THE THORAX
T ABLE OF C ONTENTS
Types of Ribs ............................................................................................................ 2
articulations of ribs .................................................................................................. 3
The Sternum ............................................................................................................. 5
Thoracic Inlet ........................................................................................................... 5
Thoracic Outlet ........................................................................................................ 6
Thoracic Muscles ..................................................................................................... 7
Intercostal Muscles .................................................................................................. 8
Intercostal Nerves .................................................................................................... 8
Intercostal Vessels ................................................................................................... 9
Internal Thoracic Vessels...................................................................................... 11
Surface Markings Of Pleurae ............................................................................... 12
External Features of The Lungs .......................................................................... 13
Bronchial Tree ........................................................................................................ 15
Arterial Supply To Lungs...................................................................................... 16
Venous Drainage of the Lungs ............................................................................ 16
Innervation of the Lungs ...................................................................................... 17
Lymphatic Grainage Of The Lungs .................................................................... 17
Features Essential For Ventilation ...................................................................... 17
Pericardium ............................................................................................................. 18
P REPARED BY M ICHAEL C. D AVID
Surface Anatomy Of Heart .................................................................................. 19
Chambers Of The Heart. ...................................................................................... 21
Arterial Supply To The Heart .............................................................................. 24
Venous Drainage from The Heart ...................................................................... 26
Innervation Of The Heart .................................................................................... 27
Thymus .................................................................................................................... 28
Brachiocephalic Veins ........................................................................................... 28
Vena Cavae.............................................................................................................. 29
The Aorta ................................................................................................................ 29
Pulmonary Arteries ................................................................................................ 31
The vagus Nerves................................................................................................... 32
The Phrenic Nerves ............................................................................................... 33
The Trachea ............................................................................................................ 34
The Oesophagus .................................................................................................... 34
Summary Of Contents of The Superior Mediastinum..................................... 34
Thoracic Duct ......................................................................................................... 36
Azygos System Of Veins ...................................................................................... 36
Sympathetic ............................................................................................................. 38
Parasympathetic...................................................................................................... 40
ON 23/08/08. P AGE 1 OF 40
 T HORACIC C AGE

T Y P E S OF R I B S

 True ribs = 1st seven ribs (vertebrosternal ribs)

 False ribs = 8th-12th pair of ribs (vertebrochondral ribs). The 11th and 12th pairs of ribs are
sometimes known as floating ribs, because they are unattached anteriorly.
 Typical ribs = 3rd to 9th pairs.
 1st rib.
 Broadest, most curved, and shortest
 Scalene tubercle on its internal-superior surface, for attachment of Scalenus anterior
muscle.
 Subclavian vein crosses rib anterior to this, and the subclavian artery.
 Inferior trunk of brachial plexus runs along this rib.
 2nd rib.
 Thinner, less curved, and twice as long.
 Large tuberosity for Scalenus anterior muscle.
 10th rib articulates with T10 vertebra only.
 11th & 12th ribs.
 Short, capped with a small costal cartilage, and only a single facet on their heads.
 11th rib has an ill-defined angle, and a shallow costal groove.
 12th rib has no angle, and no costal groove.

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 A RT I C U L A T I O N S O F R I B S

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COSTOVERTEBRAL JOINTS

Joints of the heads of the ribs.

 The two facets of the head articulate with the superior part of the corresponding vertebra, and the inferior part of the vertebra that is superior to it.
 The crest of the rib attaches to the intervertebral disc by an intra-articular ligament.
 An articular capsule surrounds each joint, and connects the head of each rib with the circumference of the joint cavity.
 The capsule is strongest anteriorly, where a radiate ligament fans out from the anterior margin of the head, to the sides of the bodies of the two vertebrae and
the intervertebral disc between them.

The Costotransverse Joints.

 The tubercle of an atypical rib articulates with the facet on the tip of the transverse process of its own vertebral body, to form a synovial joint.
 Lateral transverse ligaments pass from the tubercle of each rib to the tip of the transverse process, to strengthen the joints on each side.
 Costotransverse ligaments pass from the posterior surface of the neck of each rib, to the anterior surface of the transverse processes.
 Superior Costotransverse ligaments joins the crest of each rib’s neck, to the transverse process superior to it.
 The aperture between this and the vertebral column, allow passage of the spinal nerve, and the dorsal branch of the intercostal artery.

STERNOCOSTAL JOINTS

 1st pair of costal cartilages attaches to the manubrium, at primary cartilaginous joints  no movement.
 2nd to 7th pairs of costal cartilages attach to the sternum at synovial joints
 Joint cavities often absent in inferior articulations.
 Thin, weak articular capsules are strengthened anteriorly and posteriorly by radiate sternocostal ligaments.
 Pass from costal cartilages to anterior and posterior surfaces of sternum.

COSTOCHONDRAL JOINTS

 The rib and costal cartilage are firmly bound together by the continuity of periosteum, and perichondrium  no movement.

P REPARED BY M ICHAEL C. D AVID ON 23/08/08. P AGE 4 OF 40

INTERCHONDRAL JOINTS

 Plane synovial joints between adjacent borders of 7th-10th costal cartilages.

 Strengthened by Interchondral joints.
 Articulation between 9th and 10th costal cartilages, is a fibrous joint.

THE STERNUM

MANUBRIOSTERNAL JOINT

 Secondary cartilaginous joint – converted to a secondary fibrocartilaginous joint in later years

 Articular surfaces are covered with hyaline cartilage, and connected via a fibrocartilaginous disc.
 Joint strengthened by anterior and posterior fibrous ligaments.
 Manubriosternal joint moves slightly during respiration.

XIPHISTERNAL JOINT

 Primary cartilaginous joint, that ossifies in later years.

 Indicates:
 Infrasternal angle.
 Inferior limit of thoracic cavity, anteriorly.
 Midline pointer of to the diaphragmatic surface of Liver
 Inferior border of heart

T H OR A C I C I N L E T

 Anterior boundary = superior part of manubrium, Costal cartilage of 1st rib, and 1st rib.
 Posterior boundary = 1st thoracic vertebra.
 Contents of thoracic inlet:

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 


R+L Subclavian vein
R+L Subclavian artery
Inferior trunk of brachial plexus
} Lie on 1st rib.

 R+L Brachiocephalic Veins

 Brachiocephalic Trunk (right only)
 Left Common Carotid artery & Left Subclavian artery
 R+L Phrenic nerves
 R+L Vagus nerves
 Thoracic Duct (left only)
 Trachea
 Oesophagus

T H OR A C I C OU T L E T

Diaphragm forms boundary between thorax and abdomen.

 T8
 Inferior Vena Cava lies in central tendon, and so is unaffected by muscle contractions during breathing.
 Right phrenic nerve.
 T10
 Oesophagus
 Left Gastric arteries
 Anterior + Posterior Vagus nerves (former R+L vagus nerves)
 T12
 Aorta
 Azygos veins
 Thoracic duct

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 T H OR A C I C M U S C L E S

NAME. ORIGIN. INSERTION INNERVATION ACTION

Serratus Posterior Inferior ligamentum nuchae. Superior borders of 2nd to 4th ribs Intercostal nerves Elevates superior four ribs, to increase
Superior Spinous processes of C7 to thoracic volume, and raise sternum.
T3.

Serratus Posterior Spinous processes of T11 to
Inferior L2
Levator Costarum Transverse processes of C7
to T11
Inferior borders of inferior 3 or 4 ribs, Intercostal nerves Depresses inferior ribs, and prevents them
near their angles from being pulled superiorly by the
diaphragm.
Each rib, inferiorly, near their Intercostal nerves Elevate the ribs.
tubercles

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 I N T E RC O S TA L M U S C L E S

NAME. ORIGIN. INSERTION INNERVATION ACTION

External Intercostal Inferior border of rib above –
muscles from tubercle.
Internal intercostal Inferior border of rib above –
muscles from sternal margin.
Transversus Thoracis 1. Subcostalis – posterior internal
surface of rib
2. Innermost Intercostal – lateral
internal surfaces of ribs
3. Sternocostalis – Xiphoid process
Superior border of rib below – up to
costochondral junction, running
inferomedially.
Superior border of rib below – up to
angle of rib, running inferolaterally.
1. Subcostalis – posterior surface of
internal surface of rib inferior to
it.
2. Innermost Intercostal – lateral
internal surfaces of ribs
3. Sternocostalis – pass superolaterally
to 2nd to 6th costal cartilages
Intercostal nerves Rib is fixed by contraction of
Scalenus Anterior muscle.
Intercostal nerves Inspiratory muscles elevate the ribs
and sternum, to increase the
Intercostal nerves thoracic cavity in the transverse and
antero-posterior diameters
Keep intercostal spaces rigid, to
prevent bulging during expiration,
and being drawn in during
inspiration..

I N T E RC O S TA L N E RV E S

 Thoracic nerves , divide into primary ventral and dorsal rami, at intervertebral foramina.
 Dorsal Rami gives a cutaneous supply to back (a hand’s width on either side of midline)
 Ventral Rami of T1 to T11, become intercostal nerves, when they enter intercostal spaces, and run along Costal groove as part of the neurovascular bundle
of each intercostal space.
 1st Intercostal nerve:
 The root of T1 divides into a large superior part, which forms the inferior trunk of the brachial plexus. The smaller inferior part becomes the 1st intercostal
nerve.
 No anterior or lateral cutaneous branch
 2nd Intercostal nerve:
 The root of T2 may contribute a small branch to the brachial plexus.

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  The lateral cutaneous branch is called the Intercostobrachial nerve
 Supplies floor of axilla.
 Supplies medial side of upper limb down to elbow (aided by Medial Brachial Cutaneous nerve).
 Typical Intercostal Nerves (T3 to T6)
 White Rami Communicans to ganglion of sympathetic trunk
 Grey Rami Communicans from ganglion of sympathetic trunk
 Collateral branches arise near angle of rib, to supply intercostal muscles
 Lateral Cutaneous branches arise beyond angle of ribs:
 Pierce internal and external intercostal muscles.
 Anterior and posterior sub-branches, supply skin of lateral aspects of thoracic (and abdominal) walls.
 Anterior Cutaneous branches supply skin on anterior aspect of thoracic (and abdominal) walls
 Thoraco-abdominal Nerves (T7-T11)
 Atypical intercostal nerves.
 Share a similar structure to typical intercostal nerves.
 Increasingly distributed to the abdominal wall.
 Subcostal Nerve (T12):
 Follows the inferior border of the 12th rib.
 Passes into abdominal wall.
 Cutaneous supply to abdominal wall, and gluteal region (buttocks).

I N T E RC O S TA L V E S S E L S

One large posterior intercostal artery, a pair of smaller anterior intercostal arteries, and an intercostal vein supply each intercostal space.

POSTERIOR INTERCOSTAL ARTERIES

 The posterior intercostal arteries of the 1st and 2nd intercostal spaces, arise from the Superior Intercostal Arteries, which are branches of the Costocervical Trunks of
the Subclavian arteries.
 The posterior intercostal arteries of the 3rd to 11th intercostal spaces and the one pair of Subcostal arteries, are direct branches of the descending thoracic aorta.

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 Each posterior intercostal artery:
 Give a posterior branch that travels with the Dorsal Ramus, and supplies:
 Spinal Cord
 Vertebral Column
 Back Muscles
 Skin
 Gives a Collateral branch, which crosses the space, and runs along the superior border of the rib inferior to the space.
 Runs along costal groove with intercostal vein & nerve, in the neurovascular plane.
 Terminates by anastomosis anteriorly, with the corresponding anterior intercostal artery.

ANTERIOR INTERCOSTAL ARTERIES

 Arteries supplying 1st to 6th spaces, arise from the Internal Thoracic arteries.
 Arteries supplying 7th to 9th spaces, are derived from the Musculophrenic arteries.
 Supply intercostal muscles, and send branches to Pectoral muscles, medial side of breasts and skin.
 No anterior intercostal arteries, in 10th or 11th spaces – supplies only by posterior intercostal arteries, and their collateral branches.

INTERCOSTAL VEINS

 Deepest structure in costal grooves.

 11 pairs of posterior intercostal veins that anastomose with anterior intercostal veins (tributaries of Internal Thoracic veins), and one pair of Subcostal veins.
 Each have:
 Lateral cutaneous tributaries
 Muscular tributaries
 Intervertebral tributaries
 Posterior tributaries
 Valves to direct the blood posteriorly.
 Most intercostal veins drain posteriorly to an Azygos Vein, from where it drains into the Superior Vena Cava.
 The superior intercostal veins drain directly into the Superior Vena Cava.

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 I N T E R NA L T H O R A C I C V E S S E L S

INTERNAL THORACIC ARTERY

 Derived from the 1st part of the Subclavian artery, at the medial border of Scalenus Anterior muscle.
 Supplies 1st to 6th intercostal spaces (by a pair of anterior intercostal arteries)
 Supplies pectoral muscles, medial side of breasts, and surrounding skin, by means of perforating branches.
 Divides at 6th intercostal space:
 Superior Epigastric arteries.
 Musculophrenic arteries:
 Supplies 7th to 9th intercostal spaces (by a pair of anterior intercostal arteries)
 Supplies diaphragm.

INTERNAL THORACIC VEINS

 Venae comitantes of Internal Thoracic artery. Unite to form a single trunk around the 1st, 2nd or 3rd spaces.
 Empty into Brachiocephalic Veins.

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 P LEURAE & L UNGS

S U R FA C E M A R K I N G S O F P L E U R A E

 Apex = 2.5 cm above medial clavicle.

 Sternal Angle – the two pleural cavities come together
 4th to 6th Costal Cartilage – a small lateral depression on left side to accommodate pericardium.
 Mid-clavicular line – pleura at level of 8th rib.
 Mid-axillary – pleura at level of 10th rib.
 Mid-scapular line – pleura at level of 12th rib.
 Pleural membrane terminates about half an inch below 12th rib, on the back  out of cage and vulnerable.
 Visceral and Parietal Pleura are serous membranes, and secrete pleural fluid, to allow friction free
movement.
 A slight negative pressure gives the lungs a natural tendency to be drawn towards the pleura.
 Damage to the pleura can result in collapsed lung(s)
 Pneumothorax
 Hydrothorax
 Haemothorax
 Costomediastinal recess – mediastinal pleura is reflected into costal pleura, but anterior lung does not fit
in.
 A potential space for use during exercise, and increased breathing.
 Costodiaphragmatic recess – where diaphragmatic pleura is reflected into costal pleura.
 Larger
 Negative pressure closes off recess during passive breathing.
 Can be opened and used during exercise.
 There are no recesses at root of lung.
 Here visceral pleura and parietal pleura are reflected, and merge.
 At inferior root of lung, the pleura is baggy, and known as a Pulmonary Ligament.

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 Costal Pleura attached to the internal thoracic cage by endothoracic fascia – providing a natural cleavage plane.
 Cervical Pleura (or each Pleural Cupula) is strengthened by dense fascia called suprapleural fascia.
 This is attached to the internal; surface of the 1st rib, and the anterior surface of the transverse process of C7
 It also contains fibres of Scalenus Minimus muscle, for added strength.
 Arterial supply to the parietal pleura is through Intercostal, Internal Thoracic & Musculophrenic arteries.
 Arterial supply to the visceral pleura is through Bronchial arteries.
 Venous drainage of the parietal pleura is through Systemic veins.
 Venous drainage of the visceral pleura is direct to the Pulmonary veins.
 Parietal pleura is innervated by intercostal and phrenic nerves, while visceral pleura has very bad innervation.
 Thus even inflammation to the Pleural Cupula, is referred to by a patient as pain in the Thoracolumbar region.

E X T E R NA L F E A T U R E S OF T H E L U N G S

PART OF LUNG DETAILS

Apex 1. Lies 3 cm above middle clavicle, owing to obliquity of Thoracic Inlet.
2. Covered by Suprapleural membrane.
3. Crossed by Subclavian artery, that leaves a groove on the mediastinal surface.
Base 1. Concave diaphragmatic surface.
2. Base of right lung is deeper to accommodate the Liver.
Root 1. Connects medial surface of lung to the heart and trachea.
2. Surrounded by reflections of visceral and parietal pleura.
Hilum 1. Where root is attached to lungs.
2. Contains main bronchus, pulmonary vessels (1 artery + 2 veins), bronchial vessels, lymph vessels, and nerves.
Left Lung Has a superior and inferior lobe, separated by an oblique fissure. Remnants of middle fissure = Lingula.(folds over pericardium)
Right Lung Has a superior, middle and inferior lobe, separated by a horizontal and oblique fissure.
Costal Surface Related to costal pleura.
Mediastinal Surface 1. Concave, with a deeper concavity on the left, to accommodate the heart.
2. Contains root of lung, surrounding pleural reflections, and the pulmonary ligaments.
Diaphragmatic Surface 1. Deeply concaved surface, which forms the base of the lung.

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Anterior Border
Posterior Border
Inferior Border
Apex
Sternal Angle
4th to 6th Costal Cartilage
Mid-Clavicular Line
Mid-Axillary Line
Mid-Scapular Line
2. Postero-laterally, the diaphragmatic surface is bounded by a thin, sharp margin that projects into the Costodiaphragmatic recess.
Separates the costal and mediastinal surface.
Has a cardiac notch on the left lung.
During deep inspiration, it projects into the Costomediastinal recess.
Broad and rounded.
Separates the costal and mediastinal surface.
Lies in the Paravertebral Gutter.
Circumscribes the diaphragmatic surface, and separates it from the costal and mediastinal surfaces.
It is thin and sharp, where it projects into the Costodiaphragmatic recess.
It is blunt and rounded medially, where it separates the diaphragmatic surface from the mediastinal surface.
Lung – 2.5 cm above medial clavicle.
Pleura – 2.5 to 3 cm above medial clavicle.
Lung – mediastinal surfaces come together.
Pleura – cavities come together
Lungs – deeper cardiac notch on left.
Pleura – cardiac notch on left.
Lungs – at level of 6th rib.
Pleura – at level of 8th rib.
Lungs – at level of 8th rib.
Pleura – at level of 10th rib.
Lungs – at level of 10th rib.
Pleura – at level of 12th rib.
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 B RO N C H I A L T R E E

Trachea
 Begins beneath larynx at C6. Right Principal Bronchus
 Bifurcates at Sternal angle  16 cm long.  Short & wide – only 2.5 cm long.
 Held open by C-shaped cartilage rings.  Superior lobar bronchus, divides before
 Lies in mid-line of neck, anterior to reaching the root of lung.
oesophagus.

Superior Lobar Bronchus Middle Lobar Bronchus Inferior Lobar Bronchus

10 Segmental Bronchi
Left Principal Bronchus Superior Lobar
 Supply specific bronchopulmonary segments.
 Passes left, and curves over heart Bronchus
 No connections between segments  conditions are localised.
 Runs inferior to aortic arch.
 Each segment is conical in shape, with its apex at the root of the lung, and its
 Lies anterior to descending thoracic aorta, base on the surface.
and oesophagus.
Inferior Lobar  Each bronchopulmonary segments its own pulmonary artery, with pulmonary
 5cm long. veins & lymphatics lying at the boundaries between segments, in the
Bronchus
connective tissue.

Respiratory Terminal Conducting

ALVEOLUS Alveolar Sac Alveolar Duct Bronchioles Bronchioles Bronchioles

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 A RT E R I A L S U P P LY TO L U N G S
 Pulmonary arteries carry de-oxygenated blood to the lungs, and run
poster-laterally with the main bronchus.
 They divide with the airways, according to the bronchial tree, to
supply each bronchopulmonary segment.
 The terminal branches divide into capillaries, which lie in the walls of
the alveoli.
 This is the 1st capillary destination of blood from the heart 
often the site of a Thrombopulmonary Embolism.
 Bronchial arteries supply the connective tissue of the bronchial tree.
 They run along the posterior aspect of the airways, and divide with
them as far as the respiratory bronchioles.
 The two left bronchial arteries are direct branches of the superior
part of the descending thoracic aorta.
 Superior and inferior to the left main bronchus.
 The single right bronchial artery arises as a common trunk with the
3rd or 5th Intercostal artery, directly from the Descending Thoracic
Aorta.
 Or it can arise from the Superior Left Bronchial artery.
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V E N OU S D R A I NA G E O F T H E L U N G S
 Pulmonary veins, carry blood from the capillaries of the lungs back to
the heart, and run with the corresponding airways, within the inter-lobular-
septa .
 Tributaries progressively drain into larger veins, until four main
Pulmonary veins are formed.
 Superior Right Pulmonary Vein drains the superior and middle lobes
of the right lung.
 Superior Left Pulmonary Vein drains the superior lobe of the left
lung.
 Inferior Right + Left Pulmonary Veins drain the inferior lobes of
both lungs.
 Bronchial veins, drain the large subdivisions of the bronchi – but they
only drain some of the blood delivered by the bronchial arteries, as the
rest is drained by the pulmonary veins.
 Right bronchial vein drains into the Azygos Vein
 Left bronchial vein drains into the Accessory Hemiazygos Vein, or the
Left Superior Intercostal Vein.
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 I N N E RVA T I O N O F T H E L U N G S LY M P H A T I C G R A I NA G E O F T H E L U N G S

 Anterior & Posterior Pulmonary Plexuses – located anterior and posterior to
the roots of the lungs.
 Composed of sympathetic nerves (sympathetic trunks), and
parasympathetic nerves (vagus nerve).
 Efferent fibres of the Vagus nerve are:
 Motor to smooth muscle of bronchial tree (bronchoconstrictor).
 Inhibitory to pulmonary vessels (vasodilator).
 Secretomotor to glands of bronchial tree.
 Afferent fibres of the Vagus nerve are:
 Sensory to the respiratory epithelium (touch and pain).
 Sensory to the branches of the bronchial tree (stretch).
 Superficial Lymphatic Plexuses – lie deep to the visceral pleura, and
drain the lungs, and visceral pleura.
 Bronchopulmonary Lymph nodes at Hilum.
 Superior + Inferior Tracheobronchial lymph nodes at bifurcation of
Trachea.
 Deep Lymphatic Plexus – lie in submucosa of bronchi, and in
peribronchial connective tissue.
 Pulmonary Lymph nodes, in lung along the large branches of the
main bronchi.
 Lymph vessels follow bronchial tree to Bronchopulmonary Lymph
nodes at Hilum.
 Superior + Inferior Tracheobronchial Lymph nodes.

 Efferent Sympathetic fibres are:  Tracheobronchial Lymph nodes  Bronchomediastinal Lymph

 Inhibitory to smooth muscle of bronchial tree (bronchodilator).
 Motor to the pulmonary vessels (vasoconstrictor).
 Inhibitory to the glands of the bronchial tree.
 Afferent Sympathetic fibres are:
 Present, but function unknown.
Trunks
 Bronchomediastinal Lymph Trunks – formed by junction of parasternal,
tracheobronchial, and anterior mediastinal
 Subclavian / Internal Jugular veins, or Thoracic Duct.

FEATURES ESSENTIAL FOR VENTILATION

1. Diaphragm – Phrenic nerves (C3, C4, and C5).

2. Open airway – blocked by swallowing tongue, or when spiral muscles go into spasm during Asthma.
3. Rigid chest wall – flail chest (multiple rib fractures), does not allow rib cage to move.
4. Elastic recoil.
5. Intact Pleural Cavity – maintains negative pressure, to draw lung onto thorax wall lung expands as well as thoracic volume.

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 M IDDLE M EDIASTINUM

PERICARDIUM

FIBROUS PERICARDIUM

 Tough, conical outer sac, that protects the heart against sudden overfilling.
 Apex – at sternal angle, connected to the tunica adventitia great vessels.
 Base – attached to central tendon of diaphragm.  Pierced on the right, and posteriorly by the Inferior Vena Cava.
 Attached anteriorly, to internal surface of sternum by sternopericardial ligaments (condensations of connective tissue).
 Influenced by the movements of the diaphragm, heart, and sternum.
 Extends 1 – 1.5 cm to the right of the sternum
 Extends 5 – 7.5 cm to the left of the median plane, at the 5th intercostal space.
 Separated from thoracic cage, by pleurae and lungs (except at sternopericardial ligaments)

SEROUS PERICARDIUM

 Parietal pericardium is fused onto the internal surface of the fibrous pericardium.
 Visceral pericardium, is reflected onto the heart, where it form s the epicardium (the external surface of the heart).
 The Pericardial Cavity, lies in between the two layers of serous pericardium
 Filled with a thin film of serous fluid, that allows the heart to move and beat friction free.
 Parietal pericardium, is reflected into Visceral pericardium, where the great vessels enter and leave the heart.

ARTERIAL SUPPLY TO THE PERICARDIUM

 Pericardiophrenic, and Musculophrenic arteries, which are branches of the Internal Thoracic artery.
 Can also receive pericardial branches from the Bronchial, Oesophageal, and Superior Phrenic arteries.
 Visceral layer of serous pericardium, is supplied by the Coronary arteries.

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VENOUS DRAINAGE FROM THE PERICARDIUM

 Tributaries of the Azygos system.

 Drainage aided by Pericardiophrenic Veins, which drain into the Internal Thoracic Veins (vena comitantes of the Internal Thoracic artery).

INNERVATION OF THE PERICARDIUM

 Phrenic nerves
 Vagus nerves
 Derivations of the Sympathetic Trunk.

S U R FA C E A NA TOM Y OF H E A RT

PART OF HEART DETAILS

Base 1. Located posteriorly.
2. Composed mainly of the Left Atrium.
Apex 1. Formed by the Left Ventricle, and points infero-laterally.
2. Lies in left 5th intercostal space, just medial to left mid-clavicular line.
Sternocostal Surface Lies anteriorly, and is formed by the Right ventricle.
Diaphragmatic Surface 1. Lies inferiorly, and is formed by both ventricles (mainly left).
2. It is horizontal or slightly concave, and is related to the central tendon of the diaphragm.
3. Divided by Posterior Interventricular Groove.
Pulmonary (left) Surface 1. Formed by the Left Ventricle.
2. Occupies the Cardiac Notch of the Left Lung.
Right Border 1. Slightly convex, and formed by Right Atrium.
2. Almost in line with Superior & Inferior Vena Cavae.
3. A line drawn from the 3rd right costal cartilage, to the 6th right costal cartilage.
Left Border 1. Formed by the Left Ventricle, and partially by the Left Auricle.
2. A line drawn from the inferior margin of the 2nd left costal cartilage, to the 5th intercostal space (just medial to the mid-clavicular line).
Superior Border 1. Where the great vessels, enter and leave the heart.

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 2. Formed by the Right + Left Auricles, and the superior conical portion of the Right Ventricle (= Conus Arteriosus / Infundibulum), between
them.
3. A line drawn from the superior border of the 3rd right costal cartilage, to the inferior margin of the 2nd left costal cartilage.
Inferior Border 1. Almost horizontal, formed by the Right Ventricle, and a little of the Left Ventricle.
2. A line drawn from the 6th right costal cartilage, to the 5th intercostal space (just medial to the mid-clavicular line).

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 C H A M B E R S OF T H E H E A R T.

 Coronary groove – separates atria from ventricles.

 Anterior & Posterior Interventricular Sulci – separate the ventricles. The
interventricular septum, can be mapped out by the paths of the anterior +
posterior interventricular branches of the coronary arteries, that lie in these
grooves.
 Interatrial Septum – divides the atria.

RIGHT ATRIUM

 Receive venous blood from the Superior Vena Cava (at level of 3rd right
Costal Cartilage), Inferior Vena Cava, and the Coronary Sinus.
 Coronary Sinus lies in posterior part of coronary groove, between the
tricuspid orifice and the inferior vena cava orifice.
 Guarded by a valve, that closes during atrial contraction.
 Receives blood from the intrinsic veins of the heart.
 The internal wall of the Right Atrium consists of:
 Smooth, posterior sinus vasarum, which receives the Vena Cavae and
Coronary Sinus.
 Rough, anterior part, with internal muscular ridges = musculi pectinati.
 Separated internally by the Crista Terminalis, and externally by the Sulcus
Terminalis.
 The Right Auricle = a small muscular pouch, that projects to the left, and
overlaps the ascending aorta.
 The Interatrial Septum forms the postero-medial wall of the right atrium –
contains the fossa ovalis.
 Fossa ovalis is the remnant of the Foramen Ovale, and has a sharp, incomplete margin known as the limbus fossa ovalis.
 During atrial contraction, blood forces Tricuspid valve open, and flows anteriorly & horizontally into Right Ventricle.

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RIGHT VENTRICLE

 Conus Arteriosus / Infundibulum, forms the superior part of the right ventricle, and is the route of blood flow under pressure, towards the Pulmonary Trunk
 Therefore, its walls are smooth, to prevent damage to erythrocytes.
 The rest of the ventricle, is roughened with Papillary muscle, and Trabeculae Carneae
 A specialised Trabeculae Carneae, is the Septomarginal Trabecula, which contains the atrioventricular bundle – part of the conducting system of the heart.
 The Supraventricular Crest separates the main ventricle from the Conus Arteriosus / Infundibulum.
 Blood flows superiorly and posteriorly, during ventricular systole, into the Pulmonary Trunk.

Tricuspid Valve

 Has an anterior, posterior, and septal cusp, that are attached to a fibrous ring.
 Papillary muscles connect to two cusps, via Chordae Tendineae
 Prevent eversion of valve during ventricular systole.
 Contract just prior to systole.
 Tighten the Chordae Tendineae, and draw the cusps close together, before
ventricular contraction begins.
 Anterior Papillary Muscle:
 Largest.
 Attached to anterior wall of right ventricle.
 Its chordae tendineae attach to the anterior and posterior cusps of the tricuspid valve.
 Posterior Papillary Muscle:
 Smaller, and consists of many parts.
 Attached to the inferior wall of the right ventricle.
 Attaches to the posterior and septal cusps.
 Septal Papillary Muscle:
 Attached to the right side of the interventricular septum.
 Attaches to the septal and anterior cusps.

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 Pulmonary Valve

 2.5 cm in diameter
 Located at sternal margin of 3rd left Costal Cartilage.
 Consists of three semi-lunar cusps, attached to a fibrous ring.
 Opposite each cusp, is a pulmonary sinus (= a slight dilation in the pulmonary trunk’s
wall)
 Prevents cusps from sticking to wall, and so prevents them from failing to shut.

LEFT ATRIUM

 4 Pulmonary Veins (2 superior + 2 inferior) enter the posterior wall of the Right Atrium.
 Internal surface is smooth, except in the Left Auricles, which have musculi pectinati.
 Anterior to left atrium are the Right Atrium, Aorta & Pulmonary Trunk.
 Posterior to the left atrium, is the oesophagus.
 Superior to left atrium are the Right + Left Pulmonary arteries.
 Inferior to the left atrium is the Coronary Sinus.

LEFT VENTRICLE

 Aortic vestibule is part of ventricle, leading to ascending aorta.  Smooth internal

surface.
 Rest of ventricle wall is covered with a dense mesh of Trabeculae Carneae.
 Finer, and more numerous.
 Wall is twice as thick as right ventricle
 Two Papillary muscles, are connected to the two cusps of the Bicuspid valve, by thicker & fewer Chordae Tendineae.
 Anterior Papillary muscle is attached to the anterior wall.
 Posterior Papillary muscle is attached more posteriorly, on the ventricle’s inferior wall.
 The aortic valve has three semi-lunar valves, and hence three aortic sinuses – blood in these sinuses prevents the cusps from sticking to the wall.
 Right coronary artery branches from the right aortic sinus.
 Left coronary artery branches from the left aortic sinus.
 No branches from the noncoronary (aortic) sinus.

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 ARTERIAL SUPPLY TO T HE HEART

Also supply vasa vasorum of the great vessels.

RIGHT CORONARY ARTERY

 Arises from the right aortic sinus

 Passes between right auricle, and pulmonary trunk.
 Gives of SA-nodal artery in 45 % of cases.
 Passes to inferior border of heart, in the coronary (atrioventricular) groove.
 Gives off right marginal branch.
 Runs along inferior border, to the apex.
 Reflected onto posterior surface, where it continues to run in the posterior coronary (atrioventricular) groove.
 On reaching the posterior interventricular groove:
 It gives off its largest branch: the posterior interventricular artery.
 Travels to apex of heart, where it anastomoses with the anterior interventricular artery.
 It gives off the AV-nodal artery – supplies the AV node  in 85% of cases.
 The right coronary artery terminates by anastomosis with the circumflex branch of the left coronary artery.
 Supplies:
 Right atrium
 Right ventricle
 Interventricular septum
 SA-node & AV node
 Variable part of right atrium & ventricle.

LEFT CORONARY ARTERY

 Arises from the left aortic sinus

 Passes between the pulmonary trunk and the left auricle, to reach the coronary groove.

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 Branches into:
 Anterior Interventricular Branch
 Runs along anterior interventricular groove, to the apex.
 Here it is reflected onto the inferior surface, to anastomose with the posterior interventricular groove.
 Circumflex branch – reflected around the left border.
 Give a marginal branch, runs along the left border of the heart, to the apex.
 Supplies:
 Left atrium
 Left ventricle
 Interventricular septum + AV bundles
 Helps (or is the sole supplier) of the SA and
AV nodes.

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 V E N OU S D R A I N A G E F R OM T H E H E A R T

 Coronary Sinus runs from left of right in the posterior coronary (atrioventricular) groove.
 Drains all the venous blood of the heart, except for the anterior cardiac veins, and the venae cordis minimi.
 Opens into the right atrium.
 Tributaries are:
 Great Cardiac Vein – begins at apex, and runs along the anterior interventricular groove, with the artery.
 Enters left end of coronary sinus, with a valve.
 Drains blood supplied by Left Coronary artery.
 Middle Cardiac Vein – begins at apex, and runs along the posterior interventricular groove, with the posterior interventricular branch of the right
coronary artery.
 Enters the right end of the coronary sinus.
 Drains most of the area supplied by the right coronary artery.
 Small Cardiac Vein – runs along the inferior surface of the heart with the marginal branch of the right coronary artery. It is then reflected onto the
posterior coronary (atrioventricular) groove.
 Terminates in the coronary sinus, or may enter the right atrium directly.
 Drains most of the area supplied by the right coronary artery.
 Posterior Vein of Left Ventricle – runs along the inferior surface of the left ventricle, and empties into the coronary sinus, near to the middle cardiac vein.
 Oblique Vein of Left Atrium – small & unimportant, that runs along the posterior wall of the left atrium. It enters the left end of the coronary sinus.
 Venae Cordis Minimi – tiny vessels that begin in the myocardium, and open directly into the chambers of the heart (mainly atria)
 Although veins, they may also carry blood to the myocardium.
 Anterior Cardiac Veins – begin on the anterior surface of the right ventricle, cross over the coronary (atrioventricular) groove, and enter the right atrium
directly. They may however, merge with the small cardiac vein.

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 INNERVATION OF THE HEART

 Cardiac Plexus – autonomic fibres of the sympathetic and the

parasympathetic nervous system.
 Anterior to the bifurcation of the trachea.
 Posterior to the arch of the aorta.
 Superior to the bifurcation of the pulmonary trunk.
 Afferent fibres are transmitted to the vagus nerves, from the
walls of the great vessels & lungs, via this plexus.
 From pressure receptors.
 Sympathetic stimulation:
 Increases heart rate.
 Increases stroke volume.
 Vasodilation of coronary arteries  more oxygen and nutrients
to myocardium
 Parasympathetic stimulation:
 Slows heart
 Reduces force of contraction
 Constricts coronary arteries.

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 S UPERIOR M EDIASTINUM

 Inferior thyroid veins

THYMUS
 Highest intercostal veins (drain 1st intercostal space)
 Two flat lobules are prominent in infancy & childhood. Located in  The left and right brachiocephalic veins merge (on the right), to form the
anterior part of superior mediastinum – immediately posterior to the Superior Vena Cava – behind the 1st right Costal Cartilage.
manubrium.
RIGHT BRACHIOCEPHALIC VEIN
 Important role in the maintenance and development of the immune
system,  Posterior to manubrium.
 At puberty, the thymus diminishes in size. By adulthood, it is largely  Lateral to Brachiocephalic Trunk – right vagus runs between the two.
adipose tissue, and scarcely recognisable. However, it continues to  Right phrenic nerve, runs poster-laterally to the right brachiocephalic
produce T-Lymphocytes. vein.
 Arterial supply is from, inferior thyroid, anterior intercostal, and internal thoracic  Receives the Right Lymphatic duct.
arteries.
 Venous drainage is from, inferior thyroid, left brachiocephalic, and internal LEFT BRACHIOCEPHALIC VEIN
thoracic arteries.
 Lymph drains to the parasternal, brachiocephalic, and tracheobronchial lymph  Twice as long as the right brachiocephalic vein.
nodes.  Passes obliquely from left to right, and inferiorly.
 Passes anteriorly to the:
 Left Phrenic nerve
BRACHIOCEPHALIC VEINS
 Left vagus nerve
 Left common carotid artery
 Each vein forms by the merging of the Internal Jugular Vein (drains  The trachea
head) and the Subclavian Vein (drains arm), at the medial end of each  Brachiocephalic trunk
clavicle.  Right vagus nerve.
 Each brachiocephalic veins receives :  Receives the thoracic duct, and the left superior intercostal vein.
 Internal thoracic veins
 Vertebral veins.

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 V E N A C AVA E

SUPERIOR VENA CAVA INFERIOR VENA CAVA

 Formed by the brachiocephalic veins, posterior to the 1st right Costal  Empties into right atrium – drains the lower limbs and abdomen.
Cartilage.  Pierces central tendon of diaphragm, at level of T8.
 Azygos Vein drains into the superior vena cava, at the level of the 2nd  Unaffected by diaphragm contractions.
Costal Cartilage.  Phrenic nerve lies with it as it pierces diaphragm.
 Enters the right atrium, at the level of the 3rd Costal Cartilage  about
7cm long.
 Lies antero-laterally to the trachea.
 Lies postero-laterally to the ascending aorta.
 Lies medial to the right phrenic nerve.
 Drains the:
 Head
 Neck
 Upper Limbs
 Thoracic Wall.

T H E A ORTA

ASCENDING THORACIC AORTA

 2 inches long – spirals superiorly with the Pulmonary Trunk.

 Coronary arteries branch from its sinuses (at its proximal end).

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ARCH OF AORTA

 Begins in Plane of Louis, posterior to the right 2nd Sternocostal joint

 Arches supero-posteriorly, to the left.
 Passes anteriorly to the trachea, to reach the left side of the trachea, and oesophagus – peaks 2.5-cm below jugular notch.
 Loops over root of left lung, as it descends.
 Ends in the plane of Louis, to the left of the vertebral body of T4.
 Ligamentum arteriosum (the remnant of the Ductus Arteriosum) passes from the root of the left pulmonary artery, to the inferior, concave surface of the aortic arch.
 The left recurrent laryngeal nerve hooks around the arch, posterior to the ligamentum arteriosum – it then ascends between the trachea and oesophagus.
 Branches are:
 Brachiocephalic Trunk – in the median plane of the manubrium.
 Anterior to the trachea, and posterior to left brachiocephalic vein.
 Branches further at the right sternoclavicular joint.
 Left Common Carotid Artery – passes to the left of the trachea.
 Enters the neck by passing posteriorly to the left sternoclavicular joint.
 Left Subclavian Artery – from posterior part of arch, ascends with the left common carotid artery.
 Lies against the left lung & pleura laterally, and enters the neck by passing posteriorly to the left sternoclavicular joint.

DESCENDING THORACIC AORTA

 Lies in posterior mediastinum between T4 and T12.

 Pierces diaphragm with thoracic duct & azygos vein, through aortic hiatus.
 Branches:
 Two left Bronchial arteries.
 Oesophageal arteries.
 Branches to Pericardium.
 9 pairs of posterior intercostal arteries – supplies 3rd to 11th intercostal spaces.
 1st & 2nd space supplied by Subclavian artery.
 Subcostal arteries
 Superior Phrenic arteries:
 Pass to the posterior surface of the diaphragm, and anastomose with:

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  Musculophrenic arteries.
 Pericardiophrenic arteries.
 Branches of the internal thoracic artery.
 To the right:
 Thoracic duct
 Azygos Vein
 Bodies of Thoracic Vertebrae (posterior as well).
 To the left:
 Pleura of left lung.
 Anteriorly:
 Root of left lung (superior as well)
 Pericardium
 Oesophagus (inferior as well).

P U L M ONA RY A RT E R I E S

 Arise from the Pulmonary Trunk, at the Sternal Angle.

 Right Pulmonary artery is longer.
 Travels inferior to aortic arch, to the hilum of the right lung.
 Just before it enters the root, it gives of a right Superior Lobar Artery.
 Left pulmonary artery is shorter.
 At root of lung:
 Arteries are above.
 Bronchus is behind.
 Veins are very low down.

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 T H E VA G U S N E RV E S

 10th Cranial nerves – arising from the medulla of the brain.

 Each enters the superior mediastinum, posterior to the appropriate sternoclavicular joint and brachiocephalic vein.
 Thoracic parts run postero-laterally to the Common carotid arteries.

RIGHT VAGUS NERVE

 Enters thorax anterior to the right subclavian artery.

 Gives a right recurrent laryngeal branch – hooks around right subclavian artery, and ascends between trachea & oesophagus to supply the larynx.
 Runs posteriorly to the right brachiocephalic vein & superior vena cava
 Breaks up into branches to Right Pulmonary Plexus.
 Located posterior to root of right lung.
 Supplies lungs & bronchi.
 Vagus nerve leaves plexus as a single nerve, and passes to the oesophagus, where it divides into branches to the oesophageal plexus.
 Supplies oesophagus, pericardium & pleura.
 Vagus nerve continues to give branches to the Cardiac Plexus – between arch of aorta, and bifurcation of trachea.

LEFT VAGUS NERVE

 Descends in the neck, posterior to the left common carotid artery – between it and the left subclavian artery.
 At arch of aorta, the left superior intercostal vein laterally separates it from the phrenic nerve.
 The left vagus nerve curves medially around the inferior surface of the arch of the aorta – here it gives off the left recurrent laryngeal branch.
 Hooks around ligamentum arteriosum, and passes superiorly on the right side of the arch, and then in a groove between the trachea & oesophagus.
 Supplies the larynx, oesophagus & trachea.
 Passes posterior to the root of the left lung, where it breaks up to contribute to the left pulmonary plexus.
 It leaves this plexus as a single nerve, and contributes to the oesophageal plexus on its descent.

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 T H E P H R E N I C N E RV E S

 C3, C4, C5 – sole motor supply to the diaphragm, and one third of their sensory fibres are to the central part of the diaphragm too.
 Periphery innervated by sensory intercostal nerves.
 Phrenic nerves give sensory supply to the fibrous pericardium, and the parietal layer of the serous pericardium.
 Enter superior mediastinum, between subclavian artery, and the origin of the brachiocephalic veins.

RIGHT PHRENIC NERVE

 Passes along the right side of the:

 Right brachiocephalic vein
 Superior Vena Cava
 Pericardium over the right atrium.
 Passes anterior to the root of the right lung.
 Descends on the right side of the inferior vena cava – and pierces diaphragm with it.

LEFT PHRENIC NERVE

 Descends between the left subclavian, and the left common carotid arteries.
 Crosses the left surface of the aortic arch – anterior to the left vagus nerve.
 Passes over the left superior intercostal vein.
 Descends anterior to the root of the left lung.
 Runs along pericardium over left auricle & left ventricle.
 Pierces diaphragm to the left of the pericardium (on its own).

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 THE TRACHEA THE OESOPHAGUS

 A wide fibrocartilaginous tube – superiorly in the neck, but enters the
superior mediastinum, anterior to the oesophagus.
 Posterior surface is flat, where it lies against the oesophagus – consists of
Trachealis muscle
 Kept patent by a series of C-shaped tracheal cartilages.
 5 to 6-cm long; ends at sternal angle by bifurcating – lies between C6 &
T4.
 At bifurcation, the last ring of cartilage is visible internally = Carina.
 25-cm from the incisors of mouth – useful in bronchoscopes.
 Anterior to carina:
 Arch of aorta
 Brachiocephalic Trunk (right)
 Left Common Carotid artery (left)
 Left Brachiocephalic Vein.
 Anterior to left bronchus = aortic arch
 Anterior to right bronchus = azygos vein.
 Between aortic arch & bifurcation = Cardiac Plexus (at sternal angle)
 A narrow fibro-muscular tube – flattened antero-posteriorly.
 Connects the pharynx (throat) to the stomach  30-cm long, and has a
cervical, thoracic & abdominal part.
 Enters superior mediastinum, between the trachea, and the vertebral
bodies – lies anterior to T1-T4.
 Inclines to the left, but is pushed back into the median plane by the arch
of the aorta.
 Thoracic duct lies on its left side, deep to the arch of the aorta.
 Inferior to the arch, it once again inclines left, as it pierces the diaphragm
at T10 with the descending thoracic aorta, vagus nerve & left gastric
vessels.
 Muscle of diaphragm around it acts as a sphincter, to keep food in
stomach.
 2 layers of muscle
 inner circular muscle
 outer longitudinal muscle
 Innervated by the left recurrent laryngeal nerve, vagus nerves of the
oesophageal plexus, and sympathetic nerves.

S U M M A RY OF C O N T E N T S O F T H E S U P E R I OR M E D I A S T I N U M

1. Thymus 6. Left recurrent laryngeal nerve

2. Great vessels related to the heart and pericardium 7. Oesophagus
3. Phrenic & Vagus nerves 8. Thoracic duct
4. Cardiac plexus of nerves 9. Prevertebral muscles (e.g. longus colli muscle)
5. Trachea

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 P OSTERIOR M EDIASTINUM

T H OR A C I C D U C T

 Lies on the bodies of the inferior 7 thoracic vertebrae (T6-T12)

 Drains lymph vessels from:
 Posterior mediastinal lymph nodes
 Intercostal lymph nodes
 All nodes below diaphragm
 Cisterna chyli – anterior to T12, and posterior + right to the aorta.
Does NOT drain the Lungs.
 Passes superiorly from cisterna chyli through the aortic hiatus in the diaphragm at T10.
 Thin walled, dull white and beaded vessel (because of many valves).
 Ascends in posterior mediastinum, between descending thoracic aorta, and the azygos vein.
 Somewhere between T4-T6 – crosses over to the left, posterior to the oesophagus.
 Now ascends in the superior mediastinum, until it empties into the origin of the left brachiocephalic vein – usually as two or three separate branches.

A Z YG O S S Y S T E M O F V E I N S

No valves

AZYGOS VEIN

 Connects the superior vena cava, and the inferior vena cava.
 Drains blood from
 Drains all right intercostal spaces, up to the 4th.
 2nd & 3rd right intercostal space drained by the right superior intercostal vein – drains into the arch of the azygos vein.
 1st right intercostal space drained by the supreme intercostal vein, which drains directly into the right brachiocephalic vein.
 The posterior wall abdomen

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  Mediastinal veins
 Oesophageal veins
 Bronchial veins
 Vertebral venous plexuses – drains:
 Back
 Vertebrae
 Structures in the vertebral canal
 Ascends in the posterior mediastinum, to the right of the vertebral bodies of T5-T12
 Covered anteriorly by the oesophagus, as it passes posterior to the root of the right lung
 It then arches over the superior aspect of the root of this lung  connects to the Superior Vena Cava.

HEMIAZYGOS VEIN

 Arises on the left – at the junction of the left subcostal vein, and the ascending lumbar veins.
 Ascends on the left side of the vertebral column – posterior to descending thoracic aorta, as far as T9
 Crosses over to the right, posterior to the aorta, thoracic duct, and oesophagus  joins the Azygos vein.
 Drains the:
 Inferior three posterior intercostal veins.
 Several small mediastinal veins.

ACCESSORY HEMIAZYGOS VEIN

 Begins at medial end of 4th or 5th left intercostal spaces.

 Descends between T5 and T8, on the left side of the vertebral column.
 Receives tributaries from:
 Veins of the 4th to 8th left intercostal spaces.
 2nd & 3rd left intercostal space drained by the left superior intercostal vein – normally drains directly into left brachiocephalic vein.
 1st left intercostal space drains directly into the left brachiocephalic vein.
 Left bronchial veins (sometimes)
 Crosses over to the right, between T7 & T8, posterior to the aorta & thoracic duct  joins the azygos vein.
 The accessory hemiazygos vein is also frequently connected to the left superior intercostal vein.

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 A UTONOMIC N ERVOUS S YSTEM

 Sympathetic fibres usually have short preganglionic fibres, and long post-ganglionic fibres.
 Parasympathetic fibres usually have long preganglionic fibres, and short post-ganglionic fibres.

S Y M PA T H E T I C

 Cell bodies lie in lateral grey horns of Thoraco-lumbar outflow (T1-L2) – preganglionic fibres travel via the ventral root, joining the spinal nerves for a short distance.
 Preganglionic fibres then divert to the sympathetic ganglia of the sympathetic trunk, via the white rami communicantes.
 The route thereafter depends on the destination of the sympathetic fibres.

SOMATIC (BODY WALL)

 Provide a sympathetic supply to:

 Sweat glands
 Arterioles
 Arrectores pilorum muscles & hair follicles, of body wall and skin.
 Synapse with a sympathetic ganglion, at the same level as their origin.
 Distributed with the primary and dorsal primary rami of the spinal nerve, via the grey ramus communicans.
 Pass directly up the sympathetic trunk without synapsing to the ganglion at its own level, to a higher ganglion.
 There it synapses, and is distributed with the primary and dorsal primary rami of the cervical nerves, via the grey rami communicantes.
 Pass directly down the sympathetic trunk without synapsing to the ganglion at its own level, to a lower ganglion.
 There it synapses, and is distributed with the primary and dorsal primary rami of the lumbar, sacral & coccygeal nerves, via the grey rami communicantes.

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VISCERAL (CENTRAL)

 Preganglionic fibres synapse with a sympathetic ganglion at its own level – pass into thoracic viscera, and supply the heart and lungs with small-unnamed branches
– pass through cardiac, pulmonary, or oesophageal plexuses.
 Or they pass directly into a splanchnic nerve
 Greater Splanchnic nerve – T5-T9 (Coelic Plexus)
 Lesser Splanchnic nerve – T10-T11 (Coelic Plexus)
 Lowest Splanchnic nerve – T12 (Renal Plexus)
 Synapse with a prevertebral ganglion in the abdomen.
 Coelic ganglion
 Superior or Inferior Mesenteric ganglion
 Renal ganglion.
 Post-ganglionic fibres then pass into he abdominal or pelvic viscera
 Stomach
 Ileum
 Colon
 Or the preganglionic fibres pass directly to the Adrenal Medulla, via the lowest splanchnic nerve.
 Here the cells of the adrenal gland act as the secondary neurone, since the preganglionic fibres reach it, not post-ganglionic fibres.
 They then secrete adrenaline into the bloodstream.

HEAD & NECK

Somatic

 The preganglionic fibres pass directly up the sympathetic trunk, to the superior, middle & inferior cervical ganglia,
 They then pass to the blood vessels and Arrectores Pilorum muscles of the skin – by “hitchhiking” in the wall of the adjacent common carotid artery.

Visceral

 The preganglionic fibres pass directly up the sympathetic trunk, where they synapse to a cervical ganglion.
 Here, post-ganglionic fibres pass via the adjacent common carotid artery, to a cranial parasympathetic ganglion.

P REPARED BY M ICHAEL C. D AVID ON 23/08/08. P AGE 39 OF 40

  Then pass to their visceral destination.
 Dilator pupillae muscle of iris in eye.
 The preganglionic fibres pass directly up the sympathetic trunk, where they synapse to a cervical ganglion.
 From here, post-ganglionic fibres pass directly via the common carotid artery, to their visceral destination.
 Thyroid Gland.

AFFERENT (SENSORY) FIBRES

 Identical to sensory neurones of peripheral nervous system, but follow the same route as the efferent sympathetic fibres
 Sensitive to stretch (e.g. stomach, ileum or colon)
 Sensitive to lack of oxygen (=hypoxia – e.g. in heart).
 Cell bodies lie in the spinal dorsal root ganglia, and they terminate in the spinal cord – may trigger a reflex or connect centrally with the hypothalamus.
 Sympathetic afferent fibres of:
 Somatic origin – follow the same route as the peripheral sensory fibres.
 Thoracic viscus origin – join the spinal nerve, via unnamed branches and the white ramus communicans.
 Prevertebral ganglia origin – join the spinal nerve, via the splanchnic nerves and the white ramus communicans.

 The White Rami Communicantes contain:

 Sympathetic sensory afferents.
 Sympathetic preganglionic efferents.

PA R A S Y M PA T H E T I C

 Efferents from the Cranio-sacral Outflow.

 Cranial nerve III – Osculomotor.
 Cranial nerve VII – Facial.
 Cranial nerve IX – Glossopharyngeal.
 Cranial nerve X – Vagus.
 Spinal nerves of S2, S3, and S4 – pelvic splanchnic nerves.
 Afferents – cell bodies lie in the sensory ganglia of the cranial nerves, or in the dorsal root ganglia of the sacrospinal nerves.

P REPARED BY M ICHAEL C. D AVID ON 23/08/08. P AGE 40 OF 40