INTRODUCTION TO CLINICAL ANATOMY 39
sympathetic system in its distribution. The parasympathetic sys- information about the condition of the bodys internal envi-
tem distributes only to the head, visceral cavities of the trunk,
and erectile tissues of the external genitalia. With the exception
of the latter, it does not reach the body wall or limbs, and except
for initial parts of the anterior rami of spinal nerves S2S4, its
fibers are not components of spinal nerves or their branches.
Four discrete pairs of parasympathetic ganglia occur in the
head (see Chapters 7 and 9). Elsewhere, presynaptic parasym-
pathetic fibers synapse with postsynaptic cell bodies, which
occur singly in or on the wall of the target organ (intrinsic or
enteric ganglia). Most presynaptic parasympathetic fibers are
long, extending from the CNS to the effector organ, whereas
the postsynaptic fibers are short, running from a ganglion lo-
cated near or embedded in the effector organ.
Visceral Afferent Sensation
Visceral afferent fibers have important relationships to the
ANS, both anatomically and functionally. We are usually un-
aware of the sensory input of these fibers, which provides
Medical Imaging
Body Systems
Familiarity with imaging techniques commonly used in clinical
settings enables one to recognize abnormalities such as congeni-
tal anomalies, tumors, and fractures. The introduction of contrast
media allows the study of various luminal or vascular organs and
potential or actual spaces, such as the digestive or alimentary sys-
tem, blood vessels, kidneys, synovial cavities, and subarachnoid
space. This section consists of short descriptions of the principles
of some of the commonly used diagnostic imaging techniques:
Conventional radiography (ordinary X-ray images)
Computerized tomography (CT)
Ultrasonography (US)
Magnetic resonance imaging (MRI)
Positron emission tomography (PET)
CONVENTIONAL RADIOGRAPHY
The essence of a radiological examination is that a highly penetrat-
ing beam of X-rays transilluminates the patient, showing tissues of
differing densities of mass within the body as images of differing
densities of light and dark on the X-ray film (Fig. I.32). A tissue
or organ that is relatively dense in mass, such as compact bone in
a rib, absorbs more X-rays than does a less dense tissue, such as
spongy (cancellous) bone (Table I.5). Consequently, a dense tissue
or organ produces a relatively transparent area on the X-ray film
because relatively fewer X-rays reach the emulsion in the film.
Therefore, relatively fewer grains of silver are developed at this
Moore_Ch00_Intro.indd 39
ronment. This information is integrated in the CNS, often
triggering visceral or somatic reflexes or both. Visceral reflexes
regulate blood pressure and chemistry by altering such func-
tions as heart and respiratory rates and vascular resistance.
Visceral sensation that reaches a conscious level is generally
categorized as pain that is usually poorly localized and may
be perceived as hunger or nausea. However, adequate stim-
ulation, such as the following, may elicit true pain: sudden
distention, spasms or strong contractions, chemical irritants,
mechanical stimulation (especially when the organ is active),
and pathological conditions (especially ischemiainadequate
blood supply) that lower the normal thresholds of stimulation.
Normal activity usually produces no sensation but may do so
when there is ischemia. Most visceral reflex (unconscious)
sensation and some pain travel in visceral afferent fibers that
accompany the parasympathetic fibers retrograde. Most vis-
ceral pain impulses (from the heart and most organs of the
peritoneal cavity) travel centrally along visceral afferent fibers
accompanying sympathetic fibers.
Arch of aorta
Clavicle Rib Trachea Pulmonary
artery
Heart
Right dome
of diaphragm Apex of heart
Postero-anterior (PA) projection
FIGURE I.32. Radiograph of thorax (chest).
area when the film is processed. A very dense substance is radi-
opaque, whereas a substance of less density is radiolucent.
Many of the same principles that apply to making a shadow
apply to conventional radiography. Radiographs are made with the
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 40 INTRODUCTION TO CLINICAL ANATOMY

TABLE I.5 BASIC PRINCIPLES OF X-RAY IMAGE X-ray tube

FORMATION

Most radiolucent Air Least radiodense

Fat

Water and most tissues

Spongy bone

Least radiolucent Compact bone Most radiodense

Detectors

part of the patients body being studied close to the X-ray film or
detector to maximize the clarity of the image and minimize mag-
nification artifacts. In basic radiological nomenclature, postero- (A)
anterior (PA) projection refers to a radiograph in which the X-rays
traversed the patient from posterior (P) to anterior (A); the X-ray
tube was posterior to the patient and the X-ray film or detector Right Left
was anterior. A radiograph using anteroposterior (AP) projection
radiography is the opposite. Both PA and AP projection radio- Rib
graphs are viewed as if you and the patient were facing each other
(the patients right side is opposite your left); this is referred to as Pancreas
an anteroposterior view. Thus, the standard chest X-ray, taken to
examine the heart and lungs, is an AP view of a PA projection. For Liver Aorta
lateral radiographs, radiopaque letters (R or L) are used to indicate
Vertebra
the side placed closest to the film or detector, and the image is
viewed from the same direction that the beam was projected. Left
The introduction of contrast media (radiopaque fluids such as kidney
iodine compounds or barium) allows the study of various luminal
or vascular organs and potential or actual spacessuch as the (B) Transverse CT image of upper abdomen
digestive tract, blood vessels, kidneys, synovial cavities, and the
subarachnoid spacethat are not visible in plain films. Most
radiological examinations are performed in at least two projections
at right angles to each other. Because each radiograph presents
a two-dimensional (2-D) representation of a three-dimensional
(3-D) structure, structures sequentially penetrated by the X-ray
beam overlap each other. Thus, more than one view is usually
necessary to detect and localize an abnormality accurately.

COMPUTERIZED TOMOGRAPHY
CT shows images of the body that resemble transverse anatomi-
cal sections (Fig. I.33). A beam of X-rays is passed through the
body as the X-ray tube and detector rotate around the axis of the
body. The amount of radiation absorbed by each different type
of tissue of the chosen body plane varies with the amount of fat,
bone, and water in each element. A computer compiles and gen- (C) Three-dimensional CT reconstruction
erates images as 2-D slices and total 3-D reconstructions. of bones of wrist and hand (palmar view)

FIGURE I.33. Computerized tomography. A. The X-ray tube rotates

ULTRASONOGRAPHY
US is a technique that allows visualization of superficial or deep
structures in the body by recording pulses of ultrasonic waves
reflecting off the tissues (Fig. I.34). The images can be viewed
in real time to demonstrate the motion of structures and flow
within blood vessels (Doppler US) and then recorded as single
around the person in the CT scanner and sends a fan-shaped beam of
X-rays through the persons body from a variety of angles. X-ray detectors
on the opposite side of the persons body measure the amount of radia-
tion that passes through a transverse section of the person. B and C. A
computer reconstructs the CT images. Transverse scans are oriented so
they appear the way an examiner would view the section when standing at
the foot of the bed and looking toward a supine persons head.

Moore_Ch00_Intro.indd 40 1/9/14 9:41 PM

 INTRODUCTION TO CLINICAL ANATOMY 41

images or as a movie. Because US is noninvasive and does not

use radiation, it is the standard method of evaluating the growth
and development of the embryo and fetus.

MAGNETIC RESONANCE IMAGING

MRI shows images of the body similar to those produced by CT,
but they are better for tissue differentiation (Fig. I.35). Using
MRI, the clinician is able to reconstruct the tissues in any plane,
even arbitrary oblique planes. The person is placed in a scanner
Transducer
with a strong magnetic field, and the body is pulsed with radio
Acoustic gel waves. Signals subsequently emitted from the patients tissues
coupling agent
are stored in a computer and may be reconstructed in 2-D or
Body wall 3-D images. The appearance of tissues on the generated images
Ultrasound can be varied by controlling how radiofrequency pulses are sent
waves and received. Scanners can be gated or paced to visualize mov-
Echo ing structures, such as the heart and blood flow, in real time.

Kidney POSITRON EMISSION TOMOGRAPHY

PET scanning uses cyclotron-produced isotopes of extremely
short half-life that emit positrons. PET scanning is used to eval-
(A)
uate the physiological functions of organs such as the brain on a
dynamic basis. Areas of increased brain activity will show selec-
tive uptake of the injected isotope (Fig. I.36).

RK

RK

(B)

LK

LRV

LRA

(C) Transverse Doppler ultrasound

FIGURE I.34. Ultrasonography. A. The image results from the echo of

ultrasound waves from structures of different densities. B. A longitudinal
image of a right kidney (RK) is displayed. C. Doppler US shows blood flow
to and away from the kidney. LK, left kidney; LRA, left renal artery; LRV,
left renal vein.

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 42 INTRODUCTION TO CLINICAL ANATOMY

Right atrium Aorta Left atrium

Air-filled Brain Cerebellum Venous sinus
sinus (cerebrum) (fluid-filled)

Fluid-filled Spinal cord Subcutaneous

subarachnoid tissue (fat)
space
Right ventricle Left ventricle
(A) Left lateral views (B)

FIGURE I.35. Magnetic resonance imaging. A. Sagittal MRI study of the head and upper neck. B. Magnetic resonance angiogram of heart and great
vessels.

(B)

FIGURE I.36. Positron emission tomography. A. PET scanner.

B. Transverse scans. Observe the differences in brain activity associated
with the planning and execution of a specific task in contrast to a control
(A) brain.

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