g sy s to le , pr eve n ti n g t h e c u s p s f ro m be in g f or c ed
i n to th e lef t at ri u m . A s it tra ver s es th e lef t ven t ri c le , th e b l oo d s tre am u n d er g oes t w o rig h t an g le tu r n s ,
w h ic h t og et h er r es u lt in a 1 8 0 c h an g e i n d ire c ti on . T h is re ver s al o f fl ow ta kes p l ac e a rou n d t h e an t er io r
c u s p of t h e m i tr al v alv e ( F ig . 1 .4 7B ) .
Fi gu re 1 . 47 . I nt e ri o r o f l eft ve nt r icl e o f h ea r t. A a nd B . Th e an t eri or s u r fa c e o f t h e l ef t v en t ric l e

h as b ee n i n c is e d p a ral le l t o t h e in t er ven t ric u l ar g r oo ve, w it h th e r ig h t m arg i n of th e in c i s io n
ret ra c te d t o t h e r ig h t , r eve al in g an an t er io r vie w o f t h e c h a m b er f ea tu r in g th e ou t f lo w t rac t . T h e
c h am b e r h as a c o n ic a l s h ap e ; t h e le f t a tr io ven t ric u l ar o ri f ic e a n d m it ral val ve a re l oc a te d p o s te rio rly ,
an d t h e ao rt ic ve s ti bu le l ead s s u p eri or ly a n d t o t h e r ig h t t o t h e a or ti c v al ve.
T h e s em il u n ar a o rt i c va lv e, b et w e en t h e le ft ve n tri c le an d th e as c en d i n g a ort a , is ob l iq u el y p la c ed (F i g .
1 .4 5 ). It is l oc a te d p o s te rio r t o t h e le f t s id e of th e s te rn u m at t h e le vel o f th e 3 rd in t erc o s ta l s p ac e .
Sem ilunar Valves

E a c h of th r ee s em i lu na r cu sps o f t he pul m o na ry v al ve ( an t eri or, r ig h t , an d lef t ) , li ke t h e se m il un a r

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cu sps o f t he ao r t ic v al ve (p o s te rio r, ri g h t, a n d lef t ) , is c on c a ve w h en vi ew e d s u p er io rly (F i gs 1 .4 5 B a n d

1 .4 7 A) . S em il u n ar c u s p s d o n ot h av e t en d in o u s c ord s t o s u p p ort t h em . T h ey a re s m a ll er i n a rea th a n th e
c u s p s of t h e A V val ves , a n d th e f o rc e e xert ed o n t h em is le s s t h an h a lf t h at exe rte d o n th e c u s ps o f th e
t ri c u s pi d an d m it ra l va lve s . Th e c u s ps p ro j ec t i n to t h e art er y b u t a re p res s e d t ow ar d ( an d n o t a ga in s t ) it s
w al ls as b lo od l eav es th e ven t ri c le ( F ig . 1 .4 8 ) . A f t er re la xat io n of t h e ven t ri c le (d i as t ol e) , th e e la s ti c
re c oi l o f t h e w al l of t h e p u lm on a ry t ru n k or ao rta f orc e s th e b l oo d b a c k to w a rd th e h ear t. H o w e ver, t h e
c u s p s op e n u p l ike po c ket s as t h ey c a tc h t h e re vers e d b l oo d f l ow , c om i n g to g et h er t o c o m p let el y c lo s e
t h e o rif i c e, s u p p ort in g e ac h ot h er a n d pr eve n ti n g a n y s ig n i f ic an t am ou n t of b lo od f ro m ret u rn i n g t o t h e
ve n tr ic l e .
T h e ed g e o f eac h c u s p is t h ic k en ed in t h e re gi on o f c on t ac t , f orm in g th e lu nu le ; th e ap ex o f th e
a n gu lat ed f re e ed g e is t h ic k en ed f u rt h er a s t h e n o du l e . Im m ed i at el y s u p eri or t o e ac h s em i lu n a r c u s p ,
t h e w a ll s of t h e or ig in s o f th e p u l m on a ry t ru n k a n d a or ta are s l ig h t ly d i la te d, f o rm i n g a s in u s . T h e
p u l m on a r y an d a ort i c s i n u s es ar e th e s pa c es at t h e or ig in o f t h e p u l m on a ry t ru n k a n d a s c en d in g ao rt a
b et w e en t h e d il at ed w al l o f th e v es s el an d ea ch c u s p o f t h e s em il u n ar va lv es (F i g s . 1 .4 5 B an d 1 .4 7 A ) .
T h e b lo o d i n th e s i n u s es an d t h e d il at io n of t h e w a ll p r even t t h e c u s p s f r om s t ic ki n g to th e w al l o f th e
ve s s el , w h ic h m i g h t p re ven t c lo s u re.
T h e m o u t h o f th e rig h t c oro n ar y art er y is i n t h e r i ght ao r t ic si n us, t h e m o u t h o f th e lef t c or on a ry ar te ry
i s in t h e le ft ao r t ic si n us, a n d n o ar te ry ar is es f ro m t h e po st e ri o r a o rt i c ( no n- co ro n ar y) si nu s.
P .1 5 4
Fi gu re 1 . 48 . A o r ti c va l ve , a o rt i c s i nu se s, an d co ro n ar y a rt e ri es . A . L ike th e p u l m on a ry va lv e,
t h e ao rt ic va lve h a s th r ee s em il u n ar c u s p s : rig h t , p os t eri or, a n d lef t . E ac h c u s p h as a f i b rou s n o d u le
at th e m id p o in t of it s f ree e d ge an d a t h in c o n n ec ti ve t i ss u e are a, t h e lu n u l e, t o e ac h s id e o f th e
n od u l e . B . B l oo d ej ec t ed fr om t h e l ef t v en t ric l e f or c es th e c u s ps a pa rt . C. W h en t h e va lve c l os e s , th e
n od u l es an d lu n u les m e et in t h e c en t er. T h e c o ron a ry a rt eri es ari s e f ro m th e rig h t an d le f t ao rt ic
s in u s e s ( s p ac e s su pe rio r t o t h e c u s p s ).
Basis for Nam ing th e Cu sps of t he Aort ic and Pu lmon ary V al ves
Th e fo ll ow in g ac c o u n t e xp la in s t h e em b ry ol og i c al b a si s f or n a m in g t h e p u lm on ar y an d ao rt ic va lv es . T h e
tr un cus a r te r io s us, t h e c o m m o n a rt eri al tru n k fr om b o th ve n tr ic l es of t h e em b r yon i c h ear t, h a s f o u r
c u s ps ( F ig . B 1 .1 9 A ) . T h e t ru n c u s art er io s u s d i vid e s i n t o t w o v es s el s , eac h w it h it s ow n t h re e- c u s p v alv e
(p u l m on a ry a n d a or ti c ) ( F ig . B 1 .1 9 B ) . T h e h ea rt u n de rg oe s p a rt ia l ro ta ti on s o th a t i ts a pe x b ec om es
di rec t ed t o t h e le f t, r es u lt in g i n th e a rra n g em en t of c u s p s as s h o w n in F i gu r e B 1 .1 9 C. C on s eq u e n tl y, t h e
c u s ps a re n am ed ac c o rd in g t o t h eir e m b ryo lo g ic a l or ig in , n o t th ei r p os t n at a l an a to m i c al p o s it io n . Th u s
th e p u l m o n ary v alv e h as ri g h t, l ef t , an d an t eri or c u sp s , a n d t h e a ort i c v al ve h as ri g h t, l ef t , an d p os t eri or
c u s ps . S i m il ar ly, t h e ao rt ic s i n u s es are n am e d r ig h t , lef t , an d p os t eri or .
Th i s te rm i n ol og y al s o a g rees w it h th e co ro n ary art eri es . N o t e th a t t h e ri g h t c o ro n ary a rt ery a ris e s fr om
th e r ig h t aor ti c s in u s , s u p eri or to th e r ig h t c u s p o f t h e a or ti c val ve, a n d t h at t h e le ft c or on a ry h as a
s im i la r rel at io n to th e lef t c u s p a n d s in u s . T h e p os t eri or c u s p a n d s i n u s do n ot g ive ris e to a c or on a ry
art ery ; t h u s t h ey ar e al s o re f erre d t o a s a n on - c o ron a ry c u s p an d s in u s .
Valvu lar Heart Disease

Di s ord er s in vo lv in g th e val ves o f t h e h e art d is t u rb th e pu m pi n g ef f ic i en c y o f t h e h ea rt . V al vu la r h ea rt

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d i s eas e p ro d u c es ei th e r s te n os i s (n a rro w i n g ) o r in s u f f ic i en c y. S t en o si s is t h e f ai lu re of a v alv e to op e n

f u l ly, s l ow in g b lo od f lo w f ro m a c h am b er. In s u ffi ci en cy o r re g u rgi t at i o n, o n th e ot h er h a n d, i s f ail u re
o f th e v al ve t o c lo s e c o m p le tel y, u s u a ll y ow in g to n od u l e f or m at io n on ( or sc a rri n g an d c on t rac t i on of )
t h e c u s p s s o t h at th e ed ge s do n ot m ee t o r al ig n . T h is a ll ow s a var iab l e am ou n t of b lo od ( d ep en d in g o n
t h e s ev eri ty ) t o f l ow b a c k in t o t h e c h a m b er it w a s ju s t ej ec t ed f ro m . B ot h s te n os i s an d in s u f f ic i en c y
re s u lt in a n i n c rea s ed w o rkl oa d f o r t h e h ea rt. R es t ric t io n of h ig h p re s s u re b lo od f lo w ( s t en os i s ) o r
p as s a g e of b lo o d t h ro u gh a n arr ow o p en i n g i n to a l arg er v es s el or c h a m b er ( s t en os i s an d reg u rg i ta ti on )
p ro d u c e tu rb u len c e . Tu r bu l en c e s e ts u p ed d ie s (s m a ll w h i rlp o ol s ) t h at p rod u c e v ib ra ti on s t h at are au d ib l e
a s m u rm u r s . S u p er fi c ia l vi b rat or y s en s a ti on s ( t h r il l s) m ay b e f e lt on t h e s ki n o ve r an ar ea o f
t u rb u le n c e .
Fi gu re B 1. 1 9
T h e c l in i c al s i g n if ic a n c e of a v al vu la r d ys f u n c ti on r an g es f ro m s li gh t an d p h ys i ol og ic a ll y in s i g n if i ca n t t o
s e vere an d rap i dl y f at al . F ac t or s s u c h a s de g ree, d u ra t io n a n d et io lo gy ( c a u s e) af f ec t s e c on d a ry c h an g es
i n th e h e art , b lo od ve s s els , a n d ot h er o rg an s , b ot h p ro xim al a n d d i s ta l t o t h e va lve les i on . V a lvu l ar
d i s ord er s m ay b e c o n g en it a l or ac q u ire d . In s u f fi c ie n c y m ay res u l t f ro m p at h ol og y o f t h e v alv e it s el f or i ts
s u p p or ti n g s t ru c t u re s ( a n u lu s , t en d in o u s c ord s , d il at io n of c h a m b er w a ll , et c .) . It m a y oc c u r ac u t ely
( s u d d en ly f or exa m p le, f ro m a r u pt u re of th e c ord s ) or c h r on i c al ly ( ov er a r ela t ive ly l on g t im e f or
e xam p l e, s c ar rin g an d re tr ac t io n ). V a lvu l ar st en o s is , o n th e ot h er h a n d , is al m os t al w a ys th e res u l t o f a
va lv e ab n o rm al it y a n d i s es s en t ia ll y al w a ys a c h ro n ic p ro c es s (C ot ran e t a l., 1 9 9 9 ) .
B e c au s e va lvu l ar di s ea se s are m ec h an i c al pr ob l em s , d am a g ed or d e fe c ti ve c a rd ia c v al ves ar e of t en
re p la ce d su r g ic al ly i n a p ro c ed u re c a ll ed va lv ul o p l as ty . M os t c om m o n ly , art if i c ia l va l ve p ro st h ese s
m a d e of s yn t h et i c m at eri al s a re u s e d i n th e s e val vere p la ce m en t p roc e d u res , b u t x en o gr af t ed val ves
( va lve s tra n s p la n te d f ro m ot h er s pe c ies , s u c h a s p i g s ) a re al s o u s e d.
Mi tral V al ve Insu fficiency (Mit ral Valve Prolapse)

A pr o la ps ed m i tr a l va l ve i s an in s u f f i c ien t o r in c o m p et en t v al ve w i t h o n e o r b ot h le af le ts en l ar ge d ,
re d u n da n t o r f lo p py , an d ext en d i n g b a c k in t o t h e l ef t a tr iu m d u ri n g s y s to le . As a res u l t, b l oo d
re g u rg it at es i n to th e l ef t at riu m w h en t h e le f t ve n tr ic l e c on t ra c ts , p ro d u c in g a c h ar ac t eri s ti c m u rm u r .
T h is i s an ext re m el y c om m on c o n di t io n , oc c u rr in g in u p to 1 in ev ery 2 0 p e op le , m os t of t en i n you n g
f em al es . U s u all y, i t i s a n in c i d en t al f i n di n g on p h ys i c al e xam in at i on ; b u t i t is o f c li n ic al im p o rt an c e i n a
s m a ll f rac t io n of t h os e a f fe c te d , w it h t h e p at ien t s u f f eri n g ch e s t p a in an d f at ig u e .
Pu lmon ar y Valv e S tenosi s

W it h pul m o na r y va lv e st en o si s, t h e va lve c u s ps a re f u s ed , f or m in g a d o m e w it h a n ar row c en tr al
o p en in g . In i nf und ib ul ar pul m o na ry s t en o si s, th e c on u s ar te rio s u s is u n d erd e vel op ed . B o th t yp es o f
p u l m on a ry s t en o s es p rod u c e a res t ric t i on o f r ig h t v en t ric u l ar o u tf l ow an d m ay oc c u r t og et h er . Th e de g ree
o f h yp ert ro ph y of t h e rig h t ven t ri c le i s var ia bl e.
Pu lmon ar y Valv e I ncomp et en ce

If t h e f ree m ar gi n s (l u n u le s ) o f th e c u s p s o f a s em i lu n ar val ve t h ic k en an d b ec o m e in f l exi b le o r ar e
d am ag ed b y d is ea s e, t h e va lve w il l n o t c l os e co m p l ete ly . An i nc o mp et e nt pul m o na ry v al ve res u l ts i n a
b ac k ru s h of b lo od u n d er h i g h pr es s u re i n t o t h e ri gh t ven t ri c le d u r in g d ias t o le. P u lm on i c r eg u rg it at i on m a y
b e h e ard t h rou g h a s t et h o s co p e as a h ear t m u r m u r, an a b n orm al s o u n d fr om t h e h ea rt , p rod u c ed i n th i s
c a s e b y d am a ge to th e c u sp s o f t h e p u l m on a r y va lv e.

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Aort ic V alv e S tenos is

A o rt i c va lv e st e no si s i s th e m os t f req u en t val ve a b n orm al it y. In t h e 2 0 th c e n tu r y, rh eu m at ic f eve r w a s
a co m m o n c au s e b u t n ow ac c ou n t s f or < 1 0 % of c a se s of ao rt ic s t en o s is . T h e g rea t m a j ori ty of ao rt ic
s t en o s es is a r es u lt o f d eg e n era ti ve c a lc if i c at io n an d c om es to c li n ic a l at t en t io n i n th e 6 th d ec a d e of l if e
o r la te r. A or ti c s te n os i s c a u s es ex tra w o rk f or th e h e art , re s u lt in g in l ef t v en t ric u l ar h y pe rt rop h y.
Aort ic V alv e I nsu ffi cien cy

I nsu ffi ci en cy o f t he a o r ti c va l ve r es u lt s in a ort i c r eg u rg it at i on ( b ac kru s h o f bl oo d in t o t h e le f t
ve n tr ic l e) , p rod u c i n g a h ear t m u r m u r an d a co l l a psi ng pu ls e ( f or c ib le im p u l s e th a t r ap id l y d im i n is h es ) .
P .1 5 5
Th e B ott om Lin e
T h e h ea rt is a d u a l s u c ti on a n d p r es s u re p u m p t h at pr op el s bl oo d th r ou g h t h e in f i n it e d ou b l e lo op f or m ed
b y t h e p u lm on a ry an d s ys t em i c c irc u i ts . T h e r ig h t h e art s erv es t h e f orm er an d t h e le f t h e art th e lat t er.
T h e h ea rt is s h ap e d l ike a t ip p ed - ove r p yra m id , w i t h t h e a p ex d ir ec te d a n t ero in f er io rly a n d to th e l ef t an d
t h e b as e op p os i te th e a p ex ( p os t eri or ). E a c h s id e o f t h e h e art in c l u de s a rec e iv in g c h am b er (a tr iu m ) an d
a su ct i on , c o m p res s i on , ex p u ls io n c h am b e r (v en t ric l e) . T h e b il at era l c h am be rs ( an d th u s t h e h i gh p re s s u re s ys t em i c an d lo w e r- pr es s u re p u l m on a ry c i rc u it s ) are s e p ara te d b y a n ob li q u e c ard i ac s ep t u m
t h at is l arg el y m u s c u l ar b u t pa rt ly m e m b ra n ou s . A V val ves a re p la c ed b et w ee n u n il at era l c h am be rs to
f a ci li t at e tw o- s t ag e ( ac c u m u lat e a n d t h en e je c t) p u m p in g . O n ew ay s em il u n ar va lve s (p u l m on i c an d
a ort i c ) p la c ed at th e exi t o n eac h s i de p reve n t b ac k f lo w ( exc ep t th a t w h ic h f il ls t h e c o ron a ry a rte rie s )
a n d m ain t a in s th e d ias t o li c p re s s u re o f t h e a rt eri es . T h e c h am b e rs h ave a g li s te n in g en d ot h el ia l l in i n g,
t h e en d o c ard i u m ; a m u s c u la r w a ll or m y oc a rd iu m , t h e t h ic k n es s of w h i c h is p ro po rt io n al to th e in t ern a l
p re s s u res o cc u r rin g w it h in t h e s p ec if i c c h am b er ; a n d a gl is t en i n g ou t er c o veri n g (t h e v is c era l l aye r of
s e rou s p er ic ar di u m , o r ep ic a rd iu m ). T h e m y oc a rd iu m o f th e a tr ia a n d ven t ri cl es ( an d t h e m yo g en ic
p ro p ag at io n of c o n tr ac t in g s ti m u l i t h rou g h it ) is at t ac h ed t o a n d s e pa ra te d b y t h e c o n n ec t ive t i s su e of t h e
f i br ou s s ke let o n o f th e h ear t. T h e f ib r ou s s kel et on c o n s is t s of f ou r fi b ro u s r in g s , tw o t ri go n es , a n d t h e
m e m b ran o u s p art s of t h e c ar di ac s ep t a. O n l y s p ec ia li z ed m u s c le co n d u c ti n g c on t rac t i le i m p u ls e s f ro m t h e
a tr ia t o t h e ve n tr ic l es p en et ra te s t h e s ke le to n at de f in ed s i te s. T h e f i b rou s s ke le to n pr ovi d es at t ac h m e n t
f o r th e m yo c ard i u m an d c u s p s o f th e val ves , a n d m ain t ai n s th e in t eg ri ty o f th e ori f ic es .
P .1 5 6
Vasculature and Innervation of the Heart

T h e b lo od ves s e ls o f t h e h ea rt c om p ri s e t h e c or on a ry ar te rie s an d c ard i ac vei n s , w h i c h c arry bl oo d to an d
f ro m m os t of t h e m yo c ar di u m ( F ig s . 1 .4 9 an d 1 .5 0 ) . T h e en d o c ard i u m an d s om e s u b en d oc a rd ia l t is s u e
lo c at ed im m ed ia t ely e xt ern a l t o t h e en d o c ard i u m rec ei ve o xyg e n an d n u tr ien t s b y d if f u s io n or
m i c rov as c u la tu r e d ire c tl y f ro m th e c h am b er s o f th e h ear t. T h e b lo od ve s s els o f th e h e art , n o rm al ly
em b e dd e d i n fa t , co u rs e a c ro s s t h e s u rf a c e of t h e h ea rt ju s t d eep t o t h e ep i ca rd iu m . Oc c a s io n al ly, p a rt s
of t h e ve s s els b ec o m e e m b ed d ed w it h i n t h e m yoc a rd iu m . T h e b l oo d v es s el s of th e h ear t a re a ff e c te d b y
b ot h s ym p at h et i c a n d p a ras y m p at h et ic in n e rva ti on .
Arte rial Sup ply of the He art

T h e co r on a ry a rt e ri e s, th e f irs t b ran c h e s o f th e a or ta , s u p pl y t h e m yo c ard i u m an d ep i c ard iu m . Th e rig h t
an d le f t c o ron a ry a rt eri es ari s e f ro m th e c orr es p on d i n g a or ti c si n u s es a t t h e p rox im a l p ar t o f t h e
as c e n di n g ao rta , j u s t s u p eri or to th e a or ti c val ve, a n d p a s s a ro u n d o p p os i te s i d es of t h e p u lm o n ar y tr u n k
( F ig s . 1 .4 9 an d 1 .5 0 ; T ab le 1 .4 ) . Th e c o ro n ary art eri es s u p p ly b o th t h e at ri a an d t h e ve n tr ic le s ; h o w e ver,
t h e at ri al b ra n c h es ar e u s u al ly s m a ll an d n ot rea d il y ap p are n t i n th e ca d ave ric h e art . T h e ven t ri c u la r
d is t ri bu t io n of ea c h c oro n ar y art er y is n o t s h a rp ly d em arc a te d.
T h e ri gh t co r o na r y ar t er y ( R C A ) a ri s es f rom t h e r ig h t a or ti c s in u s of t h e as c e n di n g ao rt a an d p as s es t o
t h e rig h t s id e o f th e p u l m on a ry t ru n k, r u n n in g in t h e c o ron a ry g ro ov e (F i g s . 1 .4 8 an d 1 .4 9 A ) . N ea r it s
or ig in , t h e R C A u s u a ll y g ive s of f an as c e n d in g si nu at r ia l n o da l br an ch , w h ic h s u p p li es t h e S A n od e ( F ig .
1 .4 9 A ) . Th e R C A t h en d es c en d s in t h e c o ron a ry g ro ove an d g ive s of f th e ri ght m ar gi na l b ra nch, w h i c h
s u p p lie s th e r ig h t bo rd er o f th e h ear t as i t r u n s t o w ar d ( b u t d o es n o t re ac h ) th e a p ex o f t h e h e art . A f te r
g ivi n g of f th i s b ran c h , t h e R C A t u rn s t o t h e le f t an d c o n ti n u es in t h e c o ron a ry g ro ov e t o t h e p os t eri or
as p ec t of t h e h ea rt . A t t h e c r u x (L . c ro s s ) o f t he he ar t t h e j u n c ti on o f t h e s e pt a a n d w al ls o f t h e f o u r
h ea rt c h a m b ers th e R C A gi ve s r is e t o t h e a t ri o ve nt ri cu l ar n o da l br a nch , w h i ch s u p p li es t h e A V n od e
( F ig . 1 .4 9 A C ). T h e S A an d A V n od es a re p ar t o f t h e c o n d u c ti n g s y s te m of t h e h ea rt ( d is c u s s e d l at er i n
t h is c h ap t er) .
Do m i n an c e o f t h e c o ro n ary a rt eri al s ys te m is d ef i n ed by w h ic h a rt ery g i ves ri s e t o t h e p os t eri or

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i n te rve n tri c u la r ( IV ) b ra n c h (p o s te rio r d es c en d i n g a rt ery ). D om in a n ce of t h e ri gh t c or on a ry ar te ry is

t yp ic a l ( ap p ro xim at el y 6 7 % ) (F i g. 1 .4 9 A ); t h e ri gh t c or on a ry ar te ry g iv es ris e to th e lar g e po st e ri o r
i nt e rv en tr i cul a r br an ch, w h ic h d es c en ds i n th e p o s te rio r IV g ro ove to w a rd th e a p ex o f t h e h e art . T h is
b ra n c h s u pp l ies a d ja c en t are as of b ot h ve n tri c le s an d s en d s pe rf or at in g i nt er ve nt r icu l ar sep ta l
br a nc h es in t o t h e IV s ep t u m (F i g . 1 .4 9 C) . T h e te rm i n al ( l ef t v en t ric u l ar) b ra n c h o f th e R C A th e n
c o n ti n u es f or a s h or t d is t an c e in t h e c or on a ry g ro ove . Th u s , i n th e m os t c om m on p at t ern o f d i s tr ib u ti on ,
t h e R C A s u p p li es t h e d ia ph r ag m at i c s u r f ac e o f t h e h e art .
T yp ic a ll y, t h e R C A s u p p li es
T h e ri gh t at ri u m .
M os t of ri g h t ve n tr ic l e.
Pa rt of t h e le ft ve n tri c le (t h e d ia p h rag m a ti c s u rf ac e ).
Pa rt (u s u a ll y th e p os t eri or t h i rd ) o f t h e IV s e pt u m .
T h e S A n od e ( in a p pr oxi m a tel y 6 0 % o f p e op le ) .
T h e A V n od e ( in a p pr oxi m a tel y 8 0 % o f p e op le ) .
T h e l ef t co r o na ry a r te r y (L CA ) ari s es f ro m th e lef t ao rt ic s in u s o f th e a s c en d in g a ort a ( F ig . 1 .4 8 ) ,

p as s e s be tw een t h e l ef t a u ric l e a n d t h e l ef t s i d e of t h e p u lm o n ar y tr u n k, an d ru n s i n t h e c o ro n ary g ro o ve
( F ig . 1 .4 9 A & B ) . In ap p rox im a te ly 4 0 % o f p eop l e, t h e SA no da l b ra nch ari s es f ro m th e c irc u m f l ex
b ra n c h of t h e LC A a n d a s c en d s on t h e p os t er io r s u rf ac e o f th e lef t at ri u m to th e SA n o d e. A s it en t ers t h e
c o ro n ary g ro ov e, at t h e s u p eri or e n d o f th e a n t eri or IV g ro ov e ( F ig . 1 .4 2 B ) , th e LCA d i vid es i n to tw o
b ra n c h es , t h e an t er i o r IV br a nch (l ef t an t eri or d e sc e n d in g [ LA D ] b ra n c h ) a n d t h e ci r cum fl e x br an ch
( F ig . 1 .4 9 A & C ) . Th e an t eri or I V b ra n c h p as s es a lo n g t h e IV g ro ove to th e ap ex o f th e h e art . H er e it
t u rn s ar ou n d t h e in f er io r b ord e r of t h e h ea rt a n d c o m m o n ly an as t o m os e s w it h th e po s t eri or IV b ra n c h of
t h e ri g h t c o ron a ry a rt ery ( F ig . 1 .4 9 B ) . T h e a n ter io r IV b ran c h s u p p li es ad j ac e n t p ar ts o f b o th v en tr ic l es
a n d, v ia I V s e p ta l b ran c h e s , th e an t eri or t w o th i rd s of t h e IV S ( F ig . 1 .4 9 C ) . In m a n y p eop l e, t h e an t er io r
IV b ra n c h gi ves ri s e t o a l a t er al ( di ago n a l) br an ch, w h ic h d es c e n ds o n th e a n t eri or s u rf a c e of t h e h ea rt
( F ig . 1 .4 9 A ) .
T h e s m a ll er c i rc u m f le x b ran c h o f t h e L CA f ol lo w s t h e c or on a ry g ro ove aro u n d t h e l ef t bo rd er o f th e h ear t
t o t h e p o st er io r s u rf ac e of th e h ear t. T h e l ef t m a rgi na l a r te r y, a b ra n c h o f th e c irc u m f l ex b ra n c h ,
f o ll ow s t h e l ef t m arg i n o f th e h ear t a n d s u p p li es t h e le f t ve n tr ic le . M os t c om m o n l y, th e c irc u m f l ex b ra n c h
o f th e L CA t erm i n at es i n th e c o ro n ary g r oo ve o n t h e p o s te rio r as p e ct o f t h e h ea rt be f ore rea c h in g th e
c ru x (F i g . 1 .4 9 B ) , bu t in a pp r oxi m at el y o n e th i rd of h ea rt s it c on t in u e s t o s u p p l y a b ran c h t h at ru n s in o r
a dj a c en t t o th e p o s te rio r IV g ro ove .
T yp ic a ll y, t h e L CA su pp l ies
T h e le f t a tri u m .
M os t of t h e le f t ve n tr ic l e.
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Fi gur e 1 . 49. C o ro n ar y a rt e ri es . A an d B. In t h e m o s t c o m m o n pa tt er n of d is t rib u t io n , t h e

rig h t c oro n ar y art er y an a s to m o se s w i th t h e c ir c u m f lex br an c h of t h e l ef t c o ro n ary a rt ery ( L CA )
(a n as t om os es a re n o t s h o w n ) af t er t h e R C A h as g i ven ri s e t o t h e p os t eri or in t erv en t ric u l ar ( IV )
art er y. Th e R C A g ive s ris e t o b r an c h es s u p p lyi n g bo t h th e s i n u at ri al ( S A ) an d th e
at rio ve n tri c u la r ( A V) n o de s ; t h at t o t h e A V n od e i s t h e f i rs t o f m an y s e p ta l b ran c h e s of t h e
po s t eri or IV a rt ery. T h e a n te rio r IV ar te ry ( le ft an t er io r d es c en d in g b ra n c h ) h o ok s a ro u n d t h e
ap ex o f th e h e art t o an a s to m o s e w i th t h e p o st er io r IV art er y. C . A r te rie s of th e in t erv en t ric u l ar
s ep tu m a re s h o w n . T h e s ep t al br an c h es o f th e a n t eri or i n te rven t ri c u la r b ran c h o f t h e L CA
s u pp l y th e an t eri or t w o t h ird s of t h e IV S , w h e rea s th e s e p ta l b ra n ch e s of t h e p os t eri or
in t erv en t ric u l ar a rt ery ( u s u al ly a b ran c h o f t h e R C A ) s u p p ly t h e p o s te rio r t h ird . B ec a u s e t h e A V
bu n d l e an d b u n d le b ra n c h es ar e c en t ra lly pl ac e d i n an d on t h e IV S , t h e L CA typ i c al ly p ro vid e s
m os t b lo od t o t h is c on d u c t in g t is s u e. D . A c ro ss - s ec t i on of t h e ri g h t a n d l ef t v en t ric l es
de m o n st ra te s th e m os t c om m on p at t ern o f d i s tri b u ti on o f bl oo d f rom t h e R C A ( re d ) a n d L CA
(p i n k) t o th e v en t ric u l ar w al ls an d IV S .
P .1 5 8

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Fi gur e 1 . 50. V ar ia t i o ns i n di st ri bu t io n o f co r o na r y ar t er ie s. A . In th e m os t c om m on
pa t ter n (6 7 % ), t h e ri g h t c o ron a ry a rt ery i s do m i n an t , g ivi n g r is e t o t h e p o s te rio r
in t erv en t ric u l ar b ra n c h . B an d C. T h e l ef t c o ro n ary art ery gi ves r is e t o t h e p os t er io r
in t erv en t ric u l ar b ra n c h in ap p ro xi m at el y 1 5 % of i n di vi du a ls . D . M an y o th e r var ia ti on s o c c u r.
T abl e 1 . 4. A rt e ri al Su ppl y t o H e ar t
Ar te r y / B r an c h
Or igin
C o ur se
Di s t r ib ut i o n
A n a st o m o se s
Ri gh t
R i gh t ao rt ic
F ol lo w s
R i gh t at ri u m ,
co ro n ar y
s in u s
c or on a ry ( A V )
S A an d A V
a n te rio r IV
g r o ove
n o de s , an d
b ra n c h es of l ef t
b et w ee n at ria
p os t er io r pa rt
c o ro n ary a rt ery
an d ve n tr ic le s
o f IV S
R i gh t
A s c en d s to S A
Pu l m o n ar y
c or on a r y
n od e
t ru n k an d S A
S A n o da l
ar te ry n ea r
C irc u m f l ex a n d
n o de
it s or ig in ( i n
60%)
R i g h t m a rg in a l
R i gh t
Pa s s es t o
R i gh t ve n tri c le
c or on a r y
in f e rio r
an d a pe x of
ar te ry
m a rg in o f
h ea rt
IV b ra n c h es
h ea rt a n d
ape x
P os t e ri or
in t erve n tr ic u l ar
A V n o da l
R i gh t
R u n s in
R i gh t an d l ef t
A n t eri or IV
c or on a r y
p os t eri or IV
ve n tri c le s an d
b ra n c h of le f t
ar te ry ( in
g ro ove to
p os t er io r th i rd
67%)
ap e x of h ea rt
o f IV S
( at ap e x)
R i gh t
Pa s s es t o A V
A V n od e
c or on a r y
n od e
ar te ry n ea r
or ig in o f

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p os t eri or IV
ar te ry
L eft co r o na ry
L ef t a ort i c
R u n s in A V
M os t of l ef t
R i g h t c o ro n ary
s in u s
g ro ove an d
at ri u m an d
a r t e ry
g ive s of f
ve n tri c le , IV S ,
an t er io r IV
an d A V
an d
b u n d les ; m a y
c ir c u m f lex
s u p p ly A V n od e
b ran c h e s
S A n o da l
Ci rc u m f le x
A s c en d s on
L ef t a tr iu m a n d
b ran c h ( in
p os t e ri or
S A n od e
40%)
s u rf ac e of le f t
at ri u m to S A
n od e
A n t er i or
Ci rc u m f l e x
L ef t c o ro n ary
Pa s s es al on g
P os t eri or IV
ar te ry
an t er io r IV
b ra n c h of ri gh t
g ro ove to
an t er io r tw o
ap e x of h ea rt
t h ird s o f IV S
( at ap e x)
L ef t c o ro n ary
Pa s s es t o le f t
L ef t a tr iu m a n d
R i g h t c o ro n ary
ar te ry
in A V g ro ove
le f t ve n tr ic l e
a r t e ry
L ef t v en t ric l e
IV b ra n c h es
A n t eri or IV
an d ru n s t o
p os t e ri or
s u rf ac e of
h ea rt
L ef t m arg i n al
Ci rc u m f le x
F ol lo w s l ef t
b ran c h
b or de r of
h ea rt
P os t e ri or
L ef t c o ro n ary
R u n s in
ar te ry ( in
p os t eri or IV
b ra n c h of le f t
33%)
g ro ove to
p os t er io r th i rd
ap e x of h ea rt
o f IV S
( at ap e x)
AV , a tr io ven t ri c u lar ; I V , i n te rve n tr ic u la r; I V S , in t erv en t ric u l ar s e pt u m ; S A , s in u a tr ial .
P .1 5 9

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Fi gur e 1 . 51. C a rdi a c vei n s. T h e g rea t, m i d dl e, a n d s m all c ard i ac ve in s ; th e o b li q u e vei n of

th e l ef t at riu m ; a n d t h e l ef t p o s te rio r ve n tr ic u l ar ve in ar e t h e m ai n ves s e ls d rai n in g in t o th e
c oro n ar y s in u s . T h e c o ron a ry s i n u s , i n tu r n , em p t ie s i n to t h e rig h t at ri u m . T h e an t eri or c a rd ia c
vei n s dr ain d i rec t ly i n t o t h e au r ic le of t h e rig h t at ri u m .
l
l
Pa rt of t h e rig h t ven t ri c le .
M os t of t h e IV S ( u s u all y i ts an t er io r tw o t h ir ds ) , i n c lu d in g t h e A V bu n dl e o f t h e c o n du c t i n g s ys t em
o f t h e h ea rt , th r ou g h it s p erf o rat in g IV s ep t al br an c h es .
T h e S A n od e ( in a p pr oxi m a tel y 4 0 % o f p e op le ) .
Variations of the Coronary Arteries

V a ria ti on s i n th e b r an c h in g p at t ern s an d d is t ri b u ti on o f t h e c o ro n ary a rt eri es ar e c om m on . In t h e m o s t
c o m m o n rig h t do m i n an t pa tt er n , p res en t in a p pr oxi m at el y 6 7 % o f p e op le , th e R C A an d LC A s h a re a b ou t
e qu a ll y in t h e b lo od s u p p ly o f th e h ear t ( F ig . 1 .5 0 A ) . In ap p ro xi m at el y 1 5 % of h ea rt s , th e LCA i s
d o m in a n t i n th a t t h e p os t er io r IV br an c h is a br an c h of t h e c i rc u m f le x art er y ( Fi g . 1 .5 0 B ) . Th e re i s
c o d om i n an c e i n ap p ro xim at ely 1 8 % of p eo pl e, i n w h ic h b ra n c h es of b o th t h e ri gh t an d l ef t c o ro n ary
a rt eri es rea c h th e c r u x an d g ive ris e to br an c h es t h at c ou r s e in o r n ea r th e po s te ri or IV g ro ov e. A f ew
p eo p le h a ve o n ly a s in g le c oro n ar y art er y ( Fi g . 1 .5 0C) . In ot h er pe op l e, t h e c irc u m fl ex b ra n c h ari s es f ro m
t h e ri g h t a ort ic s i n u s (F i g . 1 .5 0D ) . A p p rox im a te ly 4 % o f pe op l e h ave an ac c e s s ory c o ro n ary art ery .
Coronary Collateral Circulation

T h e b ra n c h es of t h e c or on a ry ar te rie s are g e n era lly c on s i de red t o b e e nd a rt e ri es , art er ies t h at s u p pl y
re g io n s o f th e m yo c ard i u m la c kin g s u f f ic i en t a n as t om os es f ro m o th e r la rg e b ran c h e s t o m ai n ta in vi ab il it y
o f th e t i ss u e s h ou l d o c c lu s i on o c c u r. H o w ev er, an a s t om o s es d o ex is t b etw ee n b ra n c h es o f t h e c o ron a ry
a rt eri es , s u b ep ic a rd ia l o r m yo c ard i al, a n d be tw een t h es e a rt eri es an d ex tr ac ar di ac ve s s els s u c h as
t h or ac i c v es s el s (W il li am s et al ., 1 9 9 5 ) . A n as t om os es e xis t b et w ee n th e t er m in a ti on s o f t h e r ig h t a n d th e
l ef t c o ro n ary art eri es i n t h e c o ro n ary g ro ov e an d b et w e en th e IV br an c h es a rou n d t h e ap e x in
a pp r oxi m at el y 1 0 % o f a p pa ren t l y n orm al h e art s . T h e p ot en t ia l f o r th e de vel op m e n t o f t h i s c o ll at er al
c i rc u la ti on p ro b ab ly exi s ts i n m os t if n ot al l h e art s .
Cor onary Art er y Diseas e or Coronary Heart Di sease

Cor on a ry ar te ry d is e as e ( CA D ) i s o n e o f t h e l ea di n g c au s es o f d ea t h . CA D h as m an y c au s e s , al l of w h ic h
res u l t i n a red u c ed b lo o d s u p p ly t o th e v it al m yo ca rd ia l t is s u e .
Myocardial I nfarction
W i th s u d d en oc c l u s io n of a m aj or a rt ery b y a n em b ol u s ( G. em b ol os , p lu g ) , th e reg i on o f m y oc a rd iu m
s u pp l ied b y t h e o c cl u d ed ves s e l b ec o m es i n fa r cte d( re n de red vi rt u al ly b lo o dl es s ) an d u n d erg o es
ne cro s is (p at h o lo g ic al ti s s u e d ea th ) . T h e th r ee m o s t c o m m o n s it es o f c o ro n ary a rt ery o c c lu s i on a n d t h e
pe rc en t ag e o f oc c l u s io n s i n vo lvi n g eac h a rt ery a re ( F ig . B 1 .2 0A & B ) t h e:
A n t er io r IV (L A D) b ra n ch o f th e LCA ( 4 0 5 0 % ) .

08-May-15
R C A ( 3 0 4 0 % ).
Ci rc u m f le x b ran c h o f th e L CA ( 1 5 2 0 % ) .
Page 101 of 139
A n ar ea o f m yo c ard i u m th a t h a s u n de rg on e n e c ro s is c on s t it u t es a m yo ca r di al in fa rct i o n ( M I) . Th e m os t
c o m m o n c au s e o f i s c h em i c h ear t d is e as e i s c oro n ar y art er y in s u f f ic i en c y r es u lt in g f ro m at h er os c le ro s is .
Fi gu re B 1. 2 0
Coron ar y Ath er oscler osis

T h e a t he ro sc le ro t i c pr o ces s, w h i c h res u l ts i n l ip i d a c c u m u la ti on s o n th e in t ern a l w a ll s of t h e c or on a ry
a rt eri es , b eg in s d u ri n g e arl y ad u l th o od a n d s l ow ly re s u lt s in s t en o s is of t h e lu m in a o f th e c oro n ar y
a rt eri es . A s co ro n ar y a th er o scl e ro s is p ro g res s e s , th e c o ll at er al c h a n n el s c o n n ec t in g o n e c oro n ar y
a rt ery w it h th e ot h er ex p an d , w h i c h m ay i n it ia ll y p erm i t a d eq u at e p erf u s i on o f t h e h e art d u rin g re la ti ve
i n ac t ivi t y. De s pi t e th i s c om p e n s at ory m ec h an i s m , t h e m yo c ar di u m m a y n ot rec e ive en ou g h o xyg en w h en
t h e h ea rt n eed s t o p erf o rm i n c rea s ed am o u n ts o f w or k. S tr en u o u s e xer c is e, f o r exa m p le , in c re as es t h e
h e art 's a ct i vit y a n d i ts n e ed fo r o xyg en . T h e i n s u ff i c ie n c y of b lo od s u p p ly t o t h e h e art (m y o car di al
i s ch em i a) m a y re su l t i n M I.
S lowly Prog ressive Coronary Artery Di sease

In s l ow oc c lu s i on o f a c or on a ry ar te ry, t h e c ol la te ral c irc u l at io n h as t im e to in c re as e s o th a t a d eq u at e
p er f u si on o f th e m yo ca rd iu m ca n oc c u r w h en a p o te n ti al ly i s c h em i c e ven t oc c u r s . Con s e qu e n tl y, M I m a y
n o t r es u lt . O n s u dd e n b l oc k ag e o f a lar g e c oro n ar y b ran c h , s o m e i n f arc t io n is p ro ba b ly i n evi ta b le, b u t th e
e xte n t o f th e a rea d am a ge d d e pe n d s o n t h e d eg ree o f d evel op m en t o f c ol la ter al an as t om ot ic c h a n n els . If
l arg e b ra n c h es o f b o th c o ron ary a rt eri es are p art ia ll y ob s t ru c t ed , an ex tr ac ar di ac c o ll at era l c ir c u lat i on
m a y b e u s ed t o s u p p ly b l oo d t o t h e h e art . T h es e c o ll at era ls c on n e c t t h e c o ron a ry a rte ri es w i th t h e va s a
va s or u m in t h e t u n ic a a d ven t it ia of t h e ao rt a an d p u lm on a ry ar te rie s a n d w it h b ran c h e s of t h e in t ern a l
t h or ac i c, b r on c h i al, a n d ph r en ic a rt eri es . Cl in ic a l s t u d ies s h o w t h at an as t o m os e s ca n n ot p ro vid e c o ll at era l
ro u t es q u ic kl y en o u g h to pr eve n t t h e ef f ec t s of s u d d en c or on a ry ar te ry o c c lu s io n . T h e f u n c ti on a l va lu e o f
t h es e a n as t om os es t h u s ap p ea rs to b e m or e ef f ec t iv e in s l ow ly p ro g res s i ve CA D .
An gina Pectori s
P ai n t h a t o rig i n at es in t h e h ea rt is c al le d a n g in a o r a ngi na pe ct o ri s ( L. a n gi n a, s t ra n gl in g p ai n + L .
p ec t o ris , o f t h e c h e s t) . In d iv id u al s w i th a n gi n a c o m m o n ly d es c ri b e t h e tr an s i en t ( 1 5 s ec t o 1 5 m in ) bu t
m o d era te ly s e vere c on s t ri ct i n g p a in as t ig h t n es s in t h e t h or ax, d ee p t o t h e s t ern u m . Th e pa in i s t h e
re s u lt of i s ch e m ia of t h e m yo c ar di u m t h at fa ll s s h ort of i n du c i n g th e c e ll u la r n ec ro s is t h at de f in e s
i n f arc t io n . M os t of t en , a n gi n a re s u lt s fr om n a rro w e d a n d h a rd en e d c o ron a ry a rt eri es . T h e red u c e d b l oo d
f l ow r es u lt s in l es s ox yg en b ei n g d el iv ere d t o c a rd ia c m u s c le c e ll s ( m y oc yt es ) . A s a re s u lt of th e li m it ed
a n aer ob ic m et ab ol is m o f th e m yoc y te s , lac t i c a c id ac c u m u l at es a n d t h e p H is r ed u c ed in af f e c te d a rea s o f
t h e h ea rt . Pa in re ce p to rs in m u s c l e ar e s t im u l at ed b y la c ti c ac id . S t ren u o u s exe rc is e (e s pe c ia ll y af t er a
h e avy m eal ) , su d d e n e xp os u r e to c ol d , an d s tr es s al l req u i re i n c rea s ed ac t ivi t y on t h e p art of t h e h ea rt ,
b u t th e o c c lu d e d v es s el s c a n n ot p rov id e i t. W h en f oo d en t ers t h e s t om a c h , bl oo d f lo w to it an d o th e r
p ar ts o f th e d i ge s ti ve t ra c t i s i n c rea s ed . A s a re s u lt , s om e bl oo d is d iv ert ed f rom o t h er o rg an s , i n c lu d in g
t h e h ea rt .
A n g in a l p ai n is re li eve d b y a pe rio d of res t ( 1 2 m i n are o f t en ad eq u a te) . S u b li n g u al n it rog l yc er in

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( m e di c at io n p lac e d o r s p ra yed u n d er t h e t on g u e f o r ab s or p ti on t h ro u gh t h e o ral m u c os a ) m ay b e

a dm in i s te red b ec au s e it di la te s th e c o ro n ary ( a n d o t h er) art er ies . T h i s i n c rea s es b lo od f lo w t o t h e h ea rt ,
w h il e d ec rea s in g t h e w o rkl oa d a n d th e h e art 's n e ed f or o xyg en b ec a u s e t h e h ea rt i s pu m pi n g ag ai n s t l es s
re s is t an c e . Fu rth e rm o re, t h e d il at ed ve s se ls a c co m m o d at e m o re o f th e b l oo d v ol u m e, a n d s o le ss b l oo d
a rri ves i n t h e h e art th a t n e ed s to b e p u m p ed ou t ag ai n . T h u s t h e a n g in a i s u s u all y re li eved . S u c h an g i n a
p ro vi de s a w a rn in g t h at th e c oro n ar y art er ies a re c o m p rom is ed an d t h at th e re i s a n eed f o r a c h an g e o f
l if es t yl e, a h e al th c a re in ter ven t io n , or bo t h .
T h e p ai n res u l ti n g fr om M I i s u su a ll y m o re s ev ere t h a n w it h an g i n a p ec t ori s , an d t h e p ain r es u lt i n g f ro m
M I d oe s n ot d is ap p ea r af t er 1 2 m in o f r es t . MI m ay a ls o f o ll ow exc es s i ve e xert i on b y a p er s on w i t h
s t en o ti c (n a rro w e d) c o ron a ry a rte rie s . Th e s tr ain i n g h ear t m u s c l e d em a n d s m ore oxy ge n th a n th e
s t en o ti c art er ies c a n p r ovi d e; as a re s u lt , th e is c h em ic ar ea o f m yoc a rd iu m u n d e rg oe s i n f arc t io n an d a
h ea rt a tt a ck oc c u rs . O c c lu s i on o f an y b u t t h e s m all es t br an c h es o f a c or on a ry ar te ry u s u al ly r es u lt s in
d ea th o f th e c a rd ia c m u s c le f i b ers i t s u p p li es . T h e d am a ge d m u s c le i s rep l ac ed b y f ib ro u s ti s s u e an d a
s c a r f orm s .
Coron ar y B ypass G raft

S o m e p at ie n ts w it h ob s t ru c t io n o f th e c oro n ar y c irc u l at io n an d s eve re a n gi n a u n d er go a co r o n a ry
by pa ss gr af t o p era ti on . A s eg m e n t o f a n art er y or a vei n is c on n e c te d t o t h e a s c en d in g ao rt a o r to th e
p ro xi m al pa rt of a c o ron a ry a rt ery a n d t h en t o t h e c o ron a ry a rt ery d i st a l t o t h e s te n os i s (F i g . B1 .2 0B ).
T h e g re at s a p h en o u s v ein i s c om m on l y h arv es t ed fo r c o ron a ry b yp a ss s u r ge ry b ec a u s e ( 1 ) i t h a s a
d i am et er eq u al to or g re at er t h an t h at of t h e c or on a ry ar te rie s , (2 ) c an b e e as il y d is s e c ted f ro m t h e
l ow er l im b , ( 3 ) a n d of f ers r ela ti vel y l en g th y p o rt io n s w it h a m i n im u m oc c u rr en c e o f v al ves o r b ran c h i n g.
R e ver s al o f th e i m p la n te d s e g m en t of ve in c an n eg a te th e e f f ec t o f a va lve i f a va lve d s e g m en t m u s t b e
u s e d. U s e o f th e r ad ia l a rte ry i n by pa s s s u rg ery h a s be c om e in c re as i n gl y m o re c o m m o n . A c o ro n ary
b yp a s s g ra f t s h u n t s b lo od f rom th e a or ta to a s te n ot ic c o ro n ary a rt ery t o i n c rea s e t h e f lo w d is t al to th e
o b s tru c t i on . S im p ly s t at ed , it p ro vid es a de to u r ar ou n d t h e s te n ot ic a rea ( a rt eri al s t en o s is ) or b l oc k ag e
( ar te ria l a tre s ia ). R e vas c u l ar iz at i on o f t h e m y oc a rd iu m m a y al s o b e a c h iev ed by s u rg ic a lly an as t o m os i n g
a n in t ern a l t h ora c ic a rte ry w it h a c or on a ry ar te ry.
Coron ar y Ang ioplasty

In s e lec t ed p at ie n ts , s u rg e on s u s e pe r cut a ne o us t ra ns lu m in a l co r o na ry a ng io p la st y i n w h ic h t h ey
p as s a c at h et er w i t h a s m al l i n fl at ab l e b al lo on at t ac h ed t o i ts t ip in t o th e o b s tr u c te d c o ro n ary a rt ery ( F i g.
B 1 .2 1 ) . W h en t h e c at h et er re ac h e s t h e o b s tru c t i on , t h e b al lo on i s i n f la te d, f l at te n in g t h e at h ero s c le rot i c
p l aq u e ag a in s t th e v es s el 's w a ll , an d th e ves s e l is s t ret c h ed t o i n c reas e th e si z e o f t h e l u m en , t h u s
i m p ro vin g b lo od f lo w . In o th er c as e s , th r o m b o kin a s e is i n je c te d t h ro u g h t h e c a th e te r; t h i s e n z ym e
d i s so lv es t h e b lo od c lo t. I n tra lu m in al in s t ru m e n ts w it h rot at i n g b l ad es an d l as ers h a ve a ls o b e en
e m p lo yed . A f te r d il at io n of t h e ves s e l, an i n tr ava s c u la r s te n t m a y b e in t ro d u c ed to m ai n ta in t h e d il at io n .
In t ra vas c u l ar s t en t s are c om p o s ed of ri gi d or s e m i- ri g id tu b u l ar m e s h es , c o lla p s ed d u rin g in t ro d u c ti on .
O n c e i n pl ac e , th e y exp a n d o r ar e exp a n de d w it h a b al lo on c a th e te r, to m ai n t ain l u m i n al p a te n cy .
Co m p li c at io n s of a n gi op l as t ic p ro c ed u res i n c lu d e re oc c u rr en c e a n d f o rm a ti on o f c l ot s in t h e c o ron a ry
a r t e ry .

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Fi gu re B 1. 2 1. P er cut a ne o us t r an sl um i na l a ngi o pl a st y.
P .1 6 0
P .1 6 1
P .1 6 2
Venous Drainage of t he Heart

T h e h ea rt i s dr ai n ed m ai n ly b y v ein s t h at em p t y in t o t h e c o ro n ary s i n u s an d p art ly by s m al l vei n s th a t
em p t y in t o th e r ig h t a t riu m ( F i g. 1 .5 1 ). T h e co r o na r y si nu s, th e m ai n vei n of th e h ear t, i s a w i d e ven o u s
c h an n e l t h at ru n s f rom l ef t to rig h t in t h e p os t eri or pa rt of t h e c or on ar y g roo ve . Th e c o ro n ary si n u s
rec e ive s th e g r eat c ard i ac ve in at it s le f t en d an d t h e m i d dl e c ar di ac ve in a n d s m a ll c ard i ac vei n s at it s
ri gh t en d . T h e le f t p o s ter io r ven t ri c u la r vei n an d le f t m a rg in a l ve in al s o o p en in t o t h e c o ron a ry s i n u s .
T h e gr ea t ca r di ac ve i n is t h e m a in t ri bu t ar y of t h e c or on a ry s in u s . I ts f ir s t p ar t ( a n t er i o r
i nt er ve nt r icu l ar vei n ) b eg i n s n e ar t h e a pe x of t h e h ea rt an d as c en d s w i t h t h e a n te rio r IV b ran ch o f th e
LC A . A t t h e c or on a ry g ro ove it tu rn s l ef t , an d it s s ec o n d p ar t ru n s a ro u n d t h e l ef t s i d e of t h e h ea rt w it h
t h e c irc u m fl ex b ra n c h of t h e L CA to rea c h t h e c o ro n ary s i n u s . (A n u n u s u a l s it u a ti on i s o c c u rri n g h ere:
B lo od i s f l ow in g in t h e s am e d ire c ti on w it h in a p a ire d a rt ery a n d vei n !) T h e g rea t c ar d iac v ein d ra in s t h e
ar eas o f t h e h e art s u p pl ie d b y t h e L CA . T h e m id dle ca rdi a c vei n ( po s te r io r IV ve i n) ac c o m p an i es th e
p os t eri or in t erv en tr ic u l ar b ra n c h (u s u a ll y ari s in g f ro m th e R C A ) , an d a sm a ll ca rdi a c ve in ac c om p an ie s
t h e rig h t m ar g in al b ran c h o f t h e R C A . T h u s t h es e t w o vei n s dr ai n m os t of t h e are as c o m m on l y s u p p li ed by
t h e R C A . T h e o bl i que v ei n o f t he le ft a t ri u m ( o f M a rs h al l) is a s m a ll ves s e l, re lat i vel y u n im p o rt an t
p os t n at al ly , th a t d es c e n ds o ver t h e p o s te rio r w a ll of t h e le ft at ri u m an d m er g es w i th t h e g rea t c a rd ia c
vei n to f or m th e c o ro n ary s in u s ( de f in i n g t h e b eg i n n in g of t h e s in u s ) . T h e o bl iq u e v ein i s th e r em n a n t o f
t h e em b ry on i c l ef t S V C, w h i c h u s u a ll y at ro p h ies d u ri n g t h e f e ta l p eri od , b u t o c c as i on a ll y p ers i s ts i n
ad u l ts , re p lac i n g or a u g m en t in g t h e rig h t S V C ( Mo or e an d Pe rs au d , 2 0 0 3 ) .
S om e c ard i ac ve in s d o n o t d ra in vi a t h e c or on a ry s in u s . S e vera l s m a ll an te r io r c ar di ac v ei ns be g in ov er

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t h e a n ter io r s u rf ac e of th e rig h t ven t ri c le, c r os s o ver t h e c o ron a ry g ro ov e, an d u s u al ly e n d di rec t ly in t h e

ri g h t a tr iu m ; s om et im e s t h ey en t er t h e s m al l c a rd ia c v ein . T h e s ma l le st ca rdi a c ve in s ( L. ve n ae c o rd is
m i n im a e) ar e m i n u te v es s el s th a t b eg i n i n th e c ap il la ry b ed s of t h e m yo c ar di u m an d o p en d ire c tl y in t o
t h e c h am b ers of t h e h ea rt , c h ief l y t h e at ri a. A lt h o u gh c a ll ed vei n s , th e y are val vel es s c om m u n ic a ti on s
w it h th e c a p il la ry b ed s of t h e m yo c ard i u m an d m a y c arr y b lo od f rom th e h e art c h am be rs to th e
m y oc a r d iu m .
Col lat er al Cir culat ion v ia th e S mallest Cardi ac V ei ns

R eve rs al of f lo w i n t h e a n te rio r an d s m a ll es t ca rd ia c vei n s m ay b ri n g lu mi n al bl o o d (b l oo d f r om t h e
h ear t c h a m b ers ) to th e c ap il la ry b ed s of t h e m yo c ar di u m in s o m e r eg io n s , pr ovi d in g s om e ad d it i on al
c ol lat er al c i rc u l at io n . H ow eve r, u n le s s t h es e c ol lat er al s h a ve d i lat ed i n res p on s e to pr e- exi s ti n g is c h em ic
h ear t d is e as e, t h ey are u n l ik ely to be ab le to s u pp l y s u f f ic ie n t b l oo d t o t h e h e art d u rin g an a c u te even t
an d th u s p re ven t M I.
Lym phatic Drainage of the He art

L ym p h a ti c ves s el s in t h e m yo c ar di u m an d s u b en d o ca rd ia l c o n n ec t ive ti s s u e p as s t o t h e su b ep ic a r di al
l ym ph at i c pl ex us . V es s el s f r om t h is p le xu s p as s t o t h e c or on ar y g roo ve a n d fo ll ow th e c oro n ar y
a rt eri es . A s in g le lym ph a ti c ves s e l, f or m ed b y t h e u n io n of va rio u s ves s e ls f ro m th e h e art , as c e n d s
b et w e en t h e p u lm o n ar y tr u n k an d le f t at ri u m an d en d s i n t h e i n f eri or t r ach eo b ro n chi a l l ym ph n o de s,
u s u a ll y on t h e ri g h t s id e .
The Bot tom Line

Th e ci rc u l at ory s ys te m of t h e m yo c ar di u m is u n i q u e in t h at th e c oro n ar y art er ies f i ll d u r in g ven t ri c u lar
di as t ol e a s a res u l t o f aor ti c rec o il . Th e y are ty pi c al ly ( b u t n o t n ec es s ar il y) fu n c t i on al en d ar ter ie s. T h e
rig h t c oro n ar y art er y ( R C A ) a n d c irc u m f l ex b ra n c h of th e lef t c or on a ry ar te ry ( LC A) s u p p ly t h e w all s of
th e a t ria via s m al l b ran c h e s . Th e R C A ty pi c al ly s u p p l ies t h e S A an d A V n od es , t h e m y oc ar d iu m o f t h e
ext ern a l w all of t h e ri gh t ve n tr ic le (e xc ep t it s an t eri or s u r fa c e) , th e d iap h ra g m at ic s u r fa c e o f t h e l ef t
ven t ri c le, a n d t h e p o s te rio r t h ird o f t h e IV S . T h e L CA ty pi c al ly s u p p li es t h e an t er io r tw o t h ir ds o f t h e IV S
(i n c lu d i n g t h e A V b u n d le o f co n d u c ti ve t is s u e ) , t h e a n te rio r w all of t h e ri gh t ve n tri c le , an d th e ext ern a l
w al l o f th e l ef t ven t ri cl e ( exc e p t t h e d ia p h rag m a ti c s u rf ac e) . T h e c ap i ll ary b e ds o f th e m yoc a rd iu m d ra in
pr im a ril y i n to th e r ig h t at riu m v ia v ei n s e m p ty in g in t o t h e c o ron a ry s i n u s . H ow eve r, t h e vei n al s o m a y
en t er d ir ec t ly i n to th e ch a m b er s v ia t h e s m a ll es t c ard ia c vei n s . B ot h p at h w ay s lac k val ves .
Conducting Syste m of the Heart

In t h e o rd in a ry s eq u en c e of eve n ts i n th e ca rd ia c c yc le , th e at riu m a n d ven t ric l e w ork t o ge th e r as o n e
p u m p o n e ac h s id e o f th e h ear t. T h e co n duc ti n g syst e m o f t he he ar t ( F i g. 1 . 5 2 ), w h ic h c o ord i n at es t h e
c a rd ia c c y c le ( d is c u s s ed ea rl ier in t h is c h ap t er) , c o n si s t s o f c ard i ac m u s c le c ell s an d h ig h l y s p ec ia li z ed
c o n d u c ti n g f i b ers f or i n it i at in g im p u l s es an d c o n du c t in g t h em ra p id ly th r ou g h th e h ear t. N o d al t i s s u e
i n it ia te s th e h e art b ea t a n d c o or di n at es c o n tra c ti on s o f th e f o u r h ea rt c h am b er s .
T h e si n ua tr i al (S A) n o de i s lo c at ed an t ero la te ral ly ju s t d eep t o t h e ep ic a rd iu m a t t h e j u n c t io n of th e
S V C a n d r ig h t a tr iu m , n e ar t h e s u p eri or en d of t h e s u lc u s t erm i n al is ( F ig s . 1 .4 9 A an d 1 .5 2 A ) . T h e S A
n o d e a sm al l c ol le c ti on o f n od al ti s s u e, s p ec i ali z ed c ar di ac m u s c l e f ib er s , an d as s o c iat ed f i br oel as t ic
c o n n ec t ive ti s s u e i s th e p a c em a ker o f th e h e art . T h e S A n od e i n it ia te s an d reg u l at es th e im p u l s es f or
c o n tr ac t io n , gi vi n g o f f an im pu l s e ap p ro xi m at el y 7 0 ti m es p er m in u t e i n m os t pe op l e. T h e c on t ra c ti on
s i g n al f ro m t h e S A n od e s p re ad s m yo ge n ic a ll y (t h ro u g h th e m u s c u lat u re ) o f bo t h at ria . Th e S A n o d e is
s u p p li ed b y th e si nu at r ia l n o da l a rt er y, w h ic h u s u al ly ari s es as an a tr ia l b ran c h o f th e R CA (i n 6 0 % of
p eo p le ), b u t it m ay a ri se f rom t h e L CA ( in 4 0 % ) . T h e S A n od e i s s t i m u la te d b y t h e s ym pa th e ti c d ivi s io n
o f th e a u to n o m ic n er vou s s ys t em to ac c el era te th e h e art ra te a n d is in h i b it ed b y th e pa ra sy m p at h et ic
d i vis i on t o re tu r n to or t ow ard i ts b as a l ra te .
P .1 6 3

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Fi gu re 1 . 52 . C o n duct i n g s yst e m o f he a rt . A. Im pu l s es ( arr ow s ) i n it ia te d a t t h e s i n u at ria l n o de ,

lo c at ed at t h e s u p eri or e n d o f th e s u l c u s (i n t ern a lly , c ris t a) t erm i n al is , a re p ro p ag at ed th rou g h t h e
at ri al m u s c u lat u re to th e a t rio ven t ri c u la r n od e. B . Im p u ls e s ( a rro w s ) rec ei ve d b y t h e at ri ov en t ric u l ar
n od e , in t h e in f er io r p art of t h e in t er at ria l s e pt u m , a re c o n du c t ed t h rou g h t h e A V b u n dl e a n d i ts
b ran c h e s to th e m yoc a rd iu m . Th e A V b u n d le be gi n s at th e A V n o d e an d d iv id es i n to rig h t an d le ft
b u n d les a t t h e j u n c ti on o f th e m em b ra n ou s an d m u s c u l ar p a rts o f th e I VS .
T h e a t ri o ve nt ri cu l ar ( AV ) no d e is a s m al ler c ol lec t io n of n o da l t is s u e t h a n t h e S A n o de . Th e A V n o d e is
l oc a te d i n th e po s te ro in f er io r reg i on of t h e i n te rat ri al s e pt u m n e ar t h e op e n in g of t h e c or on a ry s in u s
( F ig s . 1 .4 9 A C an d 1 .5 2 B ) . T h e s ig n al g en era t ed by th e S A n o de p as s es t h rou g h t h e w a ll s of t h e rig h t
a tr iu m , p ro p ag at ed b y t h e c ard i ac m u s c l e ( my o gen i c c o ndu ct io n ) , w h ic h t ra n s m it s th e s ig n al rap i dl y
f ro m t h e S A n od e t o t h e A V n od e. T h e A V n o de th e n di s tr ib u t es th e s ig n al to th e ven t ri c les t h ro u gh t h e
A V bu ndl e ( F i g. 1 . 5 2 B ). S y m p at h et ic s t im u l at io n s pe ed s u p c o n d u c ti on , a n d pa ras y m p at h et ic s t im u l at io n
s l ow s i t d o w n . T h e A V b u n dl e, t h e o n ly b ri d ge be tw ee n t h e a tr ial an d ven tri c u la r m yo c ard i u m , p as s es
f ro m t h e A V n od e t h ro u gh t h e i n s u lat i n g f i br ou s s ke let o n o f th e h ear t a n d a lo n g t h e m e m b ran o u s p art of
t h e IV S .
A t th e ju n c t io n of t h e m em b ran o u s an d m u s c u la r p art s of t h e s ep t u m , t h e A V bu n d l e d ivi d es in t o r i ght
a n d l e ft bu nd le s. T h es e b ra n c h es p ro c eed on e ac h s id e o f th e m u s c u la r IV S de ep to th e en d oc a rd iu m
a n d t h en ra m i fy in t o su be ndo c ar di al bra n che s ( Pu rk in j e f ib e rs ) , w h ic h e xte n d i n t o t h e w a ll s o f th e
re s p ec t ive v en t ric l es . T h e s u b en d o ca rd ia l b ra n c h es of t h e ri g h t b u n d le s t im u la te t h e m u sc l e o f t h e IV S ,
t h e a n ter io r p ap il la ry m u s c l e t h rou g h t h e s ep t om a rg in a l t ra be c u la ( m o d era to r b an d ) , an d t h e w a ll o f th e
ri g h t v en t ric l e. T h e le f t b u n d le d i vid e s n e ar i ts o ri gi n in t o a p pr oxi m at el y s ix s m al ler tra c t s, w h ic h g iv e
ri s e t o s u b en d o c ard i al b ra n c h es t h at s ti m u la te th e I V S, t h e a n te rio r an d p o s te rio r p ap il la ry m u s c l es , an d
t h e w a ll of t h e le f t ve n tr ic le .
T h e A V n od e i s s u p pl ie d b y t h e A V no d al ar t er y, t h e la rg es t an d u s u al ly t h e f ir s t IV s ep t al br an c h of
p o s te rio r IV ar te ry, a b ra n c h of t h e R C A in 8 0 % o f pe op l e ( F ig . 1 .4 9A C) . T h u s th e art eri al s u p pl y t o
b o th t h e S A an d A V n od es i s u s u a ll y d eri ved f ro m th e R C A . H o w ev er, t h e A V b u n dl e t rav ers e s t h e c en t er
o f th e I VS , t h e a n te rio r t w o t h i rd s o f w h i c h i s s u p pl ie d b y t h e IV S b ra n c h es of t h e an t er io r IV br an c h of
t h e L CA (F i g . 1 .4 9 C & D) .
Im pu l s e g en e rat io n an d c on d u c t io n c an b e s u m m a ri z ed as f ol lo w s :
T h e S A n od e i n it ia te s an im p u l s e t h at is ra pi d ly c o n d u c te d t o c a rd ia c m u s c le f i be rs in t h e at ri a,
c au s i n g th e m to c on t rac t ( F ig . 1 .5 2 A ) .
T h e im pu l s e s p rea d s b y m yog e n ic c on d u c t io n , w h i c h rap i dl y t ran s m i t s t h e i m p u ls e f r om t h e S A n od e

t o t h e A V n od e.
T h e s ig n a l is d i s tri b u te d f ro m t h e A V n od e t h ro u g h t h e A V b u n d le a n d i t s b r an c h es ( th e rig h t an d
le f t b u n d le s ), w h ic h p as s o n eac h s i de of th e IV S to s u pp l y s u b en d oc a rd ia l b ra n c h es to th e pa p il lar y
m u s c l es an d t h e w a ll s o f th e v en t ric l es ( F ig . 1 .5 2B ) .

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I nner vation of the Heart

T h e h ea rt is s u p p li ed by au t on o m ic n e rve f i be rs f rom th e c ar di ac pl e xu s ( F ig s . 1 .5 3 a n d 1 .5 8 B & C ) ,
w h ic h is o f te n qu i te art if i c ia ll y d ivi d ed in t o s u p er fi c ia l an d d ee p p o rt io n s . Th i s n erve n et w o rk is m o s t
c o m m o n ly d es c r ib ed as l yin g o n th e a n te ri or s u rf a c e of t h e
P .1 6 4
b i fu r c at io n of t h e tr ac h e a (a res p ir at or y s tr u c tu re ) , s i n c e i t i s m os t c om m on l y ob s er ved in d i ss e c ti on
a f te r rem o va l o f t h e a sc e n d in g ao rt a an d t h e b if u rc a ti on o f th e p u l m on a ry t ru n k. H ow e ver , it s pr im a ry
re la ti on s h i p is to t h e p os t eri or a s p ec t o f th e lat t er t w o (c a rd io va sc u l ar ) s t ru c t u res , e sp e c ial ly th e
a s c en d in g ao rt a. T h e c ar d iac p l exu s is f o rm ed o f b o th s y m p at h et ic an d p ar as ym p a th e ti c fi b ers en r ou t e t o
t h e h ea rt . F ib er s a re d i st ri b u te d a lo n g a n d to th e co ro n ary ves s el s an d t o c om po n en t s of t h e c on d u c t in g
s ys t em , pa rt ic u l arl y t h e S A n o d e.
Fi gu re 1 . 53 . C a rd ia c ne rv es a nd pl e xu s. T h is d is s e c ti on o f t h e s u p er io r an d p os t eri or m ed ia s ti n a
d em o n s tr at es c ard i ac b ra n ch es of t h e vag u s n er ve ( CN X ) an d s ym p at h et i c t ru n k s r u n n in g d ow n th e
s id es o f th e t ra c h ea t o f o rm t h e c ar di ac p le xu s . A lt h o u gh s h o w n l yin g an t er io r to th e tr ac h ea l
b if u rc a ti on h e re, t h e p ri m ary rel at io n s h ip of t h e c ar di ac p le xu s is t o t h e as c e n d in g ao rt a ( br oke n
li n es ) an d p u lm o n ar y tr u n k, th e f orm er h av in g b een re m o ved to exp o s e t h e p lex u s .
T h e s ym pa th e ti c s u p pl y is f ro m p res y n ap t ic f ib er s , w it h c el l b od i es in t h e i n ter m ed i ol at era l c el l c o lu m n s

( IM L s ) o f t h e s u p er io r f ive or s i x th o ra c ic s eg m e n ts o f t h e s p i n al c o rd , an d p os t s yn a pt ic s y m p at h et ic
f i be rs , w i th c e ll b o d ies i n th e c e rvi c al a n d s u pe rio r t h or ac ic p ar ave rt eb ral g an g li a o f t h e s ym pa t h eti c
t ru n ks . T h e p o s ts yn a p ti c f ib ers t ra vers e c ard io p u lm on ar y s p lan c h n i c n erv es an d t h e c ard i ac p le xu s to en d
i n th e S A a n d A V n o de s an d in re la ti on t o t h e t erm i n at io n s of p ar as ym p a th e ti c fi b ers o n th e c o ro n ary
a r t er i es . S ym p at h et i c s t im u la ti on c a u se s in c re as ed h ea rt rat e; im pu l s e c on d u c t io n ; fo rc e o f c on t rac t i on ;
a n d, a t t h e s a m e t im e , in c re as ed b lo od f l ow t h ro u g h t h e c o ro n ary v es s el s to s u pp o rt th e i n c rea s ed
a c ti vit y. A d re n erg i c s t im u la ti on o f t h e S A n o de an d c on d u c t in g ti s s u e i n c rea se s th e r at e o f d ep o la riz a t io n
o f th e p a c em a ker c e lls w h il e in c r eas i n g a t rio ven t ri c u la r c on d u c t io n . Di rec t ad ren erg ic s t im u lat i on f ro m
t h e s ym pa th e ti c n erv e f ib ers , a s w el l a s i n d ire c t s u p ra ren a l ( ad re n al ) h o rm o n e s t im u l at io n , in c re as es
a tr ial an d ven tri c u la r c on t ra c ti li ty . Mo s t a d ren e rg ic re ce p to rs on c o ro n ary b l oo d v es s el s are 2 - re c ep to rs
w h ic h , w h e n ac t iva te d , c au s e re la xat io n ( or p er h ap s in h i b it io n ) o f
P .1 6 5
va s c u la r s m o ot h m u s c le a n d , th e ref o re, d il at io n of t h e ar te rie s (W il s on - Pa u w e ls et al ., 1 9 9 7 ) . Th i s

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s u p p li es m o re o xyg en a n d n u t ri en t s to th e m yoc a rd iu m d u r in g p eri od s of i n c rea s ed ac t ivi ty .

T h e p ar as ym p a th e ti c s u pp l y is f ro m p res y n ap ti c f ib ers o f th e v ag u s n erv es . Po s ts y n ap t ic p ara s ym p at h et i c
c e ll b o d ies ( in t ri n s ic g an g l ia) a re lo c at ed in t h e a tr ial w a ll a n d in t era tr ial s ep t u m n ear t h e S A a n d A V
n o d es an d al on g t h e c or on a ry ar te rie s . Par as ym pa th e ti c s ti m u la t io n s l ow s th e h e art ra te , red u c es t h e
f o rc e o f t h e c o n tr ac t io n , an d c on s t ri c ts t h e c or on a ry ar te rie s , s avi n g e n erg y b et w e en p eri od s o f i n c rea s ed
d em an d . Po s ts y n ap t ic p ara s ym p at h et i c f i b ers re lea s e ac e ty lc h ol in e , w h i c h b i n d s w it h m u s c ar in i c
re c ep t ors t o s l ow t h e r at es of d ep o la riz a ti on o f th e p a c em a ker c e lls a n d a tr io ven t ri c u la r c on d u c t io n an d
d ec r eas e at ria l c o n tra c ti li t y.
Elect rocardiog rap hy

Th e pa s s ag e o f i m p u ls e s ove r th e h ear t f ro m t h e S A n o d e c an b e a m p li f ied a n d re c or de d a s an
el ec tr o c a rd io gr a m ( E CG or E K G ) (F i g . B 1 .2 2 ) . F u n c ti on a l t es t in g of t h e h ea rt i n c lu d es e x erc i s e
to le ran c e t es t s ( tre ad m i ll s tre s s tes t s ) , p rim ari ly t o c h e c k th e c on s eq u e n c es of p os s i b le c o ro n ary a rt ery
di s ea s e. E xer c is e t ol er an c e t es t s are o f c on s i de rab l e im po rt an c e i n d et ec t in g th e c au s e o f h e art b ea t
irr eg u la rit ie s . H ea rt r at e, E CG , an d b lo od p res s u r e rea d in g s are m on i to re d a s th e p a ti en t do es
in c re as in g l y d em a n d in g exe rc is e o n a t rea d m il l. T h e re s u lt s s h ow t h e m a xi m u m ef f o rt a pa ti en t 's h ea rt
c an s af el y t ol era te .
Cor onary O cclus ion an d th e Con du ctin g S yst em of th e Hear t

Da m ag e t o t h e c o n du c t i n g s ys t em o f th e h ear t, o f te n r es u l ti n g f ro m i s ch e m ia c au s ed b y c o ron a ry a rt ery
di s ea s e, p rod u c e s d i s tu r ba n c es o f c a rd ia c m u s c le c o n tr ac t io n . S in c e t h e a n te rio r IV b ran c h ( L AD ) gi ves
ris e t o th e s e p ta l b ran c h e s s u pp l yin g t h e A V b u n dl e in m os t pe op l e, an d b ran ch e s of t h e R C A s u p p ly b o th
th e S A a n d A V n o de s (F i g s . B1 .2 3 an d 1 .4 9 C) , p art s of t h e c o n du c t in g s ys t em o f th e h ear t a re li kel y t o
be af f ec t ed b y th e ir o c c lu s i on , a n d a he ar t b lo ck m a y oc c u r. I n t h i s c a s e ( if t h e p at ien t s u rvi ve s t h e
in i ti al s t ag e s ), t h e ve n tr ic l es w i ll b e gi n to c on t ra c t i n de p en d en t ly a t t h ei r ow n rat e: 2 5 3 0 t im es p er
m in u t e ( m u c h s lo w e r th a n th e s lo w es t n or m al rat e ( 4 0 4 5 t im es pe r m i n u te ). T h e a tr ia c o n ti n u e t o
c on t rac t at th e n orm al r at e if t h e S A n od e h a s be en s p are d , bu t t h e im p u l s e g en er at ed b y th e SA n o d e n o
lo n ge r rea c h es t h e ven t ri c le s .
Da m ag e t o o n e o f t h e b u n d le b r an c h es re s u lt s in a b u n d le br an c h b lo c k, in w h ic h ex ci t at io n pa s s es al on g
th e u n a f f ec t ed br an c h an d c au s e s a n or m al ly t im ed s ys t ol e of t h at ven t ri c le o n ly. T h e i m p u ls e th e n
s pr ead s t o t h e ot h er ven t ri c le vi a m y og en i c (m u s c le p ro p ag at ed ) c on d u c t io n , pr od u c i n g a lat e
as yn c h ro n o u s c o n t rac t io n . In th e s e c as e s , a c ar di ac p ac e m ake r ( art if i c ia l h ea rt r eg u la to r) m ay h ave t o b e
im p l an t ed to in c re as e t h e ve n tr ic u l ar ra te of c on t ra c ti on t o 7 0 8 0 p er m i n u te (s e e c li n ic a l c or rel at io n
[b l u e] bo x A rt if i c ial Car di ac P ac em ake r ).

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Fi gu re B 1. 2 2
Fi gu re B 1. 2 3
W it h a ve n tr ic u la r s ep t al d e f ec t, t h e A V b u n d le u s u a ll y li es in t h e m a rg in o f t h e V S D . O bv io u s ly, t h is v it al
p ar t o f th e c o n d u c ti n g sy s te m m u s t b e p r es erv ed d u rin g s u rg ic a l re p air of t h e d ef ec t . De s tru c t io n of t h e
A V b u n d le w ou l d c u t t h e on l y p h ys io lo g ic a l li n k b et w e en th e at ria l a n d v en t ric u l ar m u s c u l at u re , als o
p ro d u c in g a h ea rt bl oc k as d es c ri be d a b ove .
Art ificial Car diac Pacemaker

In s o m e p eo p le w it h a h ea rt bl oc k , an a rt i fic ia l c ar di ac pa ce m ak e r ( ap p ro xim a t ely t h e s i z e o f a po c ket
w at c h ) i s in s er te d s u b c u t an eo u s ly . Th e pa c em a ker c o n s is t s of a p u l s e g en er at or o r b at t ery p ac k , a w i re
( le ad ) , an d an el ec t ro d e. Pa c em a kers p ro d u c e el ec t ric a l i m p u ls es t h at in i ti at e ve n tr ic u la r c o n tra c ti on s a t
a pr ed et erm in ed ra te . A n e le c tro d e w i th a c at h et er c o n n ec t ed to it is in s e rt ed in t o a v ei n a n d it s
p ro g res s i on t h ro u gh t h e ve n ou s p at h w a y is f o ll ow e d w it h a fl u o ro sc op e, a de vic e fo r ex am i n in g d eep
s t ru c t u res i n r eal ti m e ( a s m ot io n oc c u rs ) b y m ea n s of ra di og r ap h s . Th e te rm i n al o f th e e le c tro d e is
p as s e d t h ro u g h th e S V C t o t h e r ig h t a tr iu m a n d t h ro u g h th e t ri c u s p id val ve i n to th e rig h t ven t ri c le. H ere
t h e el ec t ro de is f ir m ly f i xed t o t h e t rab ec u l ae c a rn ea e in t h e ve n tr ic u l ar w all an d p la c ed in c on t a ct w i t h
t h e en d o c ard i u m .
Restart ing th e Hear t

In m o s t c a s es o f c a rd ia c a rre s t, f i rs t- a id w o rke rs pe rf or m ca rdi o pu lm o n ar y re su sci t at i o n t o re s to re
c a rd ia c o u t pu t an d p u lm on a ry ve n ti la ti on . B y a p pl yi n g f i rm p res s u re to th e th o rax ove r th e in f er io r p art
o f th e s t er n al b o d y (e xt ern a l o r c lo s ed c h es t c a rd ia c m as s a ge ), t h e s t ern u m m ov es p os t eri orl y 4 5 c m .
T h e i n c rea s ed in t rat h o rac i c p r es s u re f o rc es b lo od o u t o f t h e h e art in t o t h e g re at art eri es . W h en t h e
e xte rn al p res s u re is rel ea s ed an d th e in t rat h o rac i c pr es s u re f a ll s , th e h e art ag a in f il ls w i t h b l oo d . If th e
h e art s to p s be at in g ( ca rdi a c ar re st) du r in g h ea rt s u r ge ry, t h e s u rg eo n at te m p ts t o r es t art it u s in g
i n te rn al or o p en c h es t (d i rec t ) h ear t m a s s ag e.
F ibril lat ion of th e Hear t

F ib r i ll a t io n is m u l ti p le, r ap id , c ir c u it ou s c o n tr ac t io n s o r t w i tc h i n g s o f m u s c u la r f ib er s , in c lu d i n g c a rd ia c
m u s c l e. In a t ri al fi br il l at i o n, t h e n o rm al reg u l ar rh y th m ic al c on t ra c ti on s o f t h e a tri a a re re pl ac e d b y
ra p id ir reg u l ar an d u n c o ord i n at ed tw it c h in g s o f d i f fe ren t p art s of t h e at ri al w al ls . T h e ve n tr ic l es res p o n d
a t i rreg u l ar i n te rva ls t o t h e d ys rh yt h m i c im p u l s es rec e ive d f ro m t h e at ri a, b u t u s u a ll y c ir c u la ti on re m ai n s
s a ti s f ac t ory . In ve nt ri cu la r fi br i ll a ti o n , t h e n o rm a l ve n tr ic u l ar c o n tra c ti on s a re re p lac e d b y r ap id ,
i rre gu l ar t w i t ch in g m ov em e n ts t h at do n ot p u m p (i .e., t h ey do n ot m ai n t ain t h e s ys t em ic c ir cu lat i on ,
i n c lu d in g t h e c o ron a ry c i rc u la ti on ) . T h e d am a g ed c on d u c t in g s ys t em o f t h e h e art d oes n o t f u n c t io n

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n o rm a ll y. A s a res u l t , an ir reg u la r p at te rn of u n c o or di n at ed c on t ra c ti on s o c c u rs in t h e ve n tri c le s , exc e pt

i n th o s e ar eas t h at are in f ar c te d. V e n tr ic u la r f ib ri ll at io n is t h e m o s t d is o rg an i z ed o f a ll dy s rh yt h m ia s , an d
i n it s pr es en c e n o ef f ec t iv e c ard i ac ou tp u t oc c u rs . T h e c o n di t io n i s f at al i f al lo w ed t o p ers i s t.
Defi brill at ion of th e Hear t

A n el ec t ri c s h o c k m a y b e g ive n t o th e h e art t h rou g h t h e t h ora c ic w a ll via la rg e el ec t rod e s ( p ad d le s ) . T h i s
s h o c k c au s e s c e s s at io n of al l c ar d iac m o ve m en t s an d a f ew s e c on d s la te r t h e h ea rt m a y b eg in t o b e at
m o re n o rm a ll y. A s c oo rd in a te d c o n t rac t io n s an d h en c e p u m p i n g o f th e h ear t i s r e- es t ab li s h ed , s om e
d eg re e o f s y st em ic ( in c l u di n g c oro n ar y) c i rc u l at io n res u l ts .
Cardiac Referred Pain

T h e h ea rt is in s e n s it iv e to to u c h , c u t ti n g , co ld , a n d h e at ; h o w e ver , i s c h em i a a n d t h e a c c u m u la ti on o f
m e ta b ol ic p ro du c t s s ti m u l at e p ai n e n d in g s in t h e m yo c ar di u m . T h e af f e ren t pa in f i be rs ru n c en t ra ll y in
t h e m i d dl e a n d i n f eri or c e rvi c al b ra n c h es an d es p ec i al ly i n th e th o rac i c c ard i ac b ran c h e s of th e
s ym pa t h et ic tr u n k. T h e ax on s of t h es e p ri m a ry s en s o ry n eu r on s en t er sp i n al c ord s eg m e n ts T 1 th r ou g h
T 4 or T5 , e s pe c ia ll y on t h e le f t s i de .
Fi gu re B 1. 2 4
C a rdi a c re fer re d pa i n is a p h e n om e n on w h ereb y n o xi ou s s t im u l i o rig i n at in g in t h e h e art are pe rc ei ved

b y a p e rs on a s pa in a ris i n g f r om a s u p e rf ic i al p a rt o f th e b o d y t h e s ki n on t h e le f t u p p er l im b , f o r
e x am p l e . Vi sc er al re fe rr ed pa i n i s t ra n s m it t ed b y vis c e ral af f ere n t f i be rs ac c o m p an yi n g s ym p at h et ic
f i be rs an d is t yp ic a ll y ref e rre d t o s o m at i c s t ru c t u res o r ar eas s u c h as a lim b h a vi n g a f fe ren t f ib er s w it h
c e ll b o d ies i n th e s a m e s p in a l g an g l io n , an d c en t ral p roc e s s es th a t e n te r th e s pi n al c ord t h ro u gh t h e
s a m e p os t er io r roo t s (H a rd y an d N a f te l, 2 0 0 1 ) .
A ng in al pa in is c om m on l y f el t a s r ad ia t in g f rom t h e s u b s t ern a l an d l ef t p ec t o ral reg i on s t o t h e le ft
s h o u ld er an d th e m ed ia l as p e c t o f t h e l ef t u p p er lim b ( F i g. B 1 .2 4 A ). T h is p ar t o f th e l im b i s s u pp l ied b y
t h e m e di al c u ta n eo u s n e rve o f th e arm . O f t en t h e la te ral c u ta n eo u s br an c h es o f t h e 2 n d an d 3 rd
i n te rc os t al n erv es ( th e i n t erc o s to b rac h i al n e rve s ) j oi n or o ve rla p i n th e ir d i s tr ib u ti on w it h th e m ed ia l
c u t an e ou s n er ve o f t h e a rm . Co n s eq u en t ly , c ard ia c p a in i s ref er red t o t h e u p p er li m b b ec au s e th e s p i n al
c o rd s eg m en t s of t h es e c u t an e ou s n er ves ( T1 T 3 ) a re al s o c o m m o n to th e vis c e ral af f ere n t
t erm in a ti on s f or th e c o ro n ary art eri es . S yn a p ti c c on t ac t s m ay a ls o be m ad e w it h c om m is s u ra l ( c on n e c to r)
n e u ron s , w h ic h c o n du c t im pu l s es t o n eu r on s o n t h e r ig h t s i d e of c o m p ara b le a rea s o f th e s pi n al c ord .
T h is o c c u rre n c e exp l ain s w h y p ai n o f c ard i ac or ig in , a lt h o u gh u s u a ll y ref e rred t o t h e le f t s i de , m ay b e
re f err ed to th e r ig h t si d e, b ot h s id e s , or t h e b ac k ( F i g. B .2 1 B & C ) .
P .1 6 6
P .1 6 7
S urface An atomy of th e Heart an d Gr eat V essel s

T h e h ea rt an d g rea t ve s s els a re a pp ro xi m at el y in t h e m i d dl e o f t h e t h or ax, s u r rou n d e d l at era ll y an d
p o s te rio rl y by th e l u n g s an d an t eri or ly b y t h e s t ern u m a n d t h e c e n tra l p ar t o f th e t h o rac i c ca g e ( F ig . S A
1 .7 A & B ) . Th e b o rd ers o f th e h e art ar e var ia bl e a n d d ep e n d o n th e po s it io n of t h e d ia p h rag m a n d t h e
b u i ld an d p h ys ic a l c o n di t io n o f th e pe rs on . T h e o u t li n e of t h e h ea rt c a n be tr ac ed o n t h e a n te rio r s u rf a ce
o f th e t h o rax b y u s i n g t h e f o ll ow in g g u id el in e s ( F i g. S A 1 .7 C ):

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T h e s u p eri or b o rd er c o rre s po n d s to a li n e c o n n ec t in g th e in f er io r bo rd er of th e 2 n d l ef t c os t al
c ar ti la ge to th e s u pe rio r b or de r of t h e 3 rd ri g h t c o s ta l c ar ti la ge .
T h e ri gh t b or de r c or res p on d s t o a l in e dr aw n f r om t h e 3 rd ri g h t c o s ta l c ar ti la ge to th e 6 th ri g h t
c os t a l c art i lag e ; t h is b o rd er i s s l ig h t ly c o n vex to th e rig h t .
T h e in f e rio r b or de r c or res p on d s t o a l in e dr aw n f r om t h e in f e rio r en d o f t h e ri g h t b o rd er t o a po in t

in t h e 5 t h in t erc o s t al s p a c e c lo s e t o t h e le ft M CL ; t h e l ef t e n d o f th i s li n e c orr es p on d s t o t h e
lo c at io n of t h e ap e x of t h e h ea rt a n d th e a p ex b ea t.
T h e le f t b or d er c or res p o n ds t o a li n e c on n e c ti n g t h e l ef t e n d s o f th e li n es rep re s en t in g th e s u pe ri or
an d i n fe ri or b o rd ers .
T h e va lve s a re l oc a te d p o s te rio r t o t h e s t ern u m ; h o w ev er, t h e s ou n d s p ro d u c ed by t h em are

p ro je c te d t o t h e a rea s s h o w n i n F ig u re S A 1 .7B pu l m o n ary ( P ), a or ti c (A ) , m i tr al ( M ) , an d tr ic u s p id
( T) w h ere th e st et h o s c op e m a y b e p la c ed to avo id i n te rven i n g bo n e.
Fi gu re S A1 . 7
T h e a pe x be at i s t h e i m p u ls e t h at re s u lt s f r om t h e ap e x of t h e h ea rt b e in g f orc e d a g ai n s t t h e an t er io r
t h or ac i c w al l w h e n th e l ef t ven t ri c le c o n tr ac t s . Th e lo c at io n o f th e ap ex b ea t ( m i tr al a rea , M ) v ari es in
p o s it io n an d m ay b e l oc a t ed in t h e 4 th o r 5 t h in t erc o s ta l s p ac e s , 6 1 0 c m f ro m th e A ML .
Au scult at ory Ar eas

Cl in i c ia n s ' in t er es t i n th e s u rf ac e a n at om y of t h e h ea rt a n d c a rd ia c val ves re s u lt s f rom t h ei r n ee d t o
l is t en t o va lve s ou n d s . T h e f ive are as ( tw o a rea s a re f o r th e pu l m o n ary v al ve) are as w i d e ap ar t a s
p o s s ib le so t h at t h e s o u n d s pr od u c ed at an y g i ven va lv e m ay be c lea rly di s ti n g u is h e d f ro m t h os e
p ro d u c ed at ot h er v alv es ( Fi g . S A 1 .7D & E ). B l oo d te n ds t o c a rry t h e s o u n d i n th e di re ct i on o f i ts f l ow ;
c o n s eq u en t ly , eac h a rea i s s it u at ed s u p erf i c ial to t h e c h am b er or v es s el i n t o w h i c h th e bl oo d h as p as s ed
a n d i n a d ir ec t l in e w it h t h e val ve o ri f ic e.
P .1 6 8
Th e B ott om Lin e
T h e c o n du c t i n g s y st em of th e h ear t c o n s is t s of s p ec ia li z ed in t ri n s ic n o de s th a t rh y th m i c al ly g e n era te

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s t im u li a n d o f b u n dl es o f m od if i ed c ard i ac m u s c l e th a t c o n d u c t t h e i m p u ls es , r es u lt in g i n t h e c o or di n at ed
c o n tr ac t io n of th e at ria an d ven t ri c le s . Th e r at e o f g en e rat i on an d s p ee d o f c o n d u c ti vi ty a re i n c rea s ed b y
t h e s ym pa th e ti c d ivi s io n , an d in h i b it ed b y th e pa ras y m p at h et ic d iv is i on , o f t h e A N S t o m e et d e m an d s or
c o n s erv e en er gy . Th e im p u l s e- ge n era ti n g s in u at ri al n od e a n d t h e re la yin g at ri ov en t ric u l ar n o d e ar e
t yp ic a ll y s u p p lie d b y n o d al br an c h es o f t h e R C A , w h er eas t h e at ri ov en t ric u l ar b u n d le an d it s b ran c h es a re
p ri m ar il y s u p pl ie d b y s e pt al b ran c h e s o f th e LCA . O c c l u si o n o f eit h er art ery w it h s u b s eq u en t in f a rc ti on o f
n o d al o r c o n du c t iv e t is s u e m a y req u i re p l ac em e n t o f an ar ti f ic ia l c a rd ia c p a c em a ker. T h e e ff e c t o f t h e
A N S o n th e c o ro n ary a rt eri es is p a rad o xic a l, w i t h s y m p at h et ic s t im u l at io n p rod u c i n g v as o di la ti on a n d
p ar as ym pa th e ti c s ti m u l at io n p r od u c in g va s oc o n s tr ic t io n .
P .1 6 9
Supe rior Me d iastinum

T h e su per i o r m edi a st in um is s u p er io r to t h e tr an s ve rs e t h ora c ic p la n e, p as s i n g th ro u g h th e st er n al
an g l e an d t h e j u n c ti on ( IV d is c ) of ver te br ae T 4 an d T 5 (F i g . 1 .5 4 ) . F rom an t eri or t o p o s te rio r, t h e
c on t en t s of t h e s u p eri or m ed ia s ti n u m ar e ( Fi g s . 1 .5 5 A & B a n d 1 .5 6 ) t h e:
l
l
Th y m u s .
Gre at ves s e ls , w i th t h e ve in s ( b rac h i oc e ph a li c vei n s an d S V C) a n te rio r t o t h e ar te rie s (a rc h of t h e
ao rta an d t h e ro ot s of it s m aj o r b ran c h e s t h e b rac h i oc ep h a li c tru n k , lef t c om m on c a rot id a rte ry,
an d le ft s u b c la via n art ery ) a n d r el at ed n erve s (v ag u s an d p h ren i c n erve s an d th e c ard ia c p lex u s o f
n e rve s ).
F ig ure 1. 5 4 Bo u nda ri e s o f sup er io r me di as t in um . T h e s u p eri or m e d ia st i n u m ext en d s

i n f eri orl y f ro m th e s u pe rio r t h or ac ic a p ert u re t o t h e t ran s v ers e t h o rac i c p l an e , w h ic h p as s e s
t h ro u g h t h e s t ern a l a n gl e a n te rio rl y an d th e in t erv ert eb ra l d is c o f v ert eb ra e T 4 a n d T5
p o s te rio rl y .
In f eri or c o n t in u at i on of t h e c er vic a l vi s c era (t ra c h ea a n te rio rl y an d es o p h ag u s po s t eri orl y) an d

rel at ed n erv es ( lef t rec u rr en t lar yn g ea l n erv e) .
Th o ra ci c d u c t a n d l ym p h at i c t ru n k s .

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Fi gu re 1 . 55 . D i sse ct i o ns o f su per i o r m edi a st i num . A . In th i s su p e rf ic i al d i s s ec t io n , th e s t er n u m

an d ri b s h a ve b ee n exc i s ed an d th e pl eu ra e re m ov ed . It i s u n u s u al to s ee s u c h a d is t i n c t t h ym u s i n
an a du l t ; u s u a lly it is im pr es s iv e d u rin g p u b ert y b u t s u b s e qu e n tl y re gr es s es an d b ec o m es l arg el y
rep l ac ed b y f at an d f ib ro u s ti s s u e. S V C, s u p er io r ven a c ava . B . In t h is d eep d is s e c ti on o f t h e r oo t o f
t h e n ec k a n d s u p er io r m ed i as t in u m , t h e t h ym u s h a s b e en rem ove d. T h e r ig h t v ag u s n erv e ( CN X )
c ro s s es an t eri or t o th e r ig h t s u b c l avi an a rte ry a n d g i ves o ff t h e ri g h t re c u rren t la ryn g e al n e rve,
w h i c h pa s s es m ed i al ly t o r eac h t h e t rac h e a an d es o p h ag u s . T h e le ft re c u rren t la ryn g ea l n e rve p as s e s
in f e rio r an d t h en p os t eri or to th e arc h o f t h e a ort a a n d a s c en d s b et w ee n t h e t ra c h ea a n d e s op h ag u s
t o t h e la ryn x.
P .1 7 0
T o s u m m ari z e s ys t em i c al ly , th e m aj or s t ru c t u res i n th e s u p e rio r m e di as t in u m , fr om a n te rio r t o p os t er io r,
a re t h e t h ym u s , ve in s , ar te rie s , ai rw a y, al im e n ta ry t rac t , an d l ym p h at ic t ru n ks .

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Th ymu s
T h e t h y m u s, a pr im a ry l ym p h oi d org a n , is lo c at ed in t h e i n fe ri or p ar t o f t h e n e c k an d t h e an t eri or p a rt of
t h e s u p eri or m ed ia s ti n u m ( F ig s . 1 .5 5 A an d 1 .5 6 ) . It li es p os t eri or to th e m an u b ri u m an d ext en d s i n to th e
a n te rio r m e di as t in u m , an t eri or t o t h e f i br ou s p eri c ar di u m . A f te r p u b ert y, t h e t h ym u s u n d erg o es g rad u a l
i n vo lu t io n an d is la rg el y rep l ac ed b y f at . T h e ri c h a rt eri al s u pp l y of t h e t h ym u s is d er ive d m ain l y f ro m th e
a n te rio r in t er c os t al an d an t er io r me di a st in al br an che s o f th e i nt e rn al t ho r aci c a rt er i es . Th e v ein s
o f th e t h ym u s e n d i n th e lef t b rac h i oc e ph a li c , in t ern a l t h or ac ic , a n d i n f eri or th yr oi d v ein s . T h e l ym p h at i c
ve s s el s o f th e th ym u s e n d in t h e p ara s te rn al , br ac h i oc ep h a li c , an d tr ac h eo b ron c h i al lym ph n o d es .
Ag e Ch an ges in th e Th ymu s
Th e fl at , f la s k- s h ap ed lo b es of t h e t h ym u s ar e a p ro m in e n t f ea t u re o f t h e s u p er io r m ed ia s ti n u m d u ri n g
in f an c y a n d c h il dh o od . In s o m e i n f an t s , th e t h ym u s m ay c o m p res s t h e t rac h ea . T h e th y m u s p lay s an
im p o rt an t r ol e in t h e d ev elo p m en t an d m a in t en an c e of t h e im m u n e s ys t em . A s p u b ert y is r eac h e d, t h e
th y m u s be g in s t o d im i n is h i n rel at ive s iz e. B y ad u lt h oo d , it is u s u al ly rep la c ed b y ad ip o s e t is s u e a n d i s
of t en s c arc e ly r ec og n i z ab le ; h o w e ver , it c o n t in u es t o p ro d u c e T -l ym p h o c yt es .
Gr eat Vesse ls
T h e b ra c h io c ep h al ic vei n s are f orm ed po s t eri or t o t h e s t ern o c la vic u l ar ( S C) j oi n ts b y t h e u n io n of t h e
i n te rn al ju g u l ar a n d s u b c l avi an ve in s . A t th e l eve l o f t h e i n f eri or b o rd er o f th e
P .1 7 1
1 s t ri gh t c os t al c art il ag e , t h e b ra c h io c ep h al ic ve in s u n i te t o f o rm t h e S V C ( F ig s . 1 .5 5 B an d 1 .5 6 B ) . T h e
l e ft br a chi o ce pha l ic v ei n i s m or e th a n tw ic e a s lo n g a s th e r ig h t vei n b e c au s e i t p as s e s f r om t h e l ef t t o
t h e ri g h t s i de , p as s in g o ver t h e a n te rio r as p ec t s of t h e ro ot s of t h e t h ree m aj or b r an c h es o f t h e a rc h of
t h e a ort a ( F ig . 1 .5 5 B ) . It s h u n ts b l oo d f ro m t h e h ea d , n ec k, an d l ef t u p p er l im b t o t h e ri g h t a tr iu m .
Fi gu re 1 . 56 . R e la t i o nsh i ps o f st ru ct ur es o f su pe ri o r m ed ia st i nu m. A . A m ed ia n s ec ti on o f th e
t h ora x is s h o w n . B . A t ran s v ers e s e c ti on o f t h e s u p er io r m ed i as t in u m a t t h e l evel of t h e
s te rn o c lav ic u l ar j oi n t s i s s h ow n . Th e ord er of s ys t em i c st ru c t u re s i n th e s u pe rio r m e di as t in u m , f rom
an t er io r to p os t eri or , i s d em o n s tr at ed in b ot h vi ew s : t h ym u s , ve in s , ar te rie s , air w a y (t ra c h ea) ,

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al im e n ta ry t ra ct ( es o ph a g u s ), l ym p h a ti c d u c t s , ver te br al b o d ies / IV d is c s , a n d s p i n al c o rd .
T h e su pe ri o r ve n a ca va ret u rn s b lo od f ro m al l s t ru c tu r es s u p eri or t o t h e d i ap h rag m , e xc ep t th e lu n g s

a n d h e art . It pa s s es in f e rio rl y an d en d s at th e lev el o f th e 3 rd c os t al c a rt il ag e, w h ere i t e n te rs th e rig h t
a tr iu m o f t h e h e art . T h e S V C li es in t h e ri g h t s i de of t h e s u p eri or m e d ias t i n u m , an t ero la te ral to t h e
t ra c h ea a n d p o s te rol at era l t o t h e a s ce n d in g ao rt a. T h e ri gh t p h ren i c n erv e li es b et w ee n th e S V C a n d t h e
m e d ias t i n al p l eu ra . Th e ter m in a l h a lf of t h e S V C is i n th e m id d le m ed ia s ti n u m , w h e re i t l ies b es i d e t h e
a s c en d in g ao rt a an d f o rm s t h e p os t eri or b o u n d ary o f th e tra n s ver s e p eri c ard i al s i n u s (F i g . 1 .3 7 ) .
T h e a sce nd in g ao r t a, a pp r oxi m at el y 2 .5 c m i n d i am e te r, b eg in s a t t h e ao rt ic o rif i c e ( Ta b le 1 .5 ) . It s on l y
b ra n c h es ar e th e c oro n ar y art er ies , a ris i n g fr om t h e a ort ic s i n u s es ( di s c u s s ed u n d er S em i lu n a r
V a lve s , ear lie r in t h is c h a pt er ). T h e a s c en d in g ao rt a i s i n t rap er ic ar d ial ( Fi g . 1 .5 5 B ) ; f o r t h is rea s on
a n d b e ca u s e i t l ies i n f eri or t o t h e t ran s v ers e t h o rac i c pl an e , it is c on s i d ere d a co n t en t of th e m id d le
m e d ias t i n u m (p a rt o f th e in f eri o r m ed ia s ti n u m ) .
P .1 7 2
Fi gu re 1 . 57 . C o m m o n pa tt e rn o f b ra nch es o f a rc h o f ao r t a. T h e p at t ern s h o w n is p re s en t i n
ap p ro xim at el y 6 5 % of p eo p le. T h e l arg es t b ran c h ( b ra c h io ce p h al ic tr u n k) ari s es f ro m th e b e gi n n in g
of t h e ar c h an d di vi de s in t o t w o br an c h es ( ri g h t s u b c la via n art er y an d ri gh t c om m on c a rot i d a rt ery) .
T h e n ext ar te ry ( lef t c om m on c a rot id a rte ry) ar is es f ro m t h e s u p eri or p a rt o f th e a rc h . T h e t h ird
b ran c h ( le f t s u b c la vi an art er y) ari s es f ro m th e a rc h ap p ro xi m at el y 1 c m d is t al t o t h e l ef t c o m m o n
c a ro t id .
T h e a rc h o f th e a o rt a (a ort i c a rc h ) , th e c u rved c o n ti n u at io n of t h e as c e n di n g aor ta (F i g s . 1 .5 6 A an d

1 .5 7 ; T ab l e 1 .5 ) , b eg in s p os t er io r to th e 2 n d r ig h t s t er n oc o s ta l ( S C) j o in t at th e lev el o f th e s t er n al a n g le
a n d a rc h es s u p er io rly , p o s te ri orl y an d t o t h e le f t, a n d t h en i n f eri orl y. T h e ar c h of th e ao rt a as c en d s
a n te rio r t o t h e ri gh t p u lm on ar y ar ter y an d t h e b if u rc a ti on o f t h e t ra c h ea, r eac h i n g i t s a p ex a t t h e le f t
s i d e of t h e tr ac h ea an d es o p h ag u s as it p as s es o ver t h e r oo t o f t h e l ef t l u n g . Th e arc h d es c e n ds p o s te rio r
t o t h e ro ot o f t h e l u n g o n th e lef t s id e o f th e b o d y of t h e T 4 v ert eb ra . Th e arc h o f t h e a or ta e n d s b y
b ec o m i n g t h e t ho r a cic a o rt a p os t eri or t o th e 2 n d l ef t s t er n oc o s ta l j oi n t. T h e a rc h of t h e az y go s vei n
o c c u p ies a c o rre s p on d in g p os i t io n o n t h e rig h t s id e o f th e t ra c h ea o ver th e r oo t o f th e r ig h t l u n g ,
a lt h ou g h i ts c on ten t s ar e f lo w i n g i n th e op p os i te di rec t io n ( F ig . 1 .5 3 ) . T h e li ga m en t um a r te r io s um , th e
re m n an t o f f et a l d u c tu s a rte ri os u s , p as s es f ro m t h e ro ot of t h e le f t p u lm on a ry ar te ry t o t h e in f e rio r
s u rf a c e of t h e ar c h of t h e ao rt a. T h e u s u al br an c h es o f th e a rc h of t h e ao rt a a re t h e b rac h i oc e ph a li c
t ru n k, l ef t c o m m o n c aro t id art er y, an d le f t s u b c la vi an ar ter y ( F ig s . 1 .5 7 an d 1 .5 8 A ) .

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P .1 7 3
T h e br a chi o ce pha l ic t r un k, t h e f ir s t a n d l arg e s t b ra n ch o f th e arc h o f t h e a ort a, a ri se s po s t eri or t o t h e
m a n u b riu m , w h er e it is a n ter io r t o t h e tr ac h ea an d p os t eri or t o th e l ef t br ac h i oc ep h a li c v ein ( F ig s . 1 .5 5 B,
1 .5 6 A & B , an d 1 .5 8 A ) . It as c en d s s u p ero la te ral ly t o r eac h t h e ri g h t s i de of t h e tr ac h ea an d th e rig h t S C
j o in t , w h er e it d ivi d es in t o t h e ri g h t c o m m o n c aro ti d an d rig h t s u b c lav ia n a rt eri es .
Fi gu re 1 . 58 G re at ve sse l s an d ne rv es. A . Th e rel at io n s h ip s of t h e g rea t v es s el s a n d n erve s in t h e

in f e rio r n ec k a n d s u p e rio r m e di as t in u m a re s h o w n . T h e l ig am e n tu m art eri os u m i s th e rem n a n t o f th e
f et al s h u n t t h at by pa s s es t h e p ref u n c t io n al lu n g s (d u c t u s art er io s u s ). B . Th e r el at io n s h ip s at th e
b if u rc a ti on o f th e t ra c h ea f ro m s u p erf i c ia l t o d eep a re s h o w n . 1 ( m os t an t eri or ). T h e l ef t
b rac h i oc e ph a li c vei n pa s s es ac r os s t h e ro ot s of th e th r ee m a jo r b ra n c h es of t h e ar c h o f th e ao rta . 2 .

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T h e as c en d i n g a or ta an d arc h p as s a n te rio r an d s u p er io r, res p ec t i vel y, to t h e rig h t p u lm o n ar y art er y.

3 . T h e b if u rc a ti on o f t h e p u l m on a ry t ru n k a n d r ig h t p u l m on a ry a rt ery l ie d i rec t ly a n t eri or t o t h e
b if u rc a ti on o f th e t ra c h ea. 4 . T h e c a rd ia c p l exu s re m ai n s on t h e an t er io r as p ec t of t h e t rac h e al
b if u rc a ti on a f ter rem o va l of t h e p u lm on a ry t ru n k an d a rte rie s an d th e as c en d i n g a ort a a n d arc h o f
t h e ao rt a, t o w h i c h th e pl exu s i s pr im a ri ly re la te d. C . T h e n erv es in t h e s u p eri or an d p os t eri or
m ed i as t in a are s e en af t er t h e vi s c era th a t l ie a n te rio r t o t h e t rac h e a an d es o p h ag u s h ave b een
re m ov e d .
T h e l ef t co m m o n ca ro t i d ar t er y, t h e s ec o n d b ra n c h of t h e ar c h o f th e aor ta , ari s es p os t er io r to th e
m a n u b riu m , s li gh t ly po s t eri or a n d t o t h e l ef t of th e br ac h i oc ep h a li c t ru n k . It a s c en d s an t eri or t o t h e l ef t
s u b c la vi an ar te ry an d i s a t f i rs t a n te rio r t o t h e t rac h e a an d t h en t o it s le f t. It en t ers t h e n e ck by pa s s in g
p o s te rio r t o t h e le f t S C j oi n t.
T h e l ef t su bcl a vi an a r te ry , th e th i rd b ran c h o f t h e a rc h , ari s es f ro m th e po s t eri or p a rt o f th e a rc h o f
t h e a ort a, j u s t po s t eri or t o t h e l ef t c o m m o n c aro ti d art er y. It a s c en d s la te ral to th e tra c h ea a n d lef t
c o m m o n c aro ti d art ery th ro u g h th e s u pe rio r m e di as t in u m ; i t h a s n o b ran c h e s in t h e m ed i as t in u m . A s i t
l eav es t h e th o ra x an d en t ers t h e ro ot of t h e n ec k , it pa s s es p os t eri or to th e lef t S C jo in t .
An eu rys m of t he Ascen din g Aort a

Th e di s ta l p ar t o f t h e a s c en d in g ao rt a re c eiv es a s t ro n g t h ru s t of b lo od w h e n th e lef t ven t ri c le c o n tr ac t s .
B ec au s e i t s w al l i s n o t r ein f o rc ed b y f ib ro u s p eri c ard i u m ( th e f i b rou s p er ic ar di u m b le n d s w it h th e ao rti c
ad ven t i ti a at t h e b eg in n i n g o f th e arc h ; F ig . 1 .5 5 B ) , an a n e ur ys m ( lo c al iz e d d i la ti on ) m ay de vel op . T h e
an eu r ys m w i ll be evi d en t o n a c h es t f il m ( rad io g rap h o f t h e t h o rax) as a n en la rg ed as c e n di n g ao rta
s il h ou et t e. In d iv id u al s w i th a n a n eu ry s m u s u al ly c o m p la in o f c h e s t p ai n th a t ra d ia te s t o t h e b a c k.
F igu re B1 . 25
Variation s in t he Gr eat Art er ies

Branc hes of th e Ar ch of t he Aorta
Th e u su al p a tt ern o f br an c h es o f t h e a rc h of t h e ao rt a i s p re s en t in ap p ro xi m at el y 6 5 % of p eo p le ( F ig .
1 .5 7 ) . V ari at io n s in t h e or ig in o f th e b ra n c h es o f t h e a rc h of t h e ao rt a ar e f ai rly c o m m o n (F i g . B 1 .2 5 A ) .
In ap p rox im a te ly 2 7 % o f p eop l e, t h e le f t c o m m o n c a ro ti d o ri g in at es f ro m t h e b rac h i oc e ph a li c tru n k. A

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b ra c h io c ep h al ic t ru n k f ai ls t o f o rm in a p pr oxi m at el y 2 .5 % o f pe op l e; i n th e s e c as e s e ac h o f t h e f o u r
a rt eri es ( rig h t an d le ft c om m on c a rot i d a n d s u b c l avi an ar te rie s ) o ri gi n at e i n de p en d en t ly f ro m t h e ar c h o f
t h e a ort a. T h e l ef t v ert eb ra l ar te ry o rig i n at es f ro m th e a rc h o f t h e a ort a i n ap p rox im a te ly 5 % o f p eop l e.
B o th r ig h t a n d l ef t br ac h i oc ep h a li c t ru n k s o ri g in at e f ro m t h e ar c h i n ap p ro xim at ely 1 .2 % of p eo pl e. F o r a
d es c r ip t io n o f ot h er v ari at io n s in t h e or ig in s o f th e b ra n c h es o f t h e a rc h of t h e ao rt a, s ee B erg m a n e t a l.
(1988) .
A r et ro e so p ha gea l r i ght su bcl av ia n a rt e ry s o m et i m es ar is es a s th e l as t (m os t - lef t - s id ed ) br an c h o f
t h e a rc h of t h e ao rt a ( F ig . B 1 .2 5 B ) . Th e art er y c ros s e s po s t eri or t o t h e es o p h ag u s t o re ac h th e rig h t
u p p er l im b a n d m ay c o m p res s t h e es o ph ag u s , c au s i n g d i ff i c u lt y in s w al lo w in g ( d ys p h ag ia ) . A n a c c es s o ry
a rt ery t o t h e t h yro id g la n d , th e t h yr oi d i m a a rt er y ( L . art eri a t h yro id ea im a) , m ay a ris e fr om t h e a rc h
o f th e a or ta or t h e b ra ch i o ce p h al ic art er y.
An om al ies of th e Arch of t he Aorta

T h e m o s t s u p e rio r p art of t h e ar c h of th e ao rt a is u s u a lly ap p rox im a te ly 2 . 5 c m in f eri or to th e s u p e rio r
b o rd er o f t h e m a n u b riu m , bu t it m a y b e m o re s u p eri or o r i n fe ri or. S o m et im es th e arc h o f t h e a ort a
c u rv es ov er t h e ro ot of t h e ri g h t l u n g a n d p a s s es in f er io rly o n t h e rig h t s id e, f o rm i n g a ri gh t a rch o f t h e
a o rt a . In s om e c as es , t h e a bn o rm a l a rc h , af t er p as s i n g ove r th e roo t o f th e rig h t lu n g , p as s es p o s te rio r
t o t h e es o p h ag u s t o re ac h it s u s u al p o s it io n on t h e l ef t s i d e. Le s s fr eq u en t ly , a do u ble ar ch o f t he
a o rt a f orm s a vas c u l ar r in g aro u n d th e es op h a gu s a n d t ra c h ea ( F ig . B 1 .2 5 C ). A t ra ch e a t h at is
c o m p res s e d e n ou g h t o af f ec t b rea th i n g m ay r eq u ire s u rg ic a l d ivi s io n of t h e va s c u lar rin g . A n an e u rys m o f
t h e a rc h of t h e ao rt a m a y al so exe rt pr es s u re o n th e tr ac h ea an d es op h a g u s , ca u s in g d if f i c u lt y in
b re at h in g an d s w a ll ow in g ( s ee c l in ic a l c o rre lat i on [ b lu e] b ox A n e u rys m o f A s c e n di n g Ao rt a.)
Coarctati on of t he Aorta
In co a r ct at i o n o f th e a o rt a , th e arc h o f t h e a ort a o r d es c en di n g aor ta h as an a bn o rm a l n a rro w i n g
( s t en os i s ) t h a t d im in i sh es th e ca li b er o f t h e a ort i c l u m en , p ro d u c in g an o b s tr u ct i on t o b lo od f lo w t o t h e
i n f eri or p a rt o f th e b o d y ( Fi g . B 1 .2 6 ) . Th e m os t c om m on s i te f o r a c o arc t at i on is n e ar t h e s it e o f th e
d u c t u s or l ig am en t u m art er io s u m . W h e n t h e c o arc t at i on is i n f eri or t o t h i s s i te (p o s td u c t al c oar c ta ti on ) , a
g o od c ol la te ral c irc u l at io n u s u al ly d ev elo p s be tw een t h e p ro xi m al an d di s t al p a rts o f th e a or ta th ro u g h
t h e i n te rc os t al an d in t ern al t h or ac i c a rt eri es . T h is t yp e of c o arc t at i on is c o m p at ib l e w i th m a n y ye ars o f
l if e b ec a u s e t h e c ol la te ral c irc u l at io n c arr ies b l oo d t o t h e t h or ac i c a or ta i n f eri or to th e s t en o s is . T h e
c o ll at era l ve s s els m a y b ec o m e s o l ar ge th a t t h ey c a u s e n ot ab l e p u ls a ti on i n th e i n te rc o s ta l s p ac es a n d
e rod e t h e a dj a c en t s u r f ac es o f t h e ri b s , w h i c h i s vis i b le i n rad i og ra p h s o f th e th o rax .

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Fi gu re B 1. 2 6
P .1 7 4
P .1 7 5
Ner ves in the Superior M ediastinum

T h e vag u s n er ves ex it th e cr an i u m an d d es c en d t h rou g h t h e n ec k p o s te rol at er al t o t h e c o m m o n c aro ti d
ar te rie s ( F i g. 1 . 5 8 A ; T ab l e 1 .6 ) . E ac h n er ve en t er s t h e s u p er io r m ed i as t in u m p o s ter io r t o t h e res p ec t i ve
S C j oi n t a n d b ra c h io c ep h al ic ve in . T h e r igh t v ag us n er ve e n te rs th e th o rax an t eri or t o t h e r ig h t
s u b c la via n art ery , w h er e it g ive s ris e t o t h e r i ght re cur r en t l ar yn ge al ne rve ( F ig . 1 .5 8 A C ). T h is
n erv e h oo ks a rou n d t h e ri gh t s u b c la via n art ery an d as c en d s b et w e en th e tr ac h ea an d es o ph a g u s t o s u p p l y
t h e la ryn x. T h e r ig h t v ag u s n erv e ru n s p os t ero in f e rio rl y th r ou g h th e s u p eri or m e d ias t i n u m on t h e ri gh t
s id e o f th e t ra c h ea . I t t h en p as s e s p o s te rio r t o t h e
P .1 7 6
ri gh t b rac h i oc e p h ali c vei n , S V C, an d ro ot of t h e ri gh t lu n g . H e re i t d i vid es i n to m an y br an c h es , w h ic h
c on t ri b u te t o t h e r i ght pul m o na ry ple x us ( F ig . 1 .5 8 C ). U s u a ll y, th e rig h t vag u s n er ve l eav es th i s p lex u s
as a s i n g le n e rve a n d pa s s es t o t h e es o ph a g u s , w h er e it ag ai n b rea ks u p a n d c on t rib u t es f ib e rs to th e
es o pha ge a l ne rv e pl e xu s. T h e ri gh t va gu s n e rve a ls o gi ves r is e t o n e rves t h at c on t ri bu t e t o t h e c a rd ia c
p lex u s .
T h e le ft va gus n er ve d es c en d s in t h e n ec k p o s te rio r t o t h e le f t c o m m o n ca ro ti d a rt ery (F i g. 1 .5 8 A ). I t
en t ers t h e m e di as t in u m be tw een t h e l ef t c o m m o n c aro ti d art er y an d le ft s u b c la via n art er y. W h e n i t
rea c h es t h e le f t s id e of th e arc h o f t h e a or ta , th e n e rve d i ver ge s po s t eri orl y f ro m th e lef t p h ren i c n e rve .
It is s ep ar at ed la te ral ly f ro m t h e p h ren i c n erve b y th e l ef t s u pe ri or i n te rc os t al vei n . A s th e l ef t vag u s
n erv e c u rve s m ed ia ll y at th e in f er io r b ord er of t h e arc h o f th e a or ta , it gi ve s o f f th e l e ft r ec ur re nt
l ar yn gea l n er ve . T h is n erv e p as s es i n f eri or t o t h e a rc h of t h e ao rt a, i m m ed i at ely lat er al t o t h e
li g am e n tu m a rt eri os u m , a n d as c en d s to t h e la ryn x i n th e gr oo ve b et w e en th e tr ac h ea an d th e es op h a gu s
( F ig s . 1 .5 3 , 1 .5 5 B , 1 .5 8 A C, an d 1 .5 9 ) . T h e le f t va g u s n erve pa s s es p os t eri or to th e r oo t o f th e l ef t
lu n g , w h ere i t b re aks u p in t o m an y b ra n c h es t h at c o n t rib u t e t o t h e l eft pu lm o na r y pl ex us . T h e n e rve
le ave s th i s p l exu s a s a s in g le tr u n k an d p as s es t o t h e es o p h ag u s , w h e re i t j oi n s f ib ers f ro m t h e ri gh t
va gu s i n th e e s op h a ge al n e rve p l exu s ( F ig . 1 .5 8 B & C) .
T h e p h ren i c n erve s (F i g. 1 .5 8 A ) s u p p ly t h e d i ap h ra gm w it h m o to r an d s en s o ry f i be rs , t h e la tt er
ac c o u n ti n g fo r a pp ro xi m at el y on e th i rd of t h e n erv e's f i be rs . T h e p h ren i c n erve s als o s u p pl y s en s o ry
f ib er s t o th e p e ric a rd iu m a n d m ed ia s ti n al p l eu ra . E ac h n er ve en t er s t h e s u p er io r m ed i as t in u m b et w e en
t h e s u b cl av ia n a rt ery a n d th e o ri gi n of t h e b rac h i oc e p h ali c vei n (T a bl e 1 .6 ) . T h e f ac t th a t t h e p h re n ic
n erv es p as s an t er io r to th e roo t s o f th e lu n g s p rov id es an i m p or ta n t m e an s o f d i s ti n g u is h in g t h em f ro m
t h e vag u s n er ves , w h ic h p as s p os t eri or to th e roo ts . T h e r i ght phr e ni c ne rve p as s es a lo n g t h e ri g h t s i d e
of t h e ri g h t b ra c h io c ep h al ic vei n , S V C, an d p eri c ar di u m o ver t h e ri g h t a tri u m . It al s o p as s e s a n te rio r t o
t h e ro ot of t h e rig h t lu n g an d d es c e n ds o n th e r ig h t si d e o f t h e IV C t o t h e d ia p h rag m , w h ic h i t p ie rc es
n ea r th e c ava l o pe n in g ( F ig . 1 .6 0 A ) . Th e le ft phr en i c n er ve d es c en d s b et w ee n th e l ef t s u bc l av ian a n d
le f t c o m m o n c a ro ti d a rt eri es . It c ros s e s th e l ef t s u rf ac e o f th e a rc h of t h e ao rt a a n te rio r t o t h e le f t va g u s
n erv e an d p as s e s o ver th e l ef t s u pe ri or i n te rc os t al vei n . It t h en d es c e n d s a n te rio r t o t h e ro ot of t h e l ef t
lu n g an d ru n s a lo n g t h e f i br ou s p eri c ar di u m , s u p erf i c ia l t o t h e le f t a tri u m an d ve n tr ic le of t h e h ea rt,
w h e re i t p ie rc es t h e d ia ph r ag m t o t h e le f t o f t h e p er ic a rd iu m ( F ig . 1 .6 0 B ) . M os t b ran c h i n g of t h e p h ren i c
n erv es f or d i s tr ib u t io n t o t h e d i ap h ra gm o c c u rs o n t h e d i ap h rag m 's in f er io r ( ab d om i n al ) s u r fa c e.

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Fi gu re 1 . 59 . D e ep di ss ect i o n o f su per i o r m edi a st i num . F o u r s tr u c tu re s ru n p ara ll el a s th e y

t rave rs e t h e s u p eri or th o rac i c ap ert u re : t ra c h ea, e s op h ag u s , l ef t r ec u rre n t l ary n ge al n erve , an d
t h ora c ic d u c t. T h e r ig h t m ai n b ro n c h u s is m o re v ert ic a l, s h o rte r, an d w id er t h an t h e l ef t m ain
b ron c h u s . T h e c o u rs e o f th e r ig h t b r on c h i al a rt ery s h o w n h er e is a be rra n t; u s u al ly i t p a s s es p os t eri or
t o t h e b ron c h u s .
Trachea
T h e t ra c h ea d es c en d s an t er io r to th e es op h a g u s a n d e n te rs t h e s u p eri or m e d ias t i n u m , in c l in i n g a li tt le to
t h e ri g h t o f t h e m ed ia n p l an e ( F i gs . 1 .5 5 A & B an d 1 .5 8 B & C , an d 1 .5 9 ) . T h e p os t eri or su r f ac e o f t h e
t ra c h ea i s f l at w h er e it is a pp l ie d t o t h e es o p h ag u s ( F ig . 1 .5 6 B ) . T h e tr ac h ea en d s at th e l eve l o f t h e
s t ern a l a n gl e b y d iv id in g i n to th e r ig h t an d lef t m a in b ron c h i ( Fi g s . 1 .5 6 A an d 1 .5 9 ) . T h e tr ac h ea
t erm in a te s s u p e rio r t o t h e le vel of th e h ear t a n d i s n ot a c om p on en t of t h e p os t er io r m ed i as t in u m .
Inj ury to the Recurr en t Lary ngeal Nerves

Th e rec u rr en t l ar yn g eal n erv es s u p pl y al l i n tr in s ic m u sc l es o f t h e l ary n x, exc e p t o n e. Co n s eq u en t ly , a n y
in ve s ti g at ive (d i ag n os t ic ) p ro c ed u re ( e.g ., m ed ia s ti n ot om y) o r d is e as e p ro c es s in t h e s u p er io r
m ed ia s ti n u m m a y in j u re t h es e n erve s an d af f ec t th e voi c e. B ec a u s e t h e le ft re c u rren t la ryn g ea l n e rve
w in d s a rou n d t h e ar c h o f th e ao rta an d as c en ds b et w e en t h e tr ac h ea an d es o ph a g u s , it m ay b e i n vo lve d
in a b ro n c h og e n ic or es op h a ge al c a rc i n om a , en l arg em en t o f m ed ia s t in al lym p h n o d es , o r an an e u rys m o f
th e a rc h o f t h e a ort a. In t h e l at te r c on d i ti on , t h e n er ve m a y b e s t ret c h ed b y th e di la te d a rc h .
P .1 7 7
T a bl e 1. 5 . Ao r ta an d It s Br a nch es i n T ho r a x
Ar te r y
O r ig in
C o urs e
Br an c h es
A s c en d in g
A o rti c or if ic e of
A s c en d s a pp ro xi m at el y 5 c m
R i g h t a n d l ef t c oro n ar y
ao rta
l ef t v en t ric l e
t o s t er n al a n g le w h ere i t
a rt eri es
b ec o m es a rc h of a ort a
A rc h of ao rt a
Co n ti n u at io n of
A rc h e s po s t eri orl y o n l ef t
B ra c h io c ep h al ic , l ef t

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as c e n d in g ao rt a
Page 120 of 139
s i d e of t rac h e a an d
c o m m o n c aro ti d , lef t
e s op h ag u s an d s u p er io r to
s u b c la vi an
l ef t m ai n b r on c h u s
Th o ra c ic
Co n ti n u at io n of
D es c en d s i n p o s te rio r
P os t eri or in t erc o s ta l
ao rta
ar c h of ao rt a
m e d ia st i n u m to le ft o f
a rt eri es , s u b c os t al , s om e
v ert eb ra l c ol u m n ; g rad u al ly
p h re n ic ar te rie s an d
s h i f ts t o ri g h t t o l ie i n
v is c era l b ra n c h es ( e.g .,
m e d ia n p l an e a t a ort i c
e s op h ag ea l)
h i at u s
Po s te rio r
P os t eri or a s p ec t
P as s la te ral ly an d th e n
L at er al a n d a n te ri or
in t erc o s t al
o f t h o rac i c a or ta
a n te rio rl y p ara ll el t o r ib s
c u t an e ou s b ra n ch e s
B ro n ch ial
A n t eri or a s p ec t
R u n w it h th e
B ro n c h ia l a n d
( 1 2
o f a or ta or
t ra c h eob ro n c h ia l t ree
p er ib ro n c h ia l t is s u e,
b ran c h e s )
p os t e r io r
v is c era l p l eu ra
i n te rc os t al art er y
E s op h a ge a l
A n t eri or a s p ec t
( 4 5
R u n a n te rio rl y to es o p h ag u s
T o e s op h ag u s
T o d i ap h ra gm
b ran c h e s )
S u p er i or
A n t eri or a s p ec t s
A ri s e a t ao rt ic h i at u s an d
p h ren i c ( va ry
p a ss t o s u p e rio r as p ec t of
in n u m b e r)
d i ap h rag m
Es oph ag us
T h e e so p h ag us i s a f ib ro m u s c u la r t u be th a t ex te n d s f r om t h e p h ary n x t o t h e s to m a c h ( F i gs . 1 .5 6A & B ,
1 .5 8 B & C, 1 .5 9 , 1 . 6 0 A , an d 1 .6 1 ) . It e n te rs th e s u pe rio r m e di as t in u m b e tw een t h e t rac h e a an d t h e
ve rt eb ra l c ol u m n , w h e re i t l ies a n te rio r t o t h e b od i es of t h e T 1 T 4 ver teb r ae. It is u s u a ll y f lat t en ed
a n te rop o s te rio rl y. In i ti al ly, i t i n c li n es to t h e le ft b u t i s pu s h e d b a c k to th e m ed ia n p la n e b y th e arc h o f
t h e a ort a. It is t h en c o m p res s e d a n te rio rl y b y th e roo t o f th e lef t lu n g . In t h e s u p eri or m ed ia s ti n u m , t h e
t h or ac i c d u c t u s u al ly l ies o n th e lef t s id e o f t h e e s op h ag u s , d ee p ( m e di al ) t o t h e a rc h of t h e ao rt a ( F ig s .
1 .5 9 a n d 1 .6 0 B ). I n f eri or t o t h e a rc h , th e es op h a gu s a g ain i n c li n es t o t h e le ft as i t a pp r oa ch e s an d
p as s e s th ro u g h th e eso p ha ge al hi at u s in t h e d ia p h rag m ( F ig . 1 .6 1 ) .
The Bot tom Line

Th e su p e rio r m e di as t in u m e xt en d s be tw ee n t h e s u p er io r th o ra c ic ap er tu r e an d t h e tr an s ve rs e t h ora c ic
pl an e . Th e on l y org a n th a t b el on g s ex c lu s iv el y to th i s reg i on is t h e a du l t t h ym u s. T h e r em a in d er o f th e
s tru c t u re s tra ver s e th i s s p ac e, p as s i n g th ro u g h th e s u pe rio r t h or ac ic a pe rt u re t o t h e ro ot of t h e n ec k , or
pa s s in g b et w ee n th e n ec k an d a bd o m en . W it h in t h e s u p eri or m ed ia s ti n u m , s t ru c t u res o cc u r in s ys t em i c
lay ers , p ro c eed i n g f r om a n te rio r t o p os t er io r: ( 1 ) ly m p h oi d s y s te m (t h ym u s ) , ( 2 ) bl oo d vas c u l ar s ys t em
(v ein s f i rs t, t h en a rt eri es ) , (3 ) re s pi ra to ry s ys t em ( t rac h e a) , ( 4 ) a li m en t ary s ys te m ( es op h a gu s) , a n d ( 5 )
lym ph v as c u la r s ys t em ( th ora c ic d u c t, b ro n c h o m ed ia s ti n al tr u n ks , p os t eri or m ed ia s ti n al l ym p h n o de s ) .
Th e n ervo u s s ys t em d oe s n ot h ave i t s o w n l aye r in t h e s u p eri or m ed ia s ti n u m , b u t i t i s in t eg ra te d w it h
lay er 2 ( p h ren i c an d vag u s n er ves ) an d li es b et w e en la yers 3 a n d 4 ( re c u rren t la ryn g e al n e rves ) . T h e
pa tt er n of t h e b ran c h e s o f th e arc h o f t h e a ort a i s at yp ic a l in a p pr oxi m a tel y 3 5 % o f p e op le .
P osterior M ed iastinum
T h e po s te r io r m e di as ti n um (t h e p o s te rio r p art of t h e i n fe rio r m e d ias t in u m ) i s lo c at ed in f er io r to th e
t ra n s vers e th o rac i c pl an e , an t eri or t o t h e T 5 T 1 2 ve rt eb rae , p os t eri or t o t h e p er ic a rd iu m a n d
d i ap h rag m , a n d be tw een t h e p ar iet a l p leu r a o f t h e t w o lu n g s ( Fi g s . 1 .5 6 A an d 1 .5 8 C ) . T h e p os t er io r

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m e d ias t i n u m c on t ai n s th e t h o rac i c aor ta , th o ra c ic d u c t a n d l ym p h a ti c t ru n k s , po s t eri or m e d ia st i n al l ym p h

n o d es , az y go s an d h em i az y go s vei n s , an d es o p h ag u s an d es o ph a g eal n erv e p lex u s . S om e au t h ors a ls o
i n c lu d e t h e t h ora c ic s ym pa th e ti c tr u n ks an d t h ora c ic s p la n c h n ic n er ves ; h ow eve r, th e s e s t ru c tu r es li e
l at era l t o t h e ve rt eb ral bo d ie s a n d are n o t w it h i n t h e p o s te rio r m ed i as t in a l c o m p art m en t or s pa c e p er s e .
Thorac ic Aorta
T h e t h or ac ic a ort a i s th e c on t in u a ti on o f t h e a rc h of t h e ao rt a ( F ig s . 1 .5 8 C , 1 .5 9 , 1 .6 0 B , 1 .6 1 , a n d 1 .6 2 ;
T ab l e 1 .5 ) . It b e gi n s on t h e l ef t s i de of t h e in f e rio r b ord e r of t h e b od y o f th e T 4 ve rte b ra a n d d es c e n d s i n
t h e p os t er io r m ed i as t in u m o n th e l ef t s id es o f t h e T 5 T 1 2 ve rte b rae . A s i t d e sc e n d s , it ap p roa c h es t h e
m e d ian p l an e a n d d i s p lac e s th e e s op h ag u s t o t h e ri g h t. T h e t ho r a cic a o rt i c pl ex us (F i g . 1 .6 0 B ) , an
a u to n om ic n erv e n et w o rk, s u r rou n d s it . T h e t h ora c ic a ort a l ie s p o s te rio r t o t h e ro ot of t h e le f t l u n g ( F i gs .
1 .5 9 a n d 1 .6 0 B ), p e ric a rd iu m , a n d es op h a gu s . T h e t h o rac i c a or ta te rm in at es (w it h a n a m e c h an g e t o
a bd o m i n al a ort a) a n te rio r t o t h e in f e rio r b or de r of t h e T 1 2 vert eb ra an d en t ers t h e a bd o m en t h ro u gh t h e
a o rt i c hi a tu s in t h e d ia p h rag m ( F ig . 1 .6 1 ). T h e t h or ac ic d u c t an d az yg o s vei n as c en d on i ts r ig h t s i d e
a n d a c c om p a n y it th r ou g h t h is h ia tu s .
In a pa tt er n th a t w ill b e m o re ev id en t in t h e ab d o m en , t h e b ran c h e s of t h e d es c en d in g a ort a a ris e an d
c o u rs e w it h in t h ree v as c u la r p la n es (F i g . 1 .6 2A ) :
P .1 7 8

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Fi gu re 1 . 60 L at e ra l e xp o sur es o f t he m edi a st in um . A. I n t h i s r ig h t s i d e vi ew , m os t of th e c os t al
an d m e di as t in a l p le u ra h a s be en rem ove d t o exp os e th e u n de rly in g s tr u c tu r es . T h is s id e o f th e
m ed i as t in u m , t h e b lu e s id e, i s d o m in a t ed by ven o u s s t ru c t u re s: t h e az y g os vei n an d ar c h ,
S V C, ri gh t at ri u m , an d IV C. B . Th e lef t s id e o f t h e m ed ia s ti n u m , t h e red s id e, i s do m i n at ed b y
ar te ria l s t ru c tu r es : th e a rc h o f a ort a a n d th o rac i c ao rt a, le f t c o m m o n c a ro ti d a n d su bc l avi an a rt eri es ,
an d le f t ve n tr ic l e ( pl u s th e pu l m o n ary t ru n k a n d lef t p u lm o n ary art ery ). A t t h e th o ra c ic an d s u p eri or
lu m ba r le vel s , th e s ym p at h et ic t ru n k i s at ta c h ed to in t erc o s t al n e rves b y p ai re d ( w h i te an d g ray )
ra m i c o m m u n ic a n t es . Th e le ft s u p eri or i n t erc o s ta l ve in , d rai n in g t h e u p p er t w o to th r ee i n te rc os t al
s p ac es , p a s se s an t eri or ly t o e n te r th e l ef t b rac h i oc ep h a li c v ei n .
A n an t eri or , m id l in e p l an e o f u n pa ir ed vis c e ral br an c h es t o t h e g u t a n d it s de riv at ive s .

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L at era l p la n es of p ai red vi s c era l b ra n c h es s erv in g vis c e ra o th e r t h an t h e g u t an d i ts d er iva ti ves .
Po s t ero la te ral pl an e s o f p air ed , s eg m en t a l, p ari et al b ran c h es t o t h e b o dy w al l.
In t h e t h or ax, t h e u n p ai red vi s c era l b ra n c h es of t h e an t eri or vas c u l ar p l an e a re t h e es o pha ge al

a rt e ri e s u s u a ll y tw o, b u t as m an y as f ive (F i g . 1 .6 2 B an d T ab le 1 . 5 ). T h e p a ire d v is c era l b ra n c h es of
t h e l at era l p la n e ar e rep re s en t ed in t h e t h ora x b y th e b ron c h i al art eri es ( F ig . 1 .5 9 ) . A lt h o u gh t h e ri g h t
a n d l ef t br on c h i al a rt eri es m a y ari s e d ir ec tl y f ro m th e ao rta , m o s t c o m m o n ly o n ly t h e p ai red l ef t
b ro n c h ia l ar te rie s do s o, t h e ri g h t a ris i n g in d ir ec tl y as b ra n c h es of a rig h t po s t eri or i n te rc os t al ar ter y
( u s u al ly t h e 3 r d) . T h e p ai red , p ar iet a l b ran c h e s o f th e th o rac i c ao rt a t h at a ri s e p os t ero la te ral ly a re t h e
n i n e p os t eri or in t erc o s ta l a rte ri es th a t s u p p ly all b u t t h e u p p er t w o in t erc o s ta l s p ac e s a n d th e s u b c o s ta l
a rt eri es ( Fi g . 1 .6 2 B ) . Th e lat t er ve s s el s a ri se f rom t h e t h or ac i c a or ta bu t c ou r s e b elo w t h e d ia p h rag m .
T h ey a re i n s eri es w i th t h e p os t er io r in t erc o s t al a rt eri es .
E xc e p ti on s t o t h is p at t ern i n c lu d e t h e:
Su pe ri o r ph re ni c a rt er i es , pa ir ed pa rie ta l b ra n c h es t h at p a s s a n t ero la te ral ly t o t h e s u p er io r

s u rf ac e of t h e d ia ph r ag m ( w h i c h i s ac t u al ly f a ci n g po s t eri orl y at t h is le vel ow in g to th e c on ve xi ty o f
t h e d ia ph r ag m ) , w h e re t h ey
P .1 7 9
an a s to m o s e w i th t h e m u s c u l op h re n ic an d p er ic ar di ac o p h ren i c br an c h es o f t h e i n te rn al th o ra c ic
ar te ry .
P er i car di a l br an che s, u n p a ire d b ra n c h es t h at ari s e an t eri o rly b u t , in s t ea d o f pa s s in g t o t h e g u t,

s en d t w ig s t o t h e p eri c ar di u m . T h e s am e is t ru e f o r th e s m al l m ed ia st i na l a rt e ri es th a t s u p p ly t h e
ly m p h n od es a n d o th e r t is s u es o f t h e p o s te rio r m ed i as t in u m .
Es oph ag us
T h e es o p h ag u s d es c en d s in t o th e p o s te rio r m e di as t in u m f r om t h e s u p eri or m ed ia s ti n u m , p as s i n g p o s te rio r
a n d t o t h e r ig h t o f th e a rc h o f t h e a ort a ( F ig s . 1 .5 8 C , 1 .5 9 , an d 1 .6 1 ) an d p os t er io r to th e pe ric a rd iu m
a n d l ef t at riu m . Th e e s op h a gu s c o n s ti tu t es t h e p ri m ar y po s t eri or r ela ti on s h i p of t h e b as e o f t h e h e art . It
t h en d ev iat es t o t h e l ef t a n d p a s s es th r ou g h t h e es o ph a g eal h ia tu s i n th e d i ap h ra gm a t t h e l eve l o f t h e
T 1 0 ve rte b ra, a n te rio r t o t h e ao rt a. T h e es o p h ag u s m ay h ave t h re e im pr es s io n s , or c o n s tr ic t io n s ,
i n it s th o rac i c p art . Th es e m a y b e ob s er ved as n a rro w i n gs o f t h e l u m en i n ob li q u e c h es t rad i og ra p h s t h at
a re t ake n as b ari u m is s w all o w ed . T h e es o p h ag u s is c om p res s ed b y t h ree s t ru c t u res : ( 1 ) t h e a rc h of t h e
a ort a , ( 2 ) t h e le ft m a in b ro n c h u s, a n d (3 ) t h e d ia ph r ag m . T h e f ir s t t w o oc c u r i n c l os e pr oxi m i ty ; t h e
f o rm er is m o s t ev id en t in a p o s te ro an t eri or ( P A) ra d io gr ap h af t er a b a riu m sw al lo w , a n d t h e l at te r is
m o re e vid e n t i n lat er al v iew s . N o c o n s tr ic t io n s are v is i bl e i n t h e e m p ty e s op h a gu s ; h o w eve r, as i t
e xp an d s d u rin g f il li n g , th e s t ru c t u res n o t ed ab ov e c om p r es s it s w al ls .
P .1 8 0
Blockage of th e Esop hagus

Th e im p re s s io n s p ro d u c ed in t h e es o p h ag u s b y ad j ac en t s t ru c tu r es are of c li n ic a l i n te res t be c au s e o f th e
s lo w er p a s s ag e o f s u b s t an c es a t t h es e s i te s . Th e im p re s s io n s i n d ic a te w h ere s w al lo w e d f o rei g n o b j ec t s
are m os t li kel y to lo d g e an d w h e re a s t ri c tu r e m ay d e vel op af t er t h e a c c id en t al dr in ki n g of a c au s t i c
li qu i d s u ch a s lye .
Thorac ic Duc t and Lym phat ic Trunks

In t h e p os t er io r m ed i as t in u m , t h e t h or ac ic d u c t li es on t h e an t er io r as p ec t of t h e b od i es of t h e in f e rio r 7
t h or ac i c v ert eb ra e ( F ig . 1 .6 3 ) . It i s th e la rg es t l ym p h a ti c c h an n el in t h e b od y. T h e t h or ac ic d u c t c on ve ys
m o s t l ym p h o f t h e b o dy to th e v en o u s s y s te m , th a t f r om t h e lo w e r li m b s ; p e lvi c c avi ty ; a bd o m in a l c a vit y;
l ef t u p p er lim b ; a n d l ef t s i d e of t h e t h or ax, h ea d , an d n ec k th a t i s , al l b u t t h e ri g h t s u p er io r q u ad ran t
( s ee I n tr od u c t io n ). T h e t h or ac ic d u c t ori g in a te s f r om t h e ch yl e ci st er n ( L . c is t ern a c h yli ) i n th e ab d om e n
a n d a s c en d s th r ou g h t h e ao rt ic h ia tu s i n th e d i ap h ra g m (F i g . 1 .6 1 ) . Th e t h o rac i c du c t is u s u a ll y th i n
w al led an d d u ll w h i te ; o f te n it is b ead e d b ec a u s e of i ts n u m e ro u s v al ves . It as c en d s i n t h e p o s te rio r
m e d ias t i n u m am o n g th e t h o rac i c aor ta on i ts l ef t, t h e a z yg os ve in o n i t s r ig h t , th e e s op h a gu s a n te rio rl y,
a n d t h e ve rt eb ra l b od i es p os t eri orl y. A t th e l ev el o f th e T 4 , T 5 , or T 6 ve rt eb ra, t h e t h or ac i c d u c t c ros s e s
t o t h e l ef t, p o s te rio r t o t h e
P .1 8 1

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e s op h ag u s , a n d a s c en d s in t o t h e s u p eri or m ed ia s ti n u m . T h e t h ora c ic d u c t r ec ei ves b ra n c h es f rom t h e

m i d d le a n d s u p er io r in t er c os t al s p a c es of b ot h s id e s t h ro u g h se ver al c o ll ec t in g t ru n ks . It al s o re c eiv es
b ra n c h es f ro m po s t eri or m e d ia s ti n al s t ru c t u res . N e ar i ts t er m in a ti on , i t o f te n rec ei ves t h e j u g u la r ,
s u b c la vi an , an d b ro n c h om e d ias t i n al l ym p h at i c t ru n k s ( a lt h ou g h an y o r a ll t h es e v es s el s m ay t er m in a te
i n d ep en d en t ly ). T h e t h or ac ic d u c t u s u al ly em pt i es in t o t h e ve n ou s s ys t em n e ar t h e u n i on o f t h e l ef t
i n te rn al ju g u l ar a n d s u b c l avi an ve in s t h e l ef t v en o u s a n g le o r o rig i n o f th e lef t b rac h i oc e ph a li c vei n
( F ig s . 1 .6 2 a n d 1 . 6 3 A ) bu t it m a y op en i n to t h e le ft s u b c la via n vei n as s h ow n in F ig u re 1 .6 1 .
Fi gu re 1 . 61 A n te ri o r v ie w o f es o pha gu s, tr a che a , br o nc hi , an d ao r t a. T h e ar c h of ao rt a c u rve s

p os t eri or ly o n th e lef t s id e o f t h e t ra c h ea a n d e s op h ag u s . E n l arg e m en t of t h e in f er io r
t rac h eo b ro n c h ial ( c ari n al ) n o d es m ay w id en t h e a n gl e b et w e en t h e m ai n p rim a ry b ro n c h i. In t h is
s p ec im en , t h e th o ra c ic d u c t e n te rs th e l ef t s u bc l av ian v ein .

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Fi gu re 1 . 62 B ra nc he s o f t h o ra ci c ao r t a. In a pa tt er n th a t w i ll b e m o re o bv io u s a n d s tri c t ly
ad h er ed to in t h e ab d o m en , b ra n c h es of t h e t h ora c ic ao rt a t en d to ar is e w it h in t h ree v as c u l ar p la n es
( in s et ) . E s op h ag e al a n d pe ric a rd ia l b ra n c h es rep re s en t u n pa ire d vis c er al br an c h es ( A in in se t)
ar is in g a n te rio rl y; t h e b ro n c h ia l ar te rie s rep re s en t p a ire d l at era l vi s c era l b ra n c h es ( B i n in s e t) ;
p os t eri or in t erc o s ta l a n d s u b c o st a l ar te rie s ( 1 1 2 ) r ep res e n t p ai red , s eg m e n ta l p ar iet a l b ran c h e s
t h at m os t ly a ri s e p os t ero la te ral ly ( C i n in s et ) . Th e pa ir ed s u pe rio r p h re n ic art er ie s a ris i n g f rom t h e
in f e rio r p art of t h e t h or ac ic a ort a t h at s u p p ly t h e d ia p h rag m a re ex c ep ti on s t o t h e p at t ern .

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Fi gu re 1 . 63 . T h o ra ci c duc t a nd br o nc ho m ed ia st i na l t ru nk s. A . Th e th o rac i c ao rt a h as b ee n
p u ll ed s li gh t l y to th e lef t an d t h e az yg o s vei n s li gh t ly to th e rig h t to exp o s e th e th o rac i c d u c t, w h ic h
as c e n ds o n th e v ert eb ra l c o lu m n b et w e en t h e az yg o s vei n an d th e th o rac i c ao rt a. A t a p pr ox im a te ly
t h e tr an s ve rs e t h ora c ic p la n e ( s te rn al an g le , T4 T 5 I V d i s c lev el) , t h e t h ora c ic d u c t p a s s es to th e
le f t an d c o n ti n u es it s as c e n t t o t h e n ec k w h ere it arc h e s l at er all y t o o pe n n ear , or a t, t h e a n gl e o f
u n io n of t h e in t er n al j u g u la r an d s u b c la via n vei n s (l ef t ven o u s an g le ). T h e t h or ac i c d u c t rec e ive s
b ran c h e s fr om t h e i n te rc os t al s pa c es o f b o th s i de s th r ou g h s eve ral c ol lec t in g t ru n ks a n d b ra n c h es
f ro m po s t eri or m e d ia st i n al s t ru c t u res . N e ar i ts t er m in a ti on , t h e t h or ac ic d u c t rec ei ves t h e j u g u la r,
s u b c la via n , an d b ron c h o m ed i as t in a l t ru n ks . T h e ri g h t l ym p h at ic d u c t is f or m ed b y th e u n io n o f th e
ri gh t j u g u lar , s u bc l av ian , a n d br on c h o m ed ia s t in al tr u n ks . B . L ym p h n od e s a n d pa th w ay s p ro vi d in g
ly m p h at ic d rai n ag e o f th e th o rac i c c avi ty are s h o w n .
Laceration of th e Thoracic Du ct
B ec au s e t h e t h o rac i c d u c t is t h in w a ll ed an d m a y b e c ol or les s , i t m a y b e d if f i cu l t t o id en t if y.
Con s e qu e n tl y, i t i s v u ln e rab le to in a dv ert en t in j u ry d u ri n g in ve s ti g at ive an d / or s u rg i c al pr oc ed u re s in t h e
po s t eri or m e d ia st i n u m . La c era ti on o f th e t h o rac i c du c t d u rin g a n a c c id en t o r lu n g s u rg ery res u l ts i n
lym ph e s c ap in g in t o t h e t h o rac i c c a vi ty a t r at es ran g i n g f r om 7 5 t o 2 0 0 m L p er h o u r. L ym p h or c h y le
fr om t h e l ac t eal s of t h e in t es t in e (s e e Ch a pt er 2 ) m a y al s o en t er th e p l eu ra l c av it y, p ro du c i n g
c h y lo th o ra x . T h is f lu i d m ay b e re m o ved b y a n ee d le t ap o r by th o rac e n te s is ; in s o m e c as e s it m ay b e
n ec es s a ry t o li g at e t h e t h ora c ic d u c t. T h e l ym p h t h en ret u rn s t o t h e ve n ou s s ys t em b y o th e r ly m p h at ic
c h an n el s th a t j o in t h e th o ra c ic d u c t s u p er io r to th e li ga tu r e.
Variation s of t he Thor acic Du ct

V ari at io n s of t h e th o ra c ic d u c t a re c o m m on b e ca u s e t h e s u p eri or p a rt o f th e du c t rep r es en t s th e ori g in al
lef t m em be r of a p a ir o f ves s el s in t h e em b ry o ( M oo re a n d P ers a u d , 2 0 0 3 ) . So m e ti m es t w o t h o rac i c du c t s
are p r es en t f or a sh o rt d is t an c e.
P .1 8 2

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Fi gu re 1 . 64 . A zy go s sy st em o f vei n s. T h e az yg o s vei n fo rm s a di rec t c on n e c ti on b et w e en t h e

in f e rio r ve n a c ava (I V C) a n d t h e s u p er io r ven a c ava (S V C) . T h e az yg os an d h em ia z yg os ve in s ar e
al s o c o n ti n u ou s i n f eri orl y ( b elo w d ia p h rag m ) w i th t h e a s c en d in g lu m ba r ve in s .
Ve ssels and Lymp h N odes of the Posterior M ediastinum

T h e t h or ac ic a ort a a n d it s b r an c h es w ere d i s c u ss e d e arl ie r in t h is c h a pt er . Po s te r io r m e di as ti n al ly mp h
n o d es (F i g . 1 .6 3 A & B ) li e p os t er io r to th e pe ric a rd iu m , w h er e th e y ar e rel at ed t o t h e es o ph a g u s an d
t h or ac i c a or ta . Th e re a re s ev eral n od e s p o s te rio r t o t h e in f e rio r p ar t o f t h e es o p h ag u s an d m o re ( u p to
e ig h t ) a n te rio r an d l at era l t o it . T h e p os t er io r m ed ia s ti n al lym p h n o d es rec e iv e lym ph f ro m t h e
e s op h ag u s , t h e p os t eri or as p ec t of t h e p eri c ard i u m an d d iap h r ag m , an d t h e m i dd l e p os t er io r in t erc o s ta l
s p ac e s . Th e y d rai n to th e rig h t or l ef t ven o u s an g le s v ia t h e r ig h t l ym p h a ti c d u c t or t h e t h or ac i c d u c t .
T h e a zyg o s sys te m o f v ei ns , on ea c h s id e o f t h e ve rt eb ral c ol u m n , d rai n s th e ba c k an d
t h or ac o ab d om i n al w al ls ( F ig s . 1 .6 3 A a n d 1 . 6 4 A & B ) as w e ll a s th e m ed ia s ti n al vis c e ra. T h e a z yg os
s ys t em e xh i bi ts m u c h v ari at io n in i ts o rig i n , c ou rs e , tri b u ta ri es , an d an a s to m o s es . T h e az y go s vei n (G .,
a z yg os , u n p ai re d) an d i ts
P .1 8 3
P .1 8 4
m a in t ri bu t ar y, t h e h em i az y go s vei n , u s u al ly a ris e f r om ro ot s ari s in g f ro m th e p os t eri or a s p ec t o f
t h e IV C a n d /o r ren a l v ein , r es p ec t ive ly, w h ic h m e rg e w i th t h e a sc e n d in g lu m b a r vei n s .
T a bl e 1. 6 . N e rv es o f T h o ra x
N er ve
O r i g in
C o ur se
Di s t ri b u t io n
V ag u s ( CN
8 1 0 roo t let s
E n t er s s u p er io r
P u lm o n ary pl ex u s,
X)
f ro m m e du l la of
m ed ia s ti n u m p os t eri or t o
es o p h ag ea l, p l exu s , an d
b r a in s t e m
s t ern o c la vi c u lar jo in t an d
c a rd iac p l exu s
b ra c h io c ep h al ic ve in ; g ive s

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r is e t o re c u rre n t l ary n ge al
n e rve; c o n ti n u es in t o
a b do m en
Ph re n ic
A n t er io r ram i of
P as s es t h ro u g h s u p e rio r
Ce n tr al p o rt io n o f
C 3 C5 n er ves
t h or ac i c a p ert u re a n d r u n s
d ia p h rag m
b et w e en m e di as t in a l p le u ra
a n d p e ric a rd iu m
In t erc o s ta ls
A n t er io r ram i of
R u n i n in t erc o s t al s p ac e s
M u s c le s in an d s ki n ove r
( 1 1 1 )
T 1 T 1 1
b et w e en i n ter n al an d
i n te rc os t al s pa c e; lo w e r
n e rve s
i n n erm os t lay ers o f
n er ves s u p p ly m u s c les a n d
i n te rc o st a l m u s c le s
s ki n of an t er ol at era l
a bd o m in a l w all
S u b co s t a l
A n t er io r ram u s
F o ll ow s i n f eri or bo rd er o f
A b d om i n al w a ll a n d s k in o f
o f T1 2 n e rve
1 2 t h ri b a n d p a s s es in t o
g lu t ea l re g io n
a b do m i n al w al l
R e c u r r en t
V a g u s n e rve
la ryn g ea l
L oo p s aro u n d s u bc l avi an o n
In t ri n s ic m u s c l es of la ryn x
r ig h t ; o n lef t ru n s ar ou n d
( exc e p t c ri c ot h yro id ) ;
a rc h of a ort a a n d a s c en d s in
s en s o ry i n f eri or t o l eve l o f
t ra c h eoe s op h a ge al g r oo ve
vo c al f ol ds
Car di ac
C ervi c al an d
F ro m a rc h of ao rt a an d
Im p u l s es p as s t o s in u a t ria l
p lex u s
c a rd ia c
p o s te rio r s u rf ac e of h ea rt ,
n o d e; p a ras y m p at h et ic
b ra n c h es o f
f i be rs ext en d a lo n g
f ib e rs s lo w ra te , red u c e
v ag u s n erv e
c o ro n ary a rt eri es an d t o
f o rc e of h e art b eat , an d
and
s i n u at ri al n o d e
c o n s tr ic t c o ro n ary art eri es ;
s y m p at h et ic
s ym pa th e ti c f ib ers h a ve t h e
t ru n k
o pp o s it e ef f e c t
Pu l m on a r y
V a g u s n e rve
F o rm s o n r oo t o f lu n g an d
P ara s ym p at h et ic f i be rs
p lex u s
and
e xt en d s alo n g br on c h i al
c o n s tr ic t b r on c h i ol es ;
s y m p at h et ic
s u b d iv is i on s
s ym pa th e ti c f ib ers d i la te
t ru n k
t h em ; af f er en t s co n ve y
re f lex es
E s op h a ge a l
V a g u s n e rve ,
D is t al to tr ac h ea l
V ag a l an d s ym pa t h eti c
p lex u s
s y m p at h et ic
b i fu r c at io n ; v ag u s an d
f ib e rs to s m oo t h m u s c le
g a n gl ia , g rea te r
s y m p at h et ic n erv es f or m a
a n d g l an d s of in f e rio r t w o
s p l an c h n ic
p l exu s ar ou n d es o p h ag u s
t h ir ds o f e s op h a gu s
n e r ve

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Fi gu re 1 . 65 . A u to n o m ic n er ve s o f s upe r io r a n d p o st er i o r me di a st in a . T h e c e rvi c ot h or ac ic
( s te lla t e) ga n g li on is f o rm ed b y t h e f u s io n of t h e in f e rio r c erv ic a l g an g li on a n d t h e f i rs t t h o rac i c
g an g li on . T h e s e c on d g an g li on i s of t en la rg er t h an t h e ad j ac e n t g a n gl ia .
Al ternate V en ous Rou tes t o th e Heart

Th e az yg o s , h em i az yg o s , an d ac c es s o ry h e m ia z yg os ve in s o ff e r al te rn at e m e an s of ve n ou s d ra in a ge fr om
th e t h o rac i c , ab d om i n al , an d b ac k r eg io n s w h en o b st ru c t io n of t h e IV C o c c u rs . In s om e p eop l e, an
ac c es s o ry a z yg os ve in p ara ll el s t h e a z yg os ve in o n th e r ig h t si d e. O t h er p eo p le h a ve n o h e m ia z yg o s
s ys te m of ve in s . A c li n ic a ll y im p o rt an t var iat i on , a lt h ou g h u n c om m on , i s w h en t h e a z yg os s ys t em
rec ei ve s a ll th e b l oo d fr om t h e IV C e xc ep t t h a t f ro m th e li ver. I n t h es e pe op l e, t h e az yg o s s ys te m d rai n s
n ear ly a ll t h e b l oo d i n f eri or t o t h e d i ap h ra gm , exc ep t f rom th e d i ge s ti ve t ra c t. If o bs t ru c t io n of t h e S V C
oc c u rs s u p er io r to th e en t ran c e o f th e az yg o s v ei n , b l oo d c an d rai n in f er io rly i n t o t h e vei n s of t h e
ab d om i n al w al l a n d r et u rn to th e rig h t at ri u m th r ou g h th e az yg o s ven o u s sy s te m an d t h e IV C.
T h e a zyg o s ve in fo rm s a c ol lat er al p a th w ay b et w e en t h e S V C an d IV C an d d ra in s b lo od f ro m th e
p o s te rio r w a ll s of th e th o ra x an d ab d om en . It as c en d s in t h e p os t er io r m ed i as t in u m , p a ss i n g c lo s e to th e
ri g h t s i d es of t h e b od i es of t h e in f e rio r 8 th o ra c ic ve rte b rae . It a rc h es o ver t h e s u p eri or as p ec t of t h e
ro o t o f t h e ri g h t l u n g t o jo in t h e S V C, s i m il ar t o t h e w ay t h e ar c h o f th e ao rta p as s es o ver t h e ro ot of t h e
l ef t l u n g . In ad d it io n to t h e p os t eri or i n t erc o s ta l ve in s , t h e az y go s vei n c om m u n ic at es w it h th e v ert eb ra l
ve n ou s p l exu s es t h at d rai n th e ba c k, ve rte b rae , an d s tr u ct u re s in t h e ver te br al c a n al (s e e Ch ap t er 4 ) .
T h e a z yg os ve in al s o r ec ei ves t h e m ed i as t in a l, es o p h ag ea l, a n d b ro n c h ia l ve in s .
T h e h em i az ygo s v ei n a ris e s o n th e lef t s id e b y t h e j u n c ti on o f th e lef t s u b co s t al a n d as c en d in g l u m b ar
ve in s . It as c e n ds o n th e lef t s id e o f t h e v ert eb ra l c ol u m n , p os t er io r to t h e th o ra c ic ao rt a as f a r as t h e T9
ve rt eb ra . H ere i t c r os s es t o t h e ri g h t, p o s te rio r t o t h e ao rt a, t h or ac ic d u c t , an d es o p h ag u s , an d j oi n s t h e
a z yg os ve in . T h e h em ia z yg os ve in re c eiv es th e in f er io r th r ee p os t er io r in t erc o s t al v ein s , t h e i n f eri or
e s op h ag ea l ve in s , a n d s e vera l s m a ll m ed ia s ti n al vei n s .
T h e a cce sso r y he m ia zy go s ve i n b eg in s a t t h e m ed i al en d of t h e 4 th o r 5 t h in t erc o s ta l s p ac e a n d

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d es c e n ds o n th e lef t s id e o f th e v ert eb ra l c o lu m n f ro m T 5 t h ro u g h T8 . I t re c eiv es tr ib u t ari es f ro m vei n s in

t h e 4 t h 8 t h in t erc o s t al s p ac e s an d s om e ti m es f ro m t h e le f t b ro n c h ia l vei n s . It cr os s e s o ver th e T 7 o r
T 8 ver te b ra, p o st er io r to t h e th o ra c ic ao rt a an d t h or ac ic d u c t , w h er e it j oi n s t h e a z yg os ve in . S o m et im es
t h e a cc e s s ory h em i az yg o s vei n j o in s t h e h em i az y go s vei n an d op e n s w it h it in t o t h e a z yg os ve in . T h e
a c c es s or y h em i az yg o s is f req u e n tl y c on n e c te d t o t h e l ef t s u p e rio r in t er c os t al vei n , as s h ow n in F ig u re
1 .6 4 . T h e l ef t s u pe rio r i n te rc os t al vei n , w h i c h d r ain s t h e 1 s t 3 rd i n te rc os t al s pa c es , m a y c om m u n ic a te
w it h th e a c c es s o ry h em iaz y g os ve in ; h ow ever , it dr ai n s p r im a ril y in t o th e l ef t br ac h io c ep h a li c v ein .
Ne rves of the Posterior M ediastinum

T h e s ym pa th e ti c tr u n ks an d t h eir a s s oc i at ed g an g li a f o rm a m a j or p o rti on o f th e au t on o m ic n e rvo u s
s ys t em ( F i g. 1 . 6 5 , Ta b le 1 .6 ). T h e t ho r a cic s ym pa th et i c t ru nk s ar e in c o n ti n u it y w i th t h e c e rvic a l a n d
l u m b ar s y m p at h et ic t ru n ks . T h e t h ora c ic t ru n ks l ie a ga in s t th e h ead s o f t h e ri b s in t h e s u p eri or p a rt o f
t h e t h or ax, t h e c o s to ver teb r al j o in t s in t h e m id t h or ac i c l eve l, a n d t h e s i de s of t h e ver te br al b o d ies i n th e
i n f eri or p a rt o f th e t h o rax . Th e l o w e r t h or a ci c s pl an chn i c n e rve s als o kn o w n as g re at er, l es s er, a n d
l eas t s p la n c h n ic n er ves a re p ar t o f th e a b do m i n op el vi c s p l an c h n ic n e rves b ec a u s e t h ey s u p p ly v is c er a
i n f eri or t o t h e d i ap h rag m . T h ey c on s i s t o f p re s yn ap t ic f ib e rs f rom t h e 5 t h t h rou g h t h e 1 2 t h s ym p at h et ic
g an g l ia , w h i ch p a s s t h ro u g h th e d i ap h ra gm an d s yn ap s e i n pr eve rt eb ral g an g li a in t h e a bd o m en . T h ey
s u p p ly s y m p at h et ic i n n erva ti on f o r m o s t o f t h e a bd o m i n al v is c er a. T h es e s p la n c h n ic n er ves a re d is c u s s ed
f u rt h er i n Ch ap t er 2 .
A nter io r M e diastinum
T h e a nt e ri o r m ed ia st i nu m, t h e s m a ll es t s u bd i vis i on o f th e m ed ia s ti n u m ( F ig . 1 .3 4 ) , li es b et w ee n th e
b o dy of th e s te rn u m an d t h e t ran s ve rs e t h or ac i c m u s c les a n te rio rl y an d th e pe ric a rd iu m po s te ri orl y. It is
c o n ti n u ou s w it h th e su p e rio r m e di as t in u m a t t h e s t ern a l a n gl e a n d i s lim it ed in f e rio rl y by th e d i ap h ra gm .
T h e a n te rio r m ed i as t in u m c o n s is t s of l oo s e c on n e c ti ve t is s u e ( st e rn o pe ri ca rdi a l l i gam e nt s) , f at ,
l ym p h at i c v es s el s , a f ew l ym p h n o de s , an d b ran c h e s o f th e in t ern a l t h ora c ic ve s s els . I n i n f an t s an d
c h i ld re n , th e a n te ri or m e d ias t in u m c on t ai n s t h e i n f eri or p a rt o f th e th ym u s . In u n u s u al c a s es , t h is
l ym p h o id or ga n m ay e xt en d to th e lev el o f th e 4 t h c o st a l c ar ti la ge s .
The Bot tom Line

Th e po s te ri or m e d ias t i n u m is t h e n arr ow pa s s ag ew ay p o s ter io r to t h e h ea rt a n d d i ap h ra gm an d be tw een
th e l u n g s fo r c o n du c t i on s t ru c tu r es p as s i n g f ro m t h ora x t o ab d o m en o r vic e vers a . Co n ten t s in c l u d e t h e
es op h a g u s a n d e s op h a ge al n e rve pl exu s , t h o rac i c a or ta , th o ra c ic d u c t a n d l ym p h at i c t ru n k s , p o s te ri or
m ed ia s ti n al lym ph n o d es , an d a z yg os an d h em ia z yg os ve in s . B ra n c h es of t h e t h ora c ic a ort a o c c u r
pr im a ril y w i t h in t h ree v as c u la r p la n es . T h e az y go s / h em i az yg o s ven o u s s ys te m c on s t it u t es t h e ven o u s
c ou n t erp a rt t o t h e t h or ac i c a or ta an d it s po s t eri or m e d ia st i n al b ra n c h es . T h e t h ora c ic p o rti on o f th e
s ym p at h et ic t ru n ks a n d t h o rac i c s p l an c h n i c n e rve s m ay o r m ay n ot be c on s i de red c o m p on en t s of t h e
po s t eri or m e d ia st i n u m .
P .1 8 5
Med ical Imagin g of t he Thor ax

Th e m ai n im a gi n g m et h od s f or exa m in a ti on o f t h e t h or ax a re ra d io gr ap h y, e ch o c ar di og r ap h y, CT , an d
MR I.
Radi ography
Th e m os t c om m on ra d io gr ap h ic s t u d y of t h e t h ora x is t h e po s te ro a n te ri o r (P A ) p ro j ec ti o n ( F i g.
1 .6 6 A ) , pr od u c in g a P A ra di o gra ph (F i g . 1 .6 6 B ) . T h e r ad io lo g is t or t ec h n i c ia n pl ac e s t h e a n te rio r as p e ct
of t h e p at ien t 's t h or ax a g ain s t t h e X -r ay d et ec t o r or f i lm c a s s ett e a n d r ot at es t h e s h ou l d ers a n te rio rl y to
m ov e th e s c ap u la e aw ay f ro m t h e s u p eri or p a rt s o f th e l u n g s (F i g . 1 .6 6 A ) . Th e p e rs on t ak es a d eep
br eat h an d h o ld s it . T h e d eep in s p i rat io n c au s e s t h e d i ap h rag m a t ic d om e s to de s c en d , f il li n g t h e l u n g s
w it h ai r ( in c re as i n g t h ei r ra di ol u c en c y) , a n d m o vi n g t h e c o s to d ia ph r ag m a ti c pa rt s of th e lu n g s in t o t h e
c os t od i ap h rag m a t ic rec e s s es .
A P A rad i og ra ph , w h ic h i s vie w ed as i f y ou w ere f a c in g th e pa ti en t ( an an t er o po st e ri o r [ A P] v i e w) , is a
c om p o s it e of t h e i m ag es c a s t b y t h e s of t ti s s u es an d b on e s of t h e th o ra c ic w a ll . S of t t i s s u es , in c l u d in g
th o s e of t h e b re as t s, c a s t s h a d ow s o f var yin g d en s i ty, d e pe n d in g on t h ei r c om p o s it io n an d t h ic kn e s s.
Par al lel in g t h e s u p eri or m arg i n s o f th e c lav ic l es are s h ad ow s c as t b y t h e s ki n an d s u b c u ta n eo u s ti s s u es
c ove rin g t h es e b o n es . T h e c la vic l es , ri b s , an d in f er io r c erv ic al an d s u p eri or t h o rac i c v ert eb ra e ar e vi s ib le .
In PA ra di og ra p h s , m os t ri bs s t an d o u t c le arl y a ga in s t th e ba c kg ro u n d o f th e r el at ive ly l u c en t lu n g s (F i g .
1 .6 6 B & C ). T h e i n f eri or ri b s te n d t o b e o b s c u red b y t h e d iap h r ag m an d t h e s u p eri or c o n te n ts o f th e
ab d om e n (e .g ., li ver) , d ep en d i n g on t h e p h as e o f r es p ir at io n w h en t h e ra di og r ap h w as t ak en . U s u al ly

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o n ly l at era l m a rg in s o f th e m an u b ri u m are vis i b le i n th e s e p roj ec t io n s . T h e lo w e r th o ra c ic ver te br ae a re

m o re o r l es s ob s c u re d b y t h e s t ern u m a n d m ed ia s ti n u m . U n c om m on l y, c er vic a l ri b s, m is s i n g ri b s , f ork ed
ri b s , an d f u s ed rib s a re vi s ib le . O c ca s io n al ly, t h e c o s ta l c a rti la g es are c al ci f ie d i n ol d er p eo pl e ( es p ec i al ly
t h e i n fe ri or c a rti la g es ) .
Fi gu re 1 . 66 R a di o gra ph s o f th o ra x . A . T h e or ien ta ti on o f t h e p er s on ' s t h o rax r ela ti ve t o t h e f i lm

c as s e tt e o r de te c to r an d t h e X - ray be am ( a r r ow ) f o r a P A p r oj ec t io n is d em o n s tr at ed . B . A n ex am p l e
of a P A rad i og ra p h ( P A p ro j ec t io n /A P vie w ) of t h e t h ora x is s h o w n . C . Th e m ai n s tru c t u re s v is i bl e i n
t h e PA ra di og r ap h are ou t li n ed . N ot e t h at t h e rig h t d om e is u s u al ly h i g h er t h an t h e le f t d o m e. D . An
exa m p le of a l at era l ra d io gr ap h of t h e t h ora x is s h o w n . E . T h e p rin c i p al s t ru c t u res v is ib l e in t h e
la te ral rad i og ra p h a re o u tl in e d . F . T h e or ien t at i on of t h e p ers o n 's t h or ax re la ti ve t o t h e f il m c as s e tt e
or de te c to r an d t h e X - ray b e am ( a rr ow ) f o r a l at era l ra di og r ap h is d em o n s tr at ed .
Fi gu re 1 . 67 C a rdi o va sc ul ar sha do w s (m ed ia st i na l si l ho u et t es ). A. T h e c o m p os i ti on o f th e
m ar g in s of t h e c ar di ov as c u l ar s h ad o w i s i d en t if i ed . B . T h e c om m on t yp es o f c a rd io vas c u l ar s h a d ow
ar e s h ow n .

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Fi gu re 1 . 68 . C o r o na ry a rt e ri o gr am s . R ad io p aq u e d ye h a s be en in j e c ted i n to th e LCA ( A ) a n d t h e
R C A ( B) via a c at h et er pa s s ed th r ou g h t h e ao rt a ( vis i b le h e re as i t t ra vers e s th e a rc h of t h e ao rt a
an d d es c en d s t o t h e h ea rt via th e a s c en d in g ao rt a) f ro m th e fe m or al a rt ery (j u s t i n f eri or to th e
m i dp o in t of in gu i n al li ga m en t ) . Th e ori en t at io n d raw in g s s h ow th e c o u rs e o f th e c o ro n ary art eri es a s
d em o n s tr at ed b y th e art eri og ra m s . In p ar t B , o b s erv e th e s in u at ri al n od al art er y ari s in g f ro m th e
ri gh t c or on a ry ar te ry. ( Co u rt es y of D r. I. M or row , De p art m en t of R a d io lo gy , H ea lt h Sc i en c e s C en t re,
U n ive rs it y o f M a n it ob a , W i n n ip eg , M an i to b a, Ca n ad a. )

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Fi gu re 1 . 69 . A o r ti c a ngi o gr am . T h e ar c h of ao rt a an d t h e t yp ic al arr an g em en t o f it s br an c h es a re
vi s ib le . N ot e t h e m a jo r b ran c h e s of t h e s u b c lav ia n a rt eri es ar is i n g w it h in t h e s u p eri or t h o rac i c
ap er tu r e. ( Cou r te s y of D r. E . L. L an s d o w n , Pr of es s o r o f M e di c al Im ag i n g, U n i ver si t y of T or on t o,
T oro n t o, O n t ari o, Ca n ad a. )
In P A pr oj ec t io n s , th e rig h t an d le f t d om es of t h e d ia ph r ag m ar e s ep ar at ed b y th e c en tr al ten d o n , w h i c h
i s ob s c u red b y t h e h ea rt . Th e r ig h t do m e o f th e d i ap h ra gm , f orm ed by th e u n d e rly in g li ver, i s u s u al ly
a pp r oxi m at el y h al f an in t er c os t al sp a c e h ig h e r th a n th e l ef t do m e . Th e l u n g s , b ec au s e o f th e ir l ow
d en s i ty , are rel at ive ly l u c en t c om p a red w i th s u rr ou n d i n g s t ru c t u res . T h e l u n g s e xh ib i t a rad io d en s i ty
s i m il ar t o t h at o f a ir a n d , th e ref o re, p ro du c e pa ir ed rad i ol u c en t a rea s . In PA p ro je c ti on s , t h e l u n gs a re
o b s c u red in f er io r t o t h e d om e s of th e di ap h ra g m an d an t er io r an d p os t eri or t o th e m ed ia s ti n u m . T h e
p u l m on a ry a rte rie s are v is i bl e i n t h e h i lu m o f eac h l u n g . In tr ap u lm on ar y ves s e ls ar e s li g h tl y la rg er i n
c a li be r in t h e i n fe rio r l ob es . T ra n s vers e s ec ti on s o f th e a ir -f i ll ed br on c h i h ave l u c en t c en t ers a n d t h in
w al ls .
T h e a rea s o b s c u red in P A pr oj ec t io n s are u s u all y vi s ib l e in l at era l ra di og r ap h s . In la t er a l pr o j ect i o ns ,
t h e m i d dl e a n d i n f eri or t h or ac i c v ert eb ra e ar e vis i b le , alt h o u gh t h ey a re p a rti al ly o b s c u red b y t h e rib s
( F ig . 1 .6 6 D & F ) . T h e t h ree p a rt s o f th e s t er n u m are al so vi s ib le . L at e ra l r a dio g ra phs al lo w b et te r
vi ew in g of a l es i on o r an o m al y c on f i n ed to on e s id e o f t h e t h or ax. In a la te ral pr oj ec t io n , b ot h do m e s o f
t h e d ia p h rag m a re o ft en v is i bl e as t h ey a rc h s u p eri or ly f ro m th e s te rn u m . A la te ral rad i og ra p h i s m ad e
u s i n g a la te ral pr oj ec t io n , w i th t h e s i de of th e th o ra x ag ai n s t t h e f il m c as s e tt e o r X - ray d et ec t o r an d th e
u p p er l im bs el ev at ed ove r t h e h ead ( F ig . 1 .6 6E ) .
T h e h ea rt c as t s m os t of t h e c en t ral rad i op a qu e s h ad ow in PA p ro j ec t io n s ( F i g. 1 .6 6B ), b u t th e se p ara te
c h a m b ers o f t h e h e art are n ot di s t in g u is h a b le. K n o w l ed g e o f t h e s t ru c t u res f or m in g t h e ca rd io v as cul a r
s h a d o w o r s il h ou et t e is i m p or ta n t b ec a u s e c h an g es i n th e s h a d ow m ay i n d ic at e a n om a li es or fu n c t i on a l
d i s eas e ( F i g. 1 . 6 7 A ). In P A rad i og ra ph s ( A P vi ew s ), t h e b o rd ers o f t h e c a rd io vas c u l ar s h a do w a re a s
f o ll ow s:

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Fi gu re 1 . 70 . E c ho ca rd io g ra phy . A . A n or m al tw o- d im e n s io n al vie w ec h o c ard i og ra m is s h o w n . T h e

t ran s d u c er i s p lac e d i n a l ef t i n te rc os t al s p ac e i n th e p a ras t ern a l l in e , ove rly in g th e h ear t, a n d
or ien t ed s o th a t i t p ro d u ce s a lo n g it u d in a l c ro s s -s e c ti on a l i m ag e o f t h e h e art . N o te t h e t h ic k
ven t ri c u la r w a ll a n d IV S . B . T h e te c h n iq u e i s de m on s t ra te d.

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Fi gu re 1 . 71 . S er i al t ra nsv er se C T sca ns o f t ho r a x. A . T h e l eve l o f e ac h s c an i s in d ic a te d ( b ro ken

li n es ) . B . A t th e l eve l o f t h e s t ern o c la vi c u lar jo in t s , t h e le ft b rac h i oc e p h ali c vei n (2 ) c ro s s es t h e
m i dl in e an t eri or t o t h e t h ree br an c h es o f th e a rc h of t h e ao rt a ( 3 , 4 , an d 5 ) to j oi n th e r ig h t
b rac h i oc e ph a li c vei n (1 ) , f o rm in g t h e S V C ( 2 2 ) a t a m or e in f e rio r le vel . C. T h e a rc h of t h e ao rt a ( 2 0 )
is o b liq u e ly p l ac ed ( m or e s ag i tt al th a n tra n s ver s e) , w i th t h e as c e n di n g en d an t eri or ly i n th e m id li n e,
an d t h e d es c en d i n g e n d p o s te rio rl y an d to t h e le ft of t h e ve rt eb ral b od ie s (1 7 ) . T h e S V C ( 2 2 ) o n t h e
ri gh t s id e r ec ei ves t h e ar c h of th e az yg o s vei n (2 3 ) f ro m it s p os t eri or a s p ec t . D . T h e p u lm o n ar y

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t ru n k ( 2 7 ) f o rm s t h e s t em o f a n in ve rt ed Y, w it h th e a rm s f o rm ed b y t h e ri gh t ( 2 8 ) a n d lef t (2 9 )
p u lm o n ar y art er ies . T h e r ig h t p u l m on a ry a rte ry ( 2 8 ) pa s s es b en ea t h t h e a rc h of t h e ao rt a [ b et w ee n
as c e n di n g (2 4 ) an d d es c e n di n g ( 2 5 ) ao rt ae ]. E . A s c an a t t h e l evel of t h e m a xim u m di am e te r of t h e
h ea rt d e m on s t ra te s a ll fo u r c h a m b ers ( 3 2 3 5 ) an d t h e d ia go n al s la n t o f t h e IV S ( b et w ee n 3 3 an d
35).
Ke y t o St ru ct ur es i n T r an sve rs e C T S can s o f T ho r ax
1 = R i g h t b ra c h io c ep h al ic vei n
2 = L ef t b r ac h io c ep h al ic v ein
3 = B ra c h io c ep h al ic ar te ry
4 = L ef t c o m m o n c aro t id art er y
5 = L ef t s u b c l avi an a rte ry
6 = E s o ph a g u s
7 = T rac h e a
8 = R i g h t m a in b ro n c h u s
9 = L ef t m ai n b r on c h u s
1 0 = Co s t al c a rt il ag e
1 1 = S t ern u m
1 2 = Cl av ic le
1 3 = A xi ll ary vei n
14 = Ri ght l ung
1 5 = L ef t lu n g
1 6 = T 4 ver te br al b o d y
2 0 = A rc h o f a or ta
2 1 = A n t eri or m ed ia s ti n u m ( reg i on of t h ym i c rem n a n t )
2 2 = S u p er io r ven a ca va
2 3 = A rc h o f a z yg o s v ein
2 4 = A s c en d i n g a or ta
2 5 = D es c en d i n g a ort a
2 6 = Co n u s art er io s u s
2 7 = P u lm o n ar y tr u n k
2 8 = R i g h t p u lm on a ry ar te ry
2 9 = L ef t pu l m o n ary a rt ery
3 0 = H e m ia z yg os v ein
3 1 = In t er n al t h o rac i c v es s el s
3 2 = R i g h t a tri u m
3 3 = R i g h t ve n tr ic l e
3 4 = L ef t at riu m
3 5 = L ef t ven t ric l e
3 6 = In f e rio r ri gh t p u lm on ar y vei n
3 7 = In f e rio r le f t p u lm on a ry ve in

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Fi gu re 1 . 72 M a gn et i c r e so na nc e re co n st ru ct ed a ngi o gr a m o f he a rt an d gre a t ve ss el s. T h e
s tu d y i s a l at era l vi ew ( f ro m le ft an d s li g h tl y an t er io r) . Th i s n on - in v as i ve, n o n -i on i z in g i m ag e i s
rec o n s t ru c te d f r om d at a g e n era ted a n d a c c u m u la te d b y s p i ral MR I. A ll ch a m b er s o f th e h e art an d
g rea t ve s s el s a re c l ear ly v is ib l e. S V C, s u p eri or ven a c a va.
l
l
R i gh t b or de r, ri gh t b rac h i oc e p h ali c vei n , S V C, ri gh t at ri u m , an d IV C.

L ef t b o rd er, t er m in a l p art o f t h e a rc h of ao rt a ( ao rt ic kn o b ), p u l m on a ry t ru n k, l ef t a u ri c le, a n d l ef t
ve n tri c le .
T h e l ef t i n f eri or p a rt o f th e c ard io va s c u la r s h ad ow pr es en t s th e reg i on o f t h e a pe x. T h e ty p ic al

a n at om i c al ap ex, i f p res en t , is o f te n in f er io r to th e s h ad ow of t h e d iap h r ag m . T h ree m ai n t yp es o f
c a rd io vas c u l ar s h a d ow s o c c u r, d ep en d i n g p ri m ar il y on b o dy typ e o r h a bi tu s ( F ig . 1 .6 7 B ):
T ran s v ers e t yp e, o b s erve d i n ob e se p ers o n s , pr eg n an t w o m en , a n d i n f an t s .
O b li qu e typ e, c h ara c te ris t ic o f m os t p eop l e.
V ert i c al t yp e, p re s en t in p eo pl e w i t h n a rro w c h es t s .
F luoros copy
T h e m o vem en t s of d if f ere n t o rg an s ( e.g ., h e art , lu n g s , a n d d i ap h rag m ) m a y b e s tu d i ed b y m ea n s of
f l u oro s c op y. I n t h i s s y s te m , th e X -r ays i m p in g e o n th e i n p u t s c re en of a n im a ge -i n t en s if i er t u b e, w h i c h is
c o u p led t o a t el evi s io n m o n it or. T h i s i m a ge -i n t en s if i er t el evi s io n s y s te m g ive s s u p e rio r res o lu t i on al on g
w it h red u c ed ra d iat i on ex po s u re.
B ronc hograph y
B ro n c h o gr ap h y, a r ad io g rap h i c e xam in a ti on o f t h e t ra c h eob ro n c h ia l t ree af t er in tro d u c ti on o f an oi ly
ra d io p aq u e m a te ria l ( b y m ea n s of ae ros o l o r d rip ) , is r are ly p er fo rm e d n o w . It h as b ee n s u pe rs ed ed b y
h i g h -r es ol u t io n C T a n d b ro n c h os c o p y.
Cardiac Cat heteriz at ion

In c a rd ia c c a th e te riz at io n , a ra di op a qu e c at h et er i s i n s ert ed i n to a p eri p h era l ve in ( e.g ., t h e f em o ral
ve in ) an d p as s e d u n d er fl u or os c o pi c c on t ro l i n to th e r ig h t at riu m , rig h t ven t ri c le, p u l m on a ry t ru n k, a n d
p u l m on a ry a rte rie s , res p ec t iv el y. U s in g th i s te c h n iq u e, i n tr ac ar di ac p re s s u res c an b e re c or de d a n d bl oo d
s a m p les m ay b e re m ov ed . If a ra di op a q u e c on t ra s t m e di u m is i n je c te d , it ca n b e f ol lo w ed t h ro u gh t h e
h e art an d g rea t ve s s el s u s i n g se ri all y ex po s ed X - ray f i lm s . A l te rn at i vel y, ci ne ra d i o gr ap h y c a n b e
p er f orm ed to ob s erv e t h e f lo w of d ye in rea l t im e. B ot h t ec h n iq u es p er m it s t u dy o f th e c irc u l at io n
t h ro u g h t h e f u n c t io n in g h ea rt a n d are h e lp f u l i n th e st u d y o f c o n g en i ta l c ar di ac d ef ec t s .
Coron ar y Ang iograph y

U s in g co r o na r y an gi o gra ph y, t h e c or on a ry ar te rie s c a n b e vis u a li z ed w i th co r o na r y ar t er io g ra m s (F i g .

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1 .6 8 ). A l on g , n ar row c at h et er i s p a s s ed in t o t h e as c e n di n g ao rta via th e fe m o ral or b ra c h ia l ar te ry in t h e

i n g u in al or e lb o w reg i on , r es p ec t ive ly. U n d er f l u or os c o pi c c on t ro l, t h e t ip of t h e c at h et er i s pl ac e d j u s t
i n s id e t h e o pe n in g of a c o ro n ary art ery . A s m al l in j ec t i on of ra d io p aq u e c o n tra s t m at eri al i s m ad e, a n d
c i n era d io gr ap h s are ta ken t o s h o w t h e lu m e n of t h e art er y an d it s b ran c h e s as w el l a s an y s t en o ti c are as
t h at m ay be pr es en t . In a s i m il ar m an n er , an a o rt ic a n gio g ra m c a n b e m ad e b y i n j ec t in g rad i op aq u e
c o n tr as t m at eri al in t o t h e ao rt a a n d i n to op en in g s of t h e art er ies a ris i n g fr om t h e a rc h of t h e ao rt a ( F ig .
1 . 6 9 ).
Ech ocar diogr aph y

E c h o c a rdi o gr ap h y ( u l tr as on i c c ard i og ra p h y) i s a m e th o d o f g rap h ic a ll y re co rd i n g t h e p os i t io n a n d
m o t io n of th e h ear t b y t h e ec h o ob t ai n ed f rom b e am s o f u l tr as o n ic w a ves d ir ec t ed th r ou g h th e th o rac i c
w al l ( F ig . 1 .7 0 ) . E c h oc a rd io g rap h y d el in e at es va lvu l ar s t en o s is an d re g u rg it at io n , es p ec i al ly o n th e l ef t
s i d e of t h e h ea rt. T h i s t ec h n i q u e m a y d et ec t a s li tt le a s 2 0 m L o f f lu i d i n th e p e ric a rd ia l c av it y, s u c h as
t h at res u l ti n g f rom p e ric a rd ia l ef f u s io n . D o ppl er ech o ca rdi o gr ap hy i s a t ec h n iq u e t h at re c ord s t h e f lo w
o f bl oo d th ro u g h th e h ear t a n d g re at ves s el s b y Do p pl er u l tr as o n og ra ph y .
CT and MRI
CT an d M R I a re c o m m on l y u s ed t o ex am i n e t h e t h ora x ( F ig s . 1 .7 1 an d 1 .7 2 ) . CT is s o m et im e s c om b i n ed
w it h m am m og ra p h y f or d et ec t io n of b re as t c a n c er. B e fo re C T s c a n s a re t ak en , an i od i de c on t ras t m at er ia l
i s gi ven i n tr ave n ou s l y. B ec a u s e b rea s t c an c e r c el ls h av e an u n u s u a l af f i n it y f or i od i de , th e y b ec om e
re c og n i z ab le . M R I is u s u al ly b e tt er f o r d et ec t in g an d d el in ea ti n g s of t t i s s u e le s io n s. T ra n s ver s e ( axi al ) CT
a n d M R s c a n s a re a lw ays o rie n te d t o s h o w h o w a h o ri z on t al se c ti on o f a p at ie n t' s b o d y lyi n g on an
e xam i n at io n t ab le w ou l d ap p ear t o th e p h ys i c ia n w h o i s at th e pa ti en t 's f ee t. T h er ef or e, th e to p of th e
i m ag e i s an t eri or , an d th e lef t la te ral ed g e of t h e im ag e re pr es en t s th e rig h t la te ral s u rf ac e o f th e
p at i en t 's b od y. D at a f ro m CT an d M R s ca n s c an b e g ra ph i c al ly r ec on s t ru c t ed b y th e c om p u t er a s
t ra n s vers e , s ag it t al, o b li q u e, or c oro n al s ec ti o n s o f th e b o d y.
P .1 8 6
P .1 8 7
P .1 8 8
P .1 8 9
P .1 9 0
P .1 9 1
Refe re nce s and Sug g ested Read ings

A h y a S N , F lo od K , P ara n jo t h i S : W as h i n g to n M an u al of M ed i c al T h er ap eu t ic s , 3 0 t h ed . B al ti m o re,
L ip p i n c ot t W il li am s & W i lki n s , 2 0 0 1 .
B e h rm a n R E , K li eg m an R M , J en s o n H B (e d s ): N el s on T ex tb o ok o f P ed ia t ric s , 1 6 t h ed . Ph i la d elp h i a,
S a u n d ers , 2 0 0 0 .
B e rg m an R A , T h o m p s on S A , A f if i A K , S a ad eh F A : Com pe n d iu m o f H u m an A n at o m ic V ar ia ti on : T ext ,
A t la s , an d W o rl d L it er at u re. B a lt im o re , Ur ba n & S c h w arz e n b erg , 1 9 8 8 .
T h is u s ef u l s o u rc e h a s be en u p d at ed an d is a vai la bl e f ro m th e V irt u al H os p i ta l' s W eb s it e Il lu s t ra te d
E n c yc l op ed i a of H u m a n A n at om ic V ari at io n at
h t tp : // w w w . v h .or g/ P rov id er s /T ex tb o oks / A n at o m ic V a ria n ts / A n a t o m yH P .h t m l ( ac c es s e d M a y 2 0 0 4 ) .
C ot ran R S , K u m ar V , Co ll in s T : R ob b in s P at h ol og ic a l B a s is of D is ea s e, 6 t h ed . Ph i la de lp h ia , S au n d er s ,
19 99.
C rea s y R K , R es n i k R : M at ern a l- F et al Me di c in e , 4 th e d. P h il ad el p h ia , Sa u n d ers , 1 9 9 9 .
D ea n DX , H e rb en er T E : Cro s s -S e c ti on a l H u m a n A n a t om y, Li p pi n c ot t W il li am s & W i lk in s , 2 0 0 0 .
F e rg u s on J E , S c h or A M , H o w e ll A , F e rg u s on M W : Ch a n ge s in t h e ext ra c ell u la r m a tr ix o f t h e n o rm a l
b re as t d u rin g t h e m en s t ru a l c yc l e. Cel l T is s u e R es 2 6 8 : 1 6 7 1 7 7 , 1 9 9 2 .

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Ge r R , A b rah a m s P, O l s on T : E s s e n ti al s o f Cli n ic a l A n at o m y, 3 rd ed . N ew Yo rk, P ar th e n on , 1 9 9 6 .
Go ro ll AH : P rim ary C are M e di c in e : O f f ic e E val u at io n an d M an ag e m en t of t h e A du l t P at ie n t, 4 t h ed .

Ph i la de lp h i a: Li pp i n c ot t W il li am s & W i lk in s , 2 0 0 0 .
H ar dy SG P , N af t el J P: V i sc e ro s en s or y p at h w ay s . In H ai n es DE ( ed ) : Fu n d a m en t al N eu ro s c ie n c e, 2 n d
ed . N ew Yo rk, C h u rc h il l L ivi n g s to n e, 2 0 0 1 .
M oo re K L , Pe rs au d T V N : T h e D eve lo pi n g H u m an . C lin i c al ly O ri en t ed E m b ryo lo g y, 7 t h ed . Ph i lad e lp h ia ,

S au n d er s, 2 0 0 3 .
M oo re, K L , Pe rs au d T V N , S h io ta K : C ol or A t la s of Cli n ic a l E m b ry ol og y, 2 n d ed . P h ila d el ph i a, S a u n de rs ,

2000.
R os e n P: E m er ge n c y M ed ic i n e: Con c e pt s an d Cl in i c al P rac t i c e, 4 t h e d . St . L ou i s , Mo s b y, 1 9 9 8 .
R ow la n d L P ( ed ) : Me rri tt 's N e u rol og y, 1 0 th ed . B a lt im o re , Li pp i n c ot t W il li am s & W i lk in s , 2 0 0 0 .
S au er la n d E K : G ran t 's D is s ec t or , 1 2 th e d. B a lt im ore , Li p pi n c ot t W i lli am s & W ilk in s , 1 9 9 9 .
S la by FJ , M c Cu n e S K , S u m m ers R W : G ro s s A n at om y in t h e Pra c ti c e o f M e di c in e . Ph i lad e lp h ia : L ea &

F eb ig er , 1 9 9 4 .
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08-May-15

Clinically Oriented Anatomy, 5th Edition - 1. Thorax

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Clinically Oriented Anatomy, 5th Edition - 1. Thorax

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Ovid: Clinically Oriented Anatomy

Co p yri gh t 2 0 0 6 Li p pi n c ot t W i ll iam s & W ilk in s

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Ovid: Clinically Oriented Anatomy

Fi gu re 1 . 1. T ho r a cic s ke l et o n. A a n d B. T h e os t eo c art il ag i n ou s t h ora c ic c a ge in c lu de s t h e

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Ovid: Clinically Oriented Anatomy

The Bot tom Line

Tho rac ic Wall

Pr ot ec t vit al th o ra c ic an d ab d o m in a l i n te rn al org a n s ( m o s t a ir o r f lu i d f ill ed ) f rom e xt ern a l f or c es .

R es i s t t h e n e ga ti ve ( s u b - at m os p h e ric ) in t er n al p re s s u res g en e rat ed b y t h e el as t ic rec o il of t h e lu n g s

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Ovid: Clinically Oriented Anatomy

Pr ovi d e t h e an c h o rin g a tt ac h m en t ( o rig i n ) o f m an y o f th e m u s c les t h at m o ve an d m a in t ai n th e

Ske le ton of the T ho racic W all

R ibs, Costal Cartilage s, and Inter costal Sp ac es

T ru e ( ver t eb ro co s ta l ) ri bs ( 1 s t 7 t h rib s ) : T h e y at ta c h di rec t l y to th e s te rn u m t h rou g h t h ei r ow n

Fa l se ( ve rt eb ro ch o ndr a l) r i bs ( 8 th , 9 t h , a n d u s u a ll y 1 0 th r ib s ) : T h ei r c art i lag e s a re c o n n ec t ed to

Fl o a ti n g (ve rt e bra l , f re e) r i bs ( 1 1 t h , 1 2 th , a n d s o m et i m es 1 0 t h rib s ) : T h e r u di m en t ar y c ar ti la ge s

B o d y ( sh a f t) : th i n , f la t, a n d c u r ved , m o s t m a rke d ly a t t h e co st a l a ng le w h er e th e rib t u rn s

T h e 1 s t r ib is t h e b ro ad es t (i .e., i t s b o d y is w i d es t a n d n ear ly h o riz on t al ), s h o rt es t , an d m os t

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Ovid: Clinically Oriented Anatomy

ve s se ls ; t h e g roo ves a re s ep a rat e d b y a s cal e ne t u ber cl e a n d r id g e, t o w h ic h t h e an t eri or sc a le n e

T h e 2 n d rib i s m ore typ i c al ; i ts b o dy is th i n n er , les s c u rv ed , an d s u b s ta n ti al ly l on g er th a n th e 1 s t

T h e 1 0 t h 1 2 t h rib s , l ike t h e 1 s t ri b, h a ve o n ly o n e f ac e t o n th e ir h e ad s an d art i c u lat e w it h a

T h e 1 1 t h an d 1 2 th r ib s are s h ort an d h av e n o n e c k or t u b erc l e.

C o st a l ca rt i l age s p ro lo n g t h e r ib s an t eri or ly a n d c o n tr ib u t e t o t h e el as t ic i ty o f th e t h o rac i c w al l,

Fi gu re 1 . 2. T yp ica l r i bs. A . T h e 3 r d 9 t h r ib s h ave c om m on c h ar ac t eri s ti c s . E ac h ri b h a s a h ea d ,

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Ovid: Clinically Oriented Anatomy

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Ovid: Clinically Oriented Anatomy

Th orac otomy , I ntercost al Sp ace In cision s, Rib Excision , an d B one Gr afti ng

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Ovid: Clinically Oriented Anatomy

a n d r em o ve a l u n g (p n e u m on e c to m y) , f or e xam p le. In t h e ri b 's ab s en c e , en t ry i n to th e t h o rac i c c avi ty

S upern um erary Ribs

Prot ect ive Fu nct ion an d Agin g of Cost al Cart ilages

Thor ac ic Ve rte brae

T h e s p in o u s p r oc es s e s p ro j ec t in g f ro m th e v ert eb ra l a rc h es of t yp ic a l t h or ac ic v ert eb ra e are lo n g a n d

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Ovid: Clinically Oriented Anatomy

ro t at io n w it h i n th e v ert eb ra l b od y ( F ig . 1 .4A C) . Th u s s m a ll rot at o ry m o vem en ts a re p er m it t ed

Fi gu re 1 . 4. T ho r a cic v er t ebr a e. A. T 1 h as a vert eb ra l f o ram en an d b od y s i m il ar t o a c ervi c al

Fi gu re 1 . 5. C o st o ve rt e bra l a rt i cu la t io n s o f a t ypi ca l r i b. Th e c os t ov ert eb ra l j oi n ts i n c lu d e t h e

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Ovid: Clinically Oriented Anatomy

The Ste rnum

It s ju n c t io n w i th t h e s t ern a l b od y a t t h e x i phi st e rn al jo i n t i n d ic at es t h e in fe rio r l im i t o f th e c e n tr al

It is a m i d li n e m a rker f o r t h e s u p eri or l im it of th e li ver, t h e c e n tra l t en d o n o f th e di ap h ra g m , an d

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Ovid: Clinically Oriented Anatomy

Ossified X iph oid Proc esses

St ern al Fractu res

Med ian S ter not omy

The Bot tom Line

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Ovid: Clinically Oriented Anatomy

d i s cs . L at er al ly a n d a n te rio rl y, it c on s i s ts o f 1 2 rib s , m o s t c o n ti n u ou s w it h a c os t al c art i lag e a n t eri orl y

Supe rior Thoracic Ap erture

Po s te rio rl y, b y ver te br a T 1 (p ro t ru d in g or c o n ve x po s t eri or b o u n d ary/ l an d m a rk) .

A n te rio rl y, b y th e s u pe rio r b or de r of t h e m a n u b riu m ( a n ter io r la n d m ark ).

Infe rior Thoracic Ape rture