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e234


PREFACE
‘Anatomy is the basis of medical discourse.’ As a general rule, the orientation of diagrams and photographs
(Hippocrates, De locis in homine 2) throughout the book has been standardized to show the left side of the
body, irrespective of whether a lateral or medial view is presented, and
Looking through an almost complete set of the previous editions of transverse sections are viewed from below to facilitate comparison with
Gray’s Anatomy, I am struck by the marked difference in size between clinical images. Clinicopathological examples have been selected where
the first and fortieth editions. That progressive increase in girth has the pathology is either a direct result, or a consequence, of the anatomy,
occurred pari passu with groundbreaking advances in basic science and or where the anatomical features are instrumental in the diagnosis/
clinical medicine over the past 155 years. Anatomy has become a far treatment/management of the condition. Wherever possible, the photo
wider discipline than Henry Gray, Henry van Dyke Carter or any of their micrographs illustrate human histology and embryology; nonhuman
students could have envisaged. Fields such as cell biology, molecular sources are acknowledged in the captions.
genetics, neuroanatomy, embryology and bioinformatics either had not In an ideal world, anatomical terminology would satisfy both anat
emerged or were in their infancy in 1858. Techniques that today inform omists and clinicians. For the avoidance of doubt, the same word
our view of the internal landscape of the body – such as specialized should be agreed and used for each structure that is described, whether
types of light and electron microscopy; imaging modalities, including in the anatomy laboratory or the clinic. In the real world, this goal is
Xrays, magnetic resonance imaging, computed tomography and ultra achieved with varying degrees of success; alternative terms (co)exist and
sonography; the use of ‘soft’ perfusion techniques and frozenthawed, may (and frequently do) confuse or frustrate. Currently, Terminologia
unembalmed cadavers for dissectionbased studies; and the advances Anatomica (TA)1 is the reference source for the terminology for macro
in information technology that enable endoscopic and robotic surgery scopic anatomy; the text of the fortyfirst edition of Gray’s Anatomy is
and facilitate minimally invasive access to structures previously consid almost entirely TAcompliant. However, where terminology is at vari


ered inaccessible – were all unknown. As each development entered ance with, or, more likely, is not included in, the TA, the alternative
mainstream scientific or clinical use, the new perspectives on the body term that is chosen either is cited in the relevant consensus document
it afforded, whether at submicroscopic or macroscopic level, filtered or position paper – e.g. ‘European Position Paper on the Anatomical
into the pages of Gray’s Anatomy: for example, the introduction of Xray Terminology of the Internal Nose and Paranasal Sinuses’2 and the Inter
plates (twentyseventh edition, 1938) and electron micrographs (thirty national Interdisciplinary Consensus Statement on the ‘Nomenclature
second edition, 1958). of the Veins of the Lower Limbs’3 – or enjoys widespread clinical usage:
In the Preface to the first edition, Henry Gray wrote that ‘This Work for example, the use of attitudinally appropriate terms in cardiology
is intended to furnish the Student and Practitioner with an accurate view of (see Chapter 57). The continued use of eponyms is contentious.4 Pro
the Anatomy of the Human Body, and more especially the application of this ponents of their retention argue that some eponyms are entrenched in
science to Practical Surgery.’ We remain true to his intention. An appropri medical language and are (therefore) indispensable, that they facilitate
ate knowledge of clinically relevant, evidencebased anatomy is an communication because their use is so pervasive and that they serve to
essential element in the armamentarium of a practising clinician; remind us of the humanism of medicine. Detractors argue that eponyms
indeed, ‘If anything, the relevance of anatomy in surgery is more impor are inherently inaccurate, nonscientific and often undeserved. In this
tant now than at any other time in the past’ (Tubbs, in Preface Com edition of Gray’s Anatomy, synonyms and eponyms are given in paren
mentary, which accompanies this volume). theses on first usage of a preferred term and not shown thereafter in the
In my Preface to the fortieth edition, I intimated that the book was text; an updated list of eponyms remains available in the ebook for
quite literally in danger of breaking its binding if any more pages were reference purposes.


added. In order to avoid this unfortunate occurrence, the fortyfirst I offer my sincere thanks to the editorial team at Elsevier, initially
edition contains a significant amount of material that is exclusively under the leadership of Madelene Hyde and latterly of Jeremy Bowes,
electronic, in the form of 77,000 words of additional text, 300 artworks for their guidance, professionalism, good humour and unfailing
and tables, 28 videos and 24 specially invited commentaries on topics support. In particular, I thank Poppy Garraway, Humayra Rahman
as diverse as electron microscopy and fluorescence microscopy; the Khan, Wendy Lee, Joanna Souch, Julie Taylor, Jan Ross and Louise Cook,
neurovascular bundles of the prostate; stem cells in regenerative medi for being at the end of a phone or available by email whenever I needed
cine; the anatomy of facial ageing; and technical aspects and applica advice or support.
tions of diagnostic radiology. In keeping with the expectation that I dedicate my work on the fortyfirst edition of Gray’s Anatomy to the
anatomy should be evidencebased, the fortyfirst edition contains memory of my late husband, Guy Standring.
many more references in the ebook than could be included in the
thirtyninth and fortieth printed editions. Susan Standring
Neel Anand, Rolfe Birch, Pat Collins, Alan Crossman, Michael January 2015
Gleeson, Ariana Smith, Jonathan Spratt, Mark Stringer, Shane Tubbs,
Alan Wein and Caroline Wigley brought a wealth of scholarship and
experience as anatomists, cell biologists and clinicians to their roles as
Section Editors. I thank them for their dedication and enthusiastic
support, in selecting and interacting with the authors in their Sections
and for meeting deadlines, despite the everincreasing demands on 1Terminologia Anatomica (1998) is the joint creation of the Federative Committee on
Anatomical Terminology (FCAT) and the Member Associations of the Interna
their time from university and/or hospital managers. Pat Collins,
tional Federation of Associations of Anatomists (IFAA).
Girish Jawaheer, Richard Tunstall and Caroline Wigley worked closely
2Lund VJ, Stammberger H, Fokkens WJ et al 2014 European position paper on the
with many authors to update the text and artworks for organogenesis,


anatomical terminology of the internal nose and paranasal sinuses. Rhinol Suppl
paediatric anatomy, evidencebased surface anatomy and microstruc 24:1–34.
ture, respectively, across Sections 3 to 9. Jonathan Spratt acted as both 3Caggiati A, Bergan JJ, Gloviczki P et al; International Interdisciplinary Consensus
a Section Editor (thorax) and an indefatigable ‘go to’ for sourcing Committee on Venous Anatomical Terminology 2005 Nomenclature of the veins
images throughout the book; in the latter capacity, he has produced of the lower limb: extensions, refinements, and clinical application. J Vasc Surg
a superb collection of additional labelled images, available in the 41:719–24.
ebook (see Bonus imaging collection). Over a hundred highly experi 4Amarnani A, Brodell RT, Mostow EN 2013 Finding the evidence with eponyms. JAMA
Dermatol 149:664–5; Fargen KM, Hoh BL 2014 The debate over eponyms. Clin
enced anatomists and clinicians contributed text, often extensively
Anat 27:1137–40; Lo WB, Ellis H 2010 The circle before Willis: a historical account
revised from the previous edition, and/or artworks, original micro of the intracranial anastomosis. Neurosurgery 66:7–18; Ma L, Chung KC 2012 In
graphs or other images to individual chapters. defense of eponyms. Plast Reconstr Surg 129:896e–8e. ix


The continuing relevance of anatomy in
PREFACE
current surgical practice and research
COMMENTARY
R Shane Tubbs
When our anatomy forebears embarked on the uncharted study of the muscle. This distally disconnected medial half of the nerve was then
human body, they did so without reference. Their focus was to chart swung medially to the phrenic nerve, which had been transected proxi-
and map the body simply to learn and describe intricacies never chroni- mally. The two nerves were then sutured together without tension. This
cled before. The anatomical ‘map’ we use today came about thanks to ‘rearranging’ of human anatomy has now been employed clinically with
figures such as da Vinci, Vesalius, Cheselden and, more recently, Henry success. Yang et al (2011) used our study results to treat a 44-year-old
Gray. On the shoulders of these giants, we see farther than our predeces- man with complete spinal cord injury at the C2 level. Clinically, left
sors. In The Metalogicon, published in 1159, John Salisbury recognized diaphragm activity was decreased and the right diaphragm was com-
the profound observation of French philosopher Bernard of Chartres, pletely paralysed. Four weeks after surgery, training of the synchronous
who declared that ‘...we are like dwarfs on the shoulders of giants, so that activities of trapezius and inspiration was conducted. Six months after
we can see more than they, and things at a greater distance, not by virtue of surgery, motion was observed in the previously paralysed right dia-
any sharpness of sight on our part, or any physical distinction, but because phragm. Evaluation of lung function indicated improvements in vital
we are carried high and raised up by their giant size’. So, with the gross capacity and tidal volume. The patient was able to sit in a wheelchair
anatomy of man presumed, by many scholars, to have been described and conduct activities without assisted ventilation 12 months after
and understood long ago, how does the modern anatomist bring rel- surgery. For the surgeon, such manipulation of anatomy requires a
evance to the continued study of morphology? Is there any uncharted comprehensive understanding not only of normal anatomy but also of
territory for the modern anatomist to plot in order to sustain our field what might occur functionally by rewiring such nerves. For example,


of study and for it to continue to be perceived as relevant to an educa- patients undergoing this surgery will initially need to think of moving
tional world, and to medical and dental curricula in which the time their trapezius to activate their diaphragm. With time, this will not be
allotted to anatomical study has significantly waned? Simply put, yes. the case. Similar illustrations of the plasticity of the brain have been
Henry Gray, based on the title of his original text, Anatomy, Descriptive seen in patients undergoing hypoglossal to facial nerve neurotization
and Surgical, knew very well that there was a need to refocus the lenses procedures; these patients at first need to think of moving their tongue
of teaching and research in the anatomical sciences, and to expand and in order for their facial muscles to contract.
explore their surgical relevance. Our gross anatomical map of the Rewiring of nerves has been addressed in other studies. Thus, we
human body must continue to be updated and legends must continue have shown, first in a cadaveric study (Hansasuta et al 2001) and then
to be placed on that map to incorporate modern advances in technol- clinically (Wellons et al 2009), that the medial pectoral nerve can be
ogy. New methods of surgery, such as laparoscopy and endoscopy, as sectioned near its entrance into the deep surface of pectoralis major and
well as the use of the surgical microscope, offer the opportunity to view swung round and sewn into the musculocutaneous nerve (Fig. 1.6.2).
the human form in a different light and in greater surgical detail than If this procedure is successful, axonal regrowth from the medial pectoral
ever before. If anything, the relevance of anatomy in surgery is more nerve into the musculocutaneous nerve (about 1 mm/day) will
important now than at any other time in the past. The modern surgeon re-establish function in the anterior arm muscles; the loss of clinically
must take what is learned macroscopically, in the dissection room, and significant function of the dually innervated pectoralis major is minimal
apply this knowledge to structures seen under magnification and and the functional gain of having the anterior arm muscles work is


through instruments that provide a surgical field that is, at times, just significant (Wellons et al 2009). Being able to bring the hand to the
millimetres in diameter. Therefore, attention to anatomical detail is of mouth and feed oneself is a task that most take for granted. In children
vital importance as references and anatomical landmarks are mini- with birth-related injuries to the upper brachial plexus (i.e. Erb’s palsy),
mized in the surgical theatre of the new millennium. this movement is often the difference between waiting to be fed or
As mentioned before, early anatomists dissected with curiosity about feeding oneself. This method has been used at our institution for over
the unknown and gained knowledge that would become a prerequisite 15 years with an 80% success rate, where success is measured as the
for proper surgical manœuvres. Today, as anatomists, our anatomical patient regaining function of arm flexion.
knowledge should create in us a curiosity about what we can do with Another example of what we have termed ‘reverse translational
the knowledge that we have gained. The ability to apply that knowledge research in anatomy’ (i.e. from the bed to the bench and back) is the
offers an opportunity to be an integral part of the ever-progressing field location of new anatomical diversionary sites (in this case, the medul-
of surgery. For example, today, surgical problems are often the impetus lary cavity of the ilium) that could be used in patients with cerebrospi-
for dissection studies, which can influence the way in which surgery is nal fluid absorption problems (i.e. hydrocephalus) and in whom the
performed and, moreover, can sway the way in which anatomy is taught traditionally used receptacles for absorbing this diverted cerebrospinal
(e.g. redefining a focus in condensed curricula and with decreased work fluid (e.g. peritoneal and pleural cavities, heart) are not options, as a
hours for house officers). Surgically, dissection studies have allowed us consequence of e.g. malabsorption or local infection (Tubbs et al 2015)
to manipulate known human anatomy and to solve, for example, (Fig. 1.6.3). This alternative site has, for the first time, just been used
complex neurological problems. As an illustration of the surgical rele- and with success (unpublished data). Although not proven clinically,


vance of modern-day anatomical studies for neurological pathologies, an earlier study in primates showed that the manubrium of the sternum
we have conducted, in my laboratory, cadaveric feasibility studies that could also be used as a distal receptacle for cerebrospinal fluid collec-
suggested that the phrenic nerve could be reinnervated in high quadri- tion (Tubbs et al 2011). After tubing was tunnelled from the cannulated
plegic patients who are ventilator-dependent (a morbid condition with ventricle, the distal tubing was inserted subcutaneously into the supe-
an associated high mortality rate) by using the intact, adjacent accessory rior aspect of the midline manubrium, where a small hole had been
nerve (i.e. neurotization) (Tubbs et al 2008a) (Fig. 1.6.1). The theory drilled. Up to 50 ml of saline per hour could be infused into the primate
behind this investigation was that the functioning accessory nerve sternum without vital sign changes. This study, and the study using the
would be used to form a new circuit between it and the dysfunctional ilium as a depository, both demonstrate the anatomical continuity
phrenic nerve, and that this would allow recovery of diaphragm func- between the bony medullary cavities and the vascular system. Such
tion. For this technique, a longitudinal incision was made along the positive effects on patient outcomes not only make the study of human
lower half of the posterior border of sternocleidomastoid. Dissection anatomy from a slanted perspective extremely gratifying, but are also
was then performed in order to identify both the accessory nerve at this practical since the results have direct application in the surgical theatre.
level, at its entrance into trapezius, and the phrenic nerve crossing In addition to surgical anatomy playing a role in new uses of the
anterior to scalenus anterior. The medial half of the accessory nerve was normal anatomy, this field can also explore and direct new surgical
then split away from its lateral half and transected at its entrance into approaches where the goals are to make surgery more effective and e1


The conTinuing relevance of anaTomy in currenT surgical pracTice and research
Fig. 1.6.1 A schematic representation of the
anatomically defined technique of using the
accessory nerve for neurotization of the phrenic
nerve with application to patients with high
cervical quadriplegia who are ventilator-
dependent. With nerve regrowth, axons from the
intact and functioning accessory nerve travel into
the phrenic nerve to reinnervate this nerve and
restore diaphragmatic function. In this example,
only one-half of the accessory nerve is used in
order to maintain some function of trapezius.
(Drawn by Mr David Fisher.)
Fig. 1.6.2 The neurotization of the
musculocutaneous nerve with the medial pectoral
nerve (inset). Similar to the example illustrated in
Figure 1.6.1, such a method of nerve repair is
employed in the hope that a patient with an upper
brachial plexus injury and anterior arm muscles
that are dysfunctional can regain function by
regrowth of axons from the intact medial pectoral
nerve into and along the musculocutaneous nerve.
(Drawn by Mr David Fisher.)
minimally invasive, and involve fewer complications. For example, we treatment, resulted in a more limited laminectomy and myelotomy,
have performed feasibility studies looking at a wide range of novel and, in one case, assisted in identifying a residual spinal cord tumour.
approaches that might be used by the surgeon. These include a dorsal It was also useful in the fenestration of a multilevel spinal arachnoid
approach to the carpal tunnel for an entrapped median nerve (Tubbs cyst and in confirming communication of fluid spaces in the setting of
et al 2005a); an anterior approach to the sciatic nerve potentially com- a complex holocord syrinx. Endoscopy aided the visualization of the
pressed by piriformis via the obturator foramen (Tubbs, unpublished spinal cord to ensure the absence of tethering in the case of split spinal
data); an anterior approach to the upper thoracic vertebrae for spine cord malformation. These endoscopic approaches were only possible
fusion procedures (Tubbs et al 2010a); an intra-abdominal laparoscopic by knowing the normal anatomy and how it appears in a confined field


approach to decompress the pudendal nerve (Loukas et al 2008); and of view, as first seen in the anatomy laboratory.
midline endoscopic approaches to the fourth ventricle with application Lastly, the anatomist can add to the relevance of anatomy for the
to decompressing a ‘trapped’ fourth ventricle, as is seen in some cases surgeon with studies that have an impact on the identification or avoid-
of hydrocephalus (Tubbs et al 2004). We have also explored the feasibil- ance of important structures during operative manœuvres (i.e. anatomi-
ity in cadavers of using endoscopy for exploration of pathologies of the cal landmark studies). My group has defined surgical landmarks for
thecal sac (Chern et al 2011). In a series of children with intraspinal anatomical structures such as the superior and inferior gluteal nerves
pathology (arachnoid cyst, spinal cord tumour, holocord syrinx and (Apaydin et al 2013, Apaydin et al 2009); vein of Labbé (Tubbs et al
e2 split cord malformation), intradural spinal endoscopy was a useful 2012); sigmoid sinus (Tubbs et al 2009a); amygdala (Tubbs et al


The continuing relevance of anatomy in current surgical practice and research
Fig. 1.6.4 A superior view of the cranium, with the underlying superior
sagittal sinus, cortical veins and lateral lacunae illustrated. This study
explored the relationship between the underlying lateral lacunae and the
overlying coronal and sagittal sutures, and made measurements between
these structures. Neurosurgically, the initial placement of burr-holes
avoids the midline in order to prevent damage to the superior sagittal
sinus. However, the intracranial entrance of the drill often injures more
laterally placed lacunae. Using surface anatomy based on anatomical
landmarks, a neurosurgeon can be more aware of the locations of these
underlying structures while performing craniotomies. Such landmarks
have now been used by neurosurgeons at our institution. (Drawn by Mr
David Fisher.)
(Loukas et al 2006); long thoracic nerve (Tubbs et al 2006b); anterior
interosseous nerve (Tubbs et al 2006c); accessory nerve (Tubbs et al
2005b); lumbar plexus and its branches (Tubbs et al 2005c); trochlear
nerve (Tubbs and Oakes 1998); and frontal sinus (Tubbs et al 2002).
Such studies might assist in decreasing the morbidity and increasing
Fig. 1.6.3 The technique used in a patient with hydrocephalus to divert the efficiency of surgical approaches and certainly illustrate the surgical
cerebrospinal fluid from the cerebral ventricles to the ilium. The enlarged relevance of anatomy. Moreover, this list exemplifies the multitude of
ventricles are cannulated with a catheter connected to a subcutaneous anatomical structures that may be given greater surgical relevance by
valve that drains into tubing tunnelled under the skin and then implanted addressing how they may be more accurately located in the operating
into the medullary cavity of the ilium; here, the cerebrospinal fluid is theatre.
absorbed into the vascular system. The techniques described in Figures
In this day and age, if anatomists are not to lose their footing and
1.6.2 and 1.6.3, based on surgical problems and manipulation of known
simply be considered teachers of an old and outdated discipline, the


anatomy for surgical benefit, were evaluated and studied in the anatomy
onus is on us to renew interest in our field with timely and salient
laboratory, and have now been used clinically. (Drawn by Mr David
studies that gird the loins of a profession that is in danger of becoming
Fisher.)
extinct. It is my opinion, and that of others, that one effective way to
achieve this is to remind the world by demonstrations such as those
listed here that the study of anatomy is as clinically relevant today as it
2010b); buccal branch of the trigeminal nerve (Tubbs et al 2010c); was at its humble beginnings. Considering the adage that anatomy is
radial nerve and posterior interosseous branch (Cox et al 2010, Tubbs the oldest child of Mother Medicine, the fact that surgical problems and
et al 2006a); perineal branch of the posterior femoral cutaneous nerve anatomical studies go hand in hand is obvious – anatomical research
(Tubbs et al 2009b); lateral lacunae (Tubbs et al 2008b) (Fig. 1.6.4); is not a ‘dead’ science! The modern relevance of anatomy to surgical
basal vein of Rosenthal (Tubbs et al 2007); greater occipital nerve practice and research must not be underestimated.
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nerve and surgical landmarks for its localization during posterior gluteal nerve and landmarks for its localization during minimally inva-
approaches to hip. Surg Radiol Anat 31:415-18. sive approaches to the hip. Clin Anat 26:614–20. e3


The conTinuing relevance of anaTomy in currenT surgical pracTice and research
Chern JJ, Gordon AS, Naftel RP et al 2011 Intradural spinal endoscopy in Tubbs RS, Miller JH, Cohen-Gadol AA et al 2010b Intraoperative anatomic
children. J Neurosurg Pediatr 8:107–11. landmarks for resection of the amygdala during medial temporal lobe
Cox CL, Riherd D, Tubbs RS et al 2010 Predicting radial nerve location using surgery. Neurosurgery 66:974–7.
palpable landmarks. Clin Anat 23:420–6. Tubbs RS, Miller J, Loukas M et al 2009b Surgical and anatomical landmarks
Hansasuta A, Tubbs RS, Grabb PA 2001 Surgical relationship of the medial for the perineal branch of the posterior femoral cutaneous nerve: impli-
pectoral nerve to the musculocutaneous nerve: a cadaveric study. Neuro- cations in perineal pain syndromes. Laboratory investigation. J Neuro-
surgery 48:203–6. surg 111:332–5.
Loukas M, El-Sedfy A, Tubbs RS et al 2006 Identification of greater occipital Tubbs RS, Oakes WJ 1998 Relationships of the cisternal segment of the
nerve landmarks for the treatment of occipital neuralgia. Folia Morphol trochlear nerve. J Neurosurg 89:1015–19.
(Warsz) 65:337–42. Tubbs RS, Pearson B, Loukas M 2008a Phrenic nerve neurotization utilizing
Loukas M, Louis RG Jr, Tubbs RS et al 2008 Intra-abdominal laparoscopic the spinal accessory nerve: technical note with potential application in
pudendal canal decompression – a feasibility study. Surg Endosc 22: patients with high cervical quadriplegia. Childs Nerv Syst 24:1341–4.
1525–32. Tubbs RS, Salter EG, Custis JW et al 2006b Surgical anatomy of the cervical
Tubbs RS, Bauer D, Chambers MR 2011 A novel method for cerebrospinal and infraclavicular parts of the long thoracic nerve. J Neurosurg 104:


fluid diversion: a cadaveric and animal study. Neurosurgery 68:491–4. 792–5.
Tubbs RS, Custis JW, Salter EG et al 2006c Quantitation of and superficial Tubbs RS, Salter EG, Sheetz J et al 2005a Novel surgical approach to the
surgical landmarks for the anterior interosseous nerve. J Neurosurg carpal tunnel: cadaveric feasibility study. Clin Anat 18:350–6.
104:787–91. Tubbs RS, Salter EG, Wellons JC 3rd et al 2005b Superficial landmarks for
Tubbs RS, Elton S, Salter G et al 2002 Superficial surgical landmarks for the the spinal accessory nerve within the posterior cervical triangle. J Neu-
frontal sinus. J Neurosurg 96:320–2. rosurg Spine 3:375–8.
Tubbs RS, Johnson PC, Loukas M et al 2010c Anatomical landmarks for Tubbs RS, Salter EG, Wellons JC 3rd et al 2005c Anatomical landmarks for
localizing the buccal branch of the trigeminal nerve on the face. Surg the lumbar plexus on the posterior abdominal wall. J Neurosurg Spine
Radiol Anat 3:933–5. 2:335–8.
Tubbs RS, Louis RG Jr, Song YB et al 2012 External landmarks for identifying Tubbs RS, Salter EG, Wellons JC 3rd et al 2006a Superficial surgical land-
the drainage site of the vein of Labbé: application to neurosurgical marks for identifying the posterior interosseous nerve. J Neurosurg
procedures. Br J Neurosurg 26:383–5. 104:796–9.
Tubbs RS, Loukas M, Callahan JD et al 2010a A novel approach to the upper Tubbs RS, Tubbs I, Loukas M et al 2015 Ventriculoiliac shunt: a cadaveric
anterior thoracic spine: a cadaveric feasibility study. J Neurosurg Spine feasibility study. J Neurosurg Pediatr 15:310–12.
13:346–50. Tubbs RS, Wellons JC 3rd, Salter G et al 2004 Fenestration of the superior


Tubbs RS, Loukas M, Louis RG Jr et al 2007 Surgical anatomy and landmarks medullary velum as treatment for a trapped fourth ventricle: a feasibility
for the basal vein of Rosenthal. J Neurosurg 106:900–2. study. Clin Anat 17:82–7.
Tubbs RS, Loukas M, Shoja MM et al 2008b Lateral lakes of Trolard: anatomy, Wellons JC, Tubbs RS, Pugh JA et al 2009 Medial pectoral nerve to muscu-
quantitation, and surgical landmarks. Laboratory investigation. J Neu- locutaneous nerve neurotization for the treatment of persistent birth-
rosurg 108:1005–9. related brachial plexus palsy: an 11-year institutional experience.
J Neurosurg Pediatr 3:348–53.
Tubbs RS, Loukas M, Shoja MM et al 2009a Surface landmarks for the junc-
tion between the transverse and sigmoid sinuses: application of the Yang ML, Li JJ, Zhang SC 2011 Functional restoration of the paralyzed dia-
‘strategic’ burr hole for suboccipital craniotomy. Neurosurgery 65: phragm in high cervical quadriplegia via phrenic nerve neurotization
37–41. utilizing the functional spinal accessory nerve. J Neurosurg Spine 15:
190–4.
e4


ACKNOWLEDGEMENTS
Within individual figure captions, we have acknowledged all figures kindly loaned from other sources. However, we
would particularly like to thank the following authors who have generously loaned so many figures from other
books published by Elsevier:
Drake RL, Vogl AW, Mitchell A (eds), Gray’s Anatomy for Students, 2nd ed. Elsevier, Churchill Livingstone. Copyright
2010.
Drake RL, Vogl AW, Mitchell A, Tibbitts R, Richardson P (eds), Gray’s Atlas of Anatomy. Elsevier, Churchill
Livingstone. Copyright 2008.
Waschke J, Paulsen F (eds), Sobotta Atlas of Human Anatomy, 15th ed. Elsevier, Urban & Fischer. Copyright 2013.
Acknowledgements for paediatric anatomy content in chapter 45 to Ritchie Marcus, MD and Guirish A. Solanki, MD,
Birmingham Children’s Hospital, UK, and for chapter 81 to Christopher Edward Bache, MBChB, FRCS (Tr & Orth),
Birmingham, UK. The editors would like to thank all contributors and illustrators to the previous editions of Gray’s
Anatomy, including the fortieth and thirty-ninth editions. Much of the illustration in Gray’s Anatomy has as its basis
the work of illustrators and photographers who contributed towards earlier editions, their figures sometimes being
retained almost unchanged, and sometimes being used as the foundation for figures that are new to this edition.
x


CONTRIBUTORS TO THE FORTY-FIRST EDITION
The editors would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition
would not have been possible.
Michael A Adams BSc, PhD Brion Benninger MD, MSc Graham J Burton MD, DSc, FMedSci
Professor of Biomechanics Professor, Executive Director Mary Marshall and Arthur Walton Professor
Centre for Comparative and Clinical Anatomy Medical Anatomy Center – Innovation and of the Physiology of Reproduction
University of Bristol, UK Technology Research Centre for Trophoblast Research
McDaniel Surgical, Radiological & Education University of Cambridge
L Max Almond MB, ChB, MRCS, MD Research Lab Cambridge, UK
Senior Registrar in Gastrointestinal Surgery Departments of Medical Anatomical
West Midlands Deanery Sciences & Neuromuscular Medicine Andrew Bush MD, FRCP, FRCPCH, FERS
Birmingham, UK Western University of Health Sciences, Professor of Paediatrics and Head of Section
Lebanon, Oregon (Paediatrics)
Neel Anand MD Faculty Orthopaedics & Surgical Residency Imperial College;
Clinical Professor of Surgery Training Professor of Paediatric Respirology
Director, Spine Trauma, Minimally Invasive Faculty Sports Medicine Fellowship Training National Heart and Lung Institute;
Spine Surgery Samaritan Health Services, Corvallis, Oregon Consultant Paediatric Chest Physician
Spine Center USA Royal Brompton and Harefield NHS
Cedars Sinai Medical Center Foundation Trust
Los Angeles, CA, USA Barry KB Berkovitz BDS, MSc, PhD, FDS, Paediatric Respiratory Medicine
LDSRCS(Eng) London, UK
Nihal Apaydin MD, PhD Emeritus Reader in Dental Anatomy
Associate Professor of Anatomy Anatomy Department Alison Campbell BSc(Hons), MMedSci,
Department of Anatomy and Brain Research King’s College London DipRCPath
Center London, UK; Group Director of Embryology
Ankara University Faculty of Medicine Visiting Professor CARE Fertility
Ankara, Turkey Oman Dental College Nottingham, UK
Oman
Lily A Arya MD, MS Bodo EA Christ MD
Associate Professor of Obstetrics and Leela C Biant BSc(Hons), MBBS, AFRCSEd, Professor and Former Chairman
Gynecology FRCSEd(Tr & Orth), MSres(Lond), MFSTEd Department of Molecular Embryology


Perelman School of Medicine Consultant Trauma and Orthopaedic University of Freiburg
University of Pennsylvania Surgeon Freiburg, Germany
Department of Obstetrics and Gynecology Royal Infirmary of Edinburgh;
Philadelphia, PA, USA Honorary Senior Lecturer Thomas Collin MBBS, FRCS(Plast)
University of Edinburgh Consultant Plastic and Reconstructive Surgeon
Tipu Aziz FMedSci NRS Career Clinician Scientist Fellow University Hospital of North Durham
Professor of Neurosurgery Edinburgh, UK Department of Plastic Surgery
John Radcliffe Hospital Durham, UK
University of Oxford Rolfe Birch MChir, FRCPS(Glasg),
Oxford, UK FRCS(Ed), FRCS(Eng) Patricia Collins BSc, PhD, FHEA
Retired Consultant in Charge Professor of Anatomy
Jonathan BL Bard MA, PhD War Nerve Injury Clinic, Defence Medical Anglo-European College of Chiropractic
Emeritus Professor of Development and Rehabilitation Centre, Surrey; Bournemouth, UK;
Bioinformatics Retired Head, Peripheral Nerve Injury Unit, Editor for Embryology and Development
School of Biomedical Sciences Royal National Orthopaedic Hospital;
University of Edinburgh Professor in Neurological Orthopaedic Anthony T Corcoran MD
Edinburgh, UK Surgery, University College of London Assistant Professor of Urologic Oncology
London, UK and Minimally Invasive Surgery
Eli M Baron MD Department of Urology
Clinical Associate Professor of Neurosurgery Martin A Birchall MD, FRCS, FMedSci SUNY Stony Brook School of Medicine
Spine Surgeon, Cedars Sinai Professor of Laryngology Stony Brook, NY, USA
Department of Neurosurgery Consultant Otolaryngologist, Ear Institute
Cedars Sinai Spine Center, Cedars Sinai University College London and Royal Julie Cox FRCS(Eng), FRCR
Medical Center National Throat Nose and Ear Hospital Consultant Radiologist
Los Angeles, CA, USA University College Hospitals NHS Foundation City Hospitals Sunderland NHS
Trust Foundation Trust Sunderland, UK
Hugh Barr MD(Dist), ChM, FRCS(Eng), London, UK
FRCS(Ed), FHEA, FODI Alan R Crossman BSc, PhD, DSc
Consultant General and Gastrointestinal Sue Black OBE, BSc, PhD, DSc, FRSE, Professor Emeritus
Surgeon FRAI, FRCP, FSB University of Manchester
Oesophagogastric Resection Unit Professor of Anatomy and Forensic Manchester, UK


Gloucestershire Royal Hospital Anthropology
Gloucester, UK Centre for Anatomy and Human Identification
University of Dundee
Scotland, UK
xi


Contributors to the forty-first edition
Natalie M Cummings BSc(Med Sci), Simon M Gabe MD, MSc, BSc(Hons), Duane E Haines PhD, FAAAS, FAAA
MB ChB, MPhil, MD, MRCP(Ed) MBBS, FRCP Professor, Department of Neurobiology and
Consultant Respiratory Physician Consultant Gastroenterologist and Honorary Anatomy;
University Hospital of North Durham Senior Lecturer; Professor, Department of Neurology
Durham, UK Co-Chair of the Lennard-Jones Intestinal Wake Forest School of Medicine
Failure Unit, St Mark’s Hospital Winston-Salem, NC;
Anthony V D’Antoni MS, DC, PhD Middlesex, UK Professor Emeritus, University of Mississippi
Clinical Professor and Director of Anatomy Medical Center
Department of Pathobiology Andrew JT George MA, PhD, DSc, Jackson, MS, USA
Sophie Davis School of Biomedical Education FRCPath, FSB
City University of New York; Deputy Vice Chancellor (Education and Peter A Helliwell FIBMS, Cert BA, Cert Ed
Adjunct Associate Professor International) Head Biomedical Scientist
Division of Pre-Clinical Sciences and Professor of Immunology Department of Cellular Pathology
Department of Surgery Brunel University Royal Cornwall Hospitals Trust
New York College of Podiatric Medicine London, UK Truro, UK
New York, NY, USA
Serge Ginzburg MD Simon Holmes BDS, MBBS, FDS, RCS,
Paolo De Coppi MD, PhD Assistant Professor of Urologic Oncology FRCS
Professor of Paediatric Surgery; Division of Urology Professor of Craniofacial Traumatology
Head of Stem Cells and Regenerative Fox Chase Cancer Center; Department of Oral and Maxillofacial Surgery
Medicine; Department of Urology Royal London Hospital, Queen Mary
Consultant Paediatric Surgeon Albert Einstein Medical Center University of London
Great Ormond Street Hospital Philadelphia, PA, USA London, UK
UCL Institute of Child Health
London, UK Michael Gleeson MD, FRCS, FRACS Hons, Claire Hopkins MA (Oxon), FRCS
FDS Hons (ORLHNS), DM
John OL DeLancey MD Professor of Skull Base Surgery Consultant Ear, Nose and Throat Surgeon
Norman F Miller Professor of Gynecology University College London Guy’s and St Thomas’ Hospitals;


Department of Obstetrics and Gynecology The National Hospital for Neurology and Reader in ENT
Professor, Department of Urology Neurosurgery King’s College London
University of Michigan Medical School London, UK London, UK
Ann Arbor, MI, USA
Marc Goldstein MD, DSc(Hon), FACS Benjamin M Howe MD
Ronald H Douglas BSc, PhD Matthew P Hardy Distinguished Professor of Assistant Professor of Radiology
Professor of Visual Science Reproductive Medicine and Urology; Mayo Clinic
Division of Optometry and Visual Science Surgeon-in-Chief, Male Reproductive Rochester, MN, USA
School of Health Sciences Medicine and Surgery
City University London Cornell Institute for Reproductive Medicine Daisuke Izawa PhD
London, UK and Department of Urology Assistant Professor, Laboratory of
Weill Cornell Medical Center; Chromosome Dynamics
Barrie T Evans BDS(Hons), MB BCh, Adjunct Senior Scientist, Population Council, Institute of Molecular and Cellular
FRCS(Eng), FRCS(Ed), FDSRCS(Eng), Center for Biomedical Research Biosciences
FFDRCS(Ire) New York, NY, USA University of Tokyo
Consultant Oral and Maxillofacial Surgeon Tokyo, Japan
Southampton University Hospitals; Martin Götz MD, PhD
Honorary Senior Lecturer in Surgery to Professor, Interdisciplinary Endoscopy Eric Jauniaux MD, PhD, FRCOG
Southampton University Medical School; Universitätsklinikum Tübingen Professor in Obstetrics and Fetal Medicine
Civilian Consultant Advisor in Oral and Tübingen, Germany Academic Department of Obstetrics and
Maxillofacial Surgery to the Royal Navy; Gynaecology
Past President, British Association of Oral Anthony Graham BSc, PhD UCL EGA Institute for Women’s Health
and Maxillofacial Surgeons Professor of Developmental Biology University College London
Southampton, UK MRC Centre for Developmental Neurobiology London, UK
King’s College London
Juan C Fernandez-Miranda MD London, UK Girish Jawaheer MD, FRCS(Eng),
Associate Professor of Neurological Surgery; FRCS(Paed)
Associate Director, Center for Cranial Base Leonard P Griffiths MB ChB, MRCP(UK) Consultant Paediatric Surgeon
Surgery; Registrar in Gastroenterology and General Great North Children’s Hospital, Royal
Director, Surgical Neuroanatomy Laboratory Internal Medicine Victoria Infirmary


University of Pittsburgh Medical Center Royal United Hospital Bath; Newcastle upon Tyne NHS Foundation Trust
Pittsburgh, PA, USA Clinical Research Fellow Newcastle upon Tyne, UK;
University of Bath Formerly Specialty Tutor for Paediatric
Jonathan M Fishman BM BCh(Oxon), Bath, UK Surgery
MA(Cantab), MRCS(Eng), DOHNS, PhD Royal College of Surgeons of England
Clinical Lecturer Paul D Griffiths PhD, FRCR, FMedSci London, UK;
University College London Professor of Radiology, Academic Unit of Editor for Paediatric Anatomy
London, UK Radiology
University of Sheffield Marianne Juhler MD, DMSc
Roland A Fleck PhD, FRCPath, FRMS Sheffield, UK Consultant Neurosurgeon
Reader and Director, Centre for Copenhagen University Hospital;
Ultrastructural Imaging Thomas J Guzzo MD, MPH Professor of Neurosurgery
King’s College London Vice-Chief of Urology University Clinic of Neurosurgery
London, UK Assistant Professor of Urology Copenhagen, Denmark
Perelman School of Medicine
David N Furness BSc, PhD University of Pennsylvania Helmut Kettenmann PhD
Professor of Cellular Neuroscience Philadelphia, PA, USA Professor, Charité Universitätsmedizin Berlin
School of Life Sciences Max Delbrück Center for Molecular Medicine
Keele University in the Helmholtz Society
Newcastle-under-Lyme, UK Berlin, Germany
xii


Contributors to the forty-first edition
Abraham L Kierszenbaum MD, PhD Peter J Lunniss BSc, MS, FRCS Horia Muresian MD, PhD
Medical (Clinical) Professor Emeritus Retired Senior Lecturer Head of Cardiovascular Surgery Department
The Sophie Davis School of Biomedical Academic Surgical Unit, St Bartholomew’s University Hospital of Bucharest
Education and The London Medical College, Queen Bucharest, Romania;
The City University of New York Mary University London; Visiting Professor, St George’s University
New York, NY, USA Retired Honorary Consultant Colorectal School of Medicine
Surgeon Grenada, West Indies
Alexander Kutikov MD, FACS Royal London and Homerton Hospitals
Associate Professor of Urologic Oncology London, UK Robert P Myers MD, MS, FACS
Department of Surgical Oncology Professor Emeritus
Fox Chase Cancer Center, Temple University the late Joseph Mathew MBBS, FMCPath, Department of Urology
Health System FRCPath, CertTLHE, PGCE, CertBusStud, Mayo Clinic
Philadelphia, PA, USA FHEA Rochester, MN, USA
Consultant in Histopathology
Joey E Lai-Cheong BMedSci(Hons), MBBS, Department of Histopathology Donald A Neumann PT, PhD, FAPTA
PhD, MRCP(UK) Royal Cornwall Hospitals Trust Professor of Physical Therapy
Consultant Dermatologist Truro, UK Marquette University
King Edward VII Hospital (Frimley Health Milwaukee, WI, USA
NHS Foundation Trust) John A McGrath MD, FRCP, FMedSci
Windsor, UK Professor of Molecular Dermatology Dylan Myers Owen PhD
St John’s Institute of Dermatology Lecturer in Experimental Biophysics
Simon M Lambert BSc, MBBS, FRCS, King’s College London Department of Physics and Randall Division
FRCS(Ed) (Orth) London, UK of Cell and Molecular Biophysics
Consultant Orthopaedic Surgeon King’s College London
Shoulder and Elbow Service Stephen McHanwell BSc, PhD, FHEA, FLS, London, UK
Royal National Orthopaedic Hospital Trust CBiol FSB, NTF
Stanmore, Middlesex; Professor of Anatomical Sciences Erlick AC Pereira MA(Camb), DM(Oxf),


Honorary Senior Lecturer School of Medical Education and School of FRCS(Eng), FRCS(NeuroSurg), MBPsS,
Institute of Orthopaedics and Dental Sciences SFHEA
Musculoskeletal Science Faculty of Medical Sciences Senior Clinical Fellow in Complex Spinal
University College London Newcastle University Surgery
London, UK Newcastle upon Tyne, UK Guy’s and St Thomas’ Hospitals
National Hospital of Neurology and
John G Lawrenson MSc(Oxon), PhD, Akanksha Mehta MD Neurosurgery
FCOptom Assistant Professor of Urology, London, UK
Professor of Clinical Visual Science Emory University School of Medicine
Division of Optometry and Visual Science Atlanta, GA, USA Nancy Dugal Perrier MD, FACS
City University London Professor, Anderson Cancer Center
London, UK Bryan C Mendelson FRCS(Ed), FRACS, Department of Surgical Oncology
FACS Houston, TX, USA
Nir Lipsman MD, PhD Head of Faculty
Neurosurgery Resident Melbourne Advanced Facial Anatomy Clayton C Petro MD
University of Toronto Course; General Surgery Resident;
Toronto, ON, Canada Private Practitioner, Centre for Facial Plastic Allen Research Scholar
Surgery Department of General Surgery
J Peter A Lodge MD, FRCS Melbourne, VIC, Australia University Hospitals Case Medical Center
Professor of Surgery Cleveland, OH, USA
Hepatobiliary and Transplant Unit Zoltán Molnár MD, DPhil
St James’s University Hospital Professor of Developmental Neuroscience Andy Petroianu MD, PhD
Leeds, UK Department of Physiology, Anatomy and Professor of Surgery
Genetics Department of Surgery
Marios Loukas MD, PhD University of Oxford School of Medicine of the Federal University
Professor, Department of Anatomical Oxford, UK of Minas Gerais
Sciences Belo Horizonte, Minas Gerais, Brazil
Dean of Basic Sciences Antoon FM Moorman MD, PhD
St George’s University Professor of Embryology and Molecular Jonathon Pines PhD, FMedSci
Grenada, West Indies Biology of Cardiovascular Diseases Director of Research in Cell Division
Department of Anatomy, Embryology and University of Cambridge
Andres M Lozano MD, PhD, FRCSC, FRSC, Physiology Cambridge, UK
FCAHS University of Amsterdam, Academic Medical
Professor and Chairman, Center Alexander G Pitman BMedSci, MBBS,


Dan Family Chair in Neurosurgery Amsterdam, The Netherlands MMed(Rad), FRANZCR, FAANMS
University of Toronto Professorial Fellow
Department of Neurosurgery Gillian M Morriss-Kay DSc Department of Anatomy and Neuroscience
Toronto Western Hospital Emeritus Professor of Developmental Anatomy University of Melbourne
Toronto, ON, Canada Department of Physiology, Anatomy and Parkville, VIC, Australia
Genetics
Ellen A Lumpkin PhD University of Oxford Y Raja Rampersaud MD, FRCSC
Associate Professor of Somatosensory Oxford, UK Associate Professor, Division of Orthopaedic
Biology Surgery and Neurosurgery
Columbia University College of Physicians Donald Moss MB, BS, FRACS, FACS Department of Surgery
and Surgeons Consultant Urologist University of Toronto
Departments of Dermatology and of Ballarat, VIC, Australia Toronto, ON, Canada
Physiology and Cellular Biophysics
New York, NY, USA
xiii


Contributors to the forty-first edition
Mettu Srinivas Reddy MS, FRCS, PhD Richard M Sharpe BSc, Msc, PhD, FRSE Susan Standring MBE, DSc, FKC, Hon FAS,
Consultant Surgeon Professor and Group Leader Hon FRCS
Institute of Liver Disease and Transplantation MRC Centre for Reproductive Health Emeritus Professor of Anatomy
Global Health City The Queen’s Medical Research Institute King’s College London
Chennai, India University of Edinburgh London, UK
Edinburgh, UK
Mohamed Rela MS, FRCS, DSc Ido Strauss MD, PhD
Director, Institute of Liver Disease and Mohammadali M Shoja MD Department of Neurosurgery
Transplantation Research Fellow Toronto Western Hospital
Global Health City, Chennai, India; Department of Neurosurgery Toronto, ON, Canada
Professor of Liver Surgery University of Alabama at Birmingham
Institute of Liver Studies, King’s College Birmingham, AL, USA Mark D Stringer BSc, MS, FRCP, FRCS,
Hospital FRCS(Ed), FRACS
London, UK Victoria L Shone PhD, MSc, BSc Professor of Paediatric Surgery
Research Associate in Developmental Christchurch Hospital;
Guilherme C Ribas MD Biology Honorary Professor of Anatomy
Professor of Surgery King’s College London University of Otago
University of São Paulo Medical School; London, UK Dunedin, New Zealand
Neurosurgeon, Hospital Israelita Albert
Einstein Monty Silverdale MD, PhD, FRCP Paul H Sugarbaker MD, FACS, FRCS
São Paulo, Brazil; Consultant Neurologist Medical Director, Center for Gastrointestinal
Visiting Professor of Neurosurgery Salford Royal NHS Foundation Trust; Malignancies;
University of Virginia Honorary Senior Lecturer in Neuroscience Chief, Program in Peritoneal Surface Oncology
Charlottesville, VA, USA University of Manchester MedStar Washington Hospital Center
Manchester, UK Washington, DC, USA
Bruce Richard MBBS, MS, FRCS(Plast)
Consultant Plastic Surgeon Jonathan MW Slack MA, PhD, FMedSci Cheryll Tickle MA, PhD
Birmingham Children’s Hospital Emeritus Professor, University of Bath Emeritus Professor
Birmingham, UK Bath, UK; Department of Biology and Biochemistry
Emeritus Professor, University of Minnesota, University of Bath
Michael J Rosen MD Minneapolis, MN, USA Bath, UK
Professor of Surgery;


Chief, Division of Gastrointestinal and Ariana L Smith MD Kimberly S Topp PT, PhD, FAAA
General Surgery Associate Professor of Urology Professor and Chair, Department of Physical
Case Medical Center Director of Pelvic Medicine and Therapy and Rehabilitation Science
Case Western Reserve University Reconstructive Surgery Professor, Department of Anatomy
University Hospitals of Cleveland Penn Medicine, Perelman School of University of California, San Francisco
Cleveland, OH, USA Medicine San Francisco, CA, USA
University of Pennsylvania Health System
Alistair C Ross MB, FRCS Philadelphia, PA, USA Drew A Torigian MD, MA, FSAR
Consultant Orthopaedic Surgeon Associate Professor of Radiology;
The Bath Clinic Carl H Snyderman MD, MBA Clinical Director, Medical Image Processing
Bath, UK Professor of Otolaryngology and Group
Neurological Surgery Department of Radiology
Stefano Sandrone PhD student Co-Director, UPMC Center for Cranial Base Hospital of the University of Pennsylvania
Neuroscientist, NatBrainLab Surgery Philadelphia, PA, USA
Sackler Institute of Translational University of Pittsburgh Medical Center
Neurodevelopment Pittsburgh, PA, USA David Tosh BSc, PhD
Department of Forensic and Professor of Stem Cell and Regenerative
Neurodevelopmental Sciences Jane C Sowden PhD Biology
Institute of Psychiatry, Psychology and Professor of Developmental Biology and Centre for Regenerative Medicine
Neuroscience Genetics University of Bath
King’s College London UCL Institute of Child Health Bath, UK
London, UK University College London
London, UK R Shane Tubbs MS, PA-C, PhD
Martin Scaal PhD Chief Scientific Officer
Professor of Anatomy and Developmental Robert J Spinner MD Seattle Science Foundation, Seattle, WA,
Biology Chair, Department of Neurologic Surgery USA;
Institute of Anatomy II Burton M Onofrio, MD Professor of Professor of Human Gross and
University of Cologne Neurosurgery; Developmental Anatomy
Cologne, Germany Professor of Orthopedics and Anatomy Department of Anatomical Sciences
Mayo Clinic St. George’s University, Grenada, West
Paul N Schofield MA, DPhil Rochester, MN, USA Indies;
University Reader in Biomedical Informatics Professor
Department of Physiology, Development and Jonathan D Spratt MA(Cantab), FRCS(Eng), Centre of Anatomy and Human Identification
Neuroscience FRCR University of Dundee, Dundee, UK
University of Cambridge Clinical Director of Diagnostic Radiology


Cambridge, UK City Hospitals Sunderland NHS Foundation Richard Tunstall BMedSci, PhD, PGCLTHE
Trust FHEA
Nadav Schwartz MD Sunderland, UK; Head of Clinical Anatomy and Imaging
Assistant Professor, Maternal Fetal Medicine Visiting Professor of Anatomy Warwick Medical School
Department of Obstetrics and Gynecology, Former anatomy examiner for the Royal University of Warwick, UK;
Perelman School of Medicine College of Surgeons of England and Royal University Hospitals Coventry and
University of Pennsylvania College of Radiologists Warwickshire NHS Trust
Philadelphia, PA, USA Editor for Imaging Anatomy Coventry, UK;
Visiting Professor of Anatomy
Vikram Sharma BSc(Hons), MBBS(Lon), Jacob Bertram Springborg MD, PhD St George’s University, Grenada, West Indies
MRCS(Eng), PG(Cert) Consultant Neurosurgeon; Editor for Surface Anatomy
Clinical Research Fellow Associate Professor of Neurosurgery
Nuffield Department of Surgical Sciences University Clinic of Neurosurgery
University of Oxford Copenhagen University Hospital
Oxford, UK Copenhagen, Denmark
xiv


Contributors to the forty-first edition
Andry Vleeming PhD Gary Warburton DDS, MD, FDSRCS, FACS Caroline B Wigley BSc, PhD
Professor of Clinical Anatomy Associate Professor; University of Exeter Medical School
University of New England Program Director and Division Chief Exeter, UK
College of Osteopathic Medicine Oral and Maxillofacial Surgery Editor for Cell and Tissue Microstructure
Biddeford, ME, USA; University of Maryland Dental School
Department of Rehabilitation Sciences and Baltimore, MD, USA Frank H Willard PhD
Physiotherapy Professor of Anatomy
Faculty of Medicine and Health Sciences Jeremy PT Ward BSc, PhD University of New England College of
Ghent University Head of Department of Physiology; Osteopathic Medicine
Ghent, Belgium Professor of Respiratory Cell Physiology Biddeford, Maine, USA
Department of Physiology
Jan Voogd MD King’s College London Chin-Ho Wong MBBS, MRCS(Ed),
Emeritus Professor of Anatomy London, UK MMed(Surg), FAMS(Plast Surg)
Department of Neuroscience Plastic Surgeon, Private Practice
Erasmus Medical Center John C Watkinson MSc, MS, FRCS, DLO Singapore
Rotterdam, The Netherlands Consultant ENT, Head and Neck and Thyroid
Surgeon Stephanie J Woodley PhD, MSc, BPhty
Bart Wagner BSc, CSci, FIBMS, Dip Ult Queen Elizabeth Hospital Senior Lecturer
Path. University of Birmingham NHS Trust Department of Anatomy
Chief Biomedical Scientist Birmingham, UK University of Otago
Electron Microscopy Unit Dunedin, New Zealand
Histopathology Department Alan J Wein MD, PhD(Hon), FACS
Royal Hallamshire Hospital (Sheffield Founders Professor and Chief of Urology
Teaching Hospitals) Director, Urology Residency Program
Sheffield, UK Penn Medicine, Perelman School of
Medicine
University of Pennsylvania Health System
Philadelphia, PA, USA
xv


HISTORICAL INTRODUCTION
Gray’s Anatomy is now on its way to being 160 years old. The book is a required to operate on real patients, or on soldiers injured at Sebastopol
rarity in textbook publishing in having been in continuous publication or some other battlefield. The book they planned together was a practi-
on both sides of the Atlantic Ocean, since 1858. One and a half centu- cal one, designed to encourage youngsters to study anatomy, help them
ries is an exceptionally long era for a textbook. Of course, the volume pass exams, and assist them as budding surgeons. It was not simply an
now is very different from the one Mr Henry Gray first created with his anatomy textbook, but a guide to dissecting procedure, and to the major
colleague Dr Henry Vandyke Carter, in mid-Victorian London. In this operations.
introductory essay, I shall explain the long history of Gray’s, from those Gray and Carter belonged to a generation of anatomists ready to
Victorian days right up to today. infuse the study of human anatomy with a new, and respectable, scien-
The shortcomings of existing anatomical textbooks probably tificity. Disreputable aspects of the profession’s history, acquired during
impressed themselves on Henry Gray when he was still a student at St the days of body-snatching, were assiduously being forgotten. The
George’s Hospital Medical School, near London’s Hyde Park Corner, in Anatomy Act of 1832 had legalized the requisition of unclaimed bodies
the early 1840s. He began thinking about creating a new anatomy from workhouse and hospital mortuaries, and the study of anatomy
textbook a decade later, while war was being fought in the Crimea. New (now with its own Inspectorate) was rising in respectability in Britain.
legislation was being planned that would establish the General Medical The private anatomy schools that had flourished in the Regency period
Council (1858) to regulate professional education and standards. were closing their doors, and the major teaching hospitals were erecting
Gray was twenty-eight years old, and a teacher himself at St George’s. new, purpose-built dissection rooms (Richardson 2000).
He was very able, hard-working and highly ambitious, already a Fellow The best-known student works when Gray and Carter had qualified


of the Royal Society, and of the Royal College of Surgeons. Although were probably Erasmus Wilson’s Anatomist’s Vade Mecum, and Elements
little is known about his personal life, his was a glittering career so far, of Anatomy by Jones Quain. Both works were small – pocket-sized – but
achieved while he served and taught on the hospital wards and in the Quain came in two thick volumes. Both Quain’s and Wilson’s works
dissecting room (Fig. 1) (Anon 1908). were good books in their way, but their small pages of dense type, and
Gray shared the idea for the new book with a talented colleague on even smaller illustrations, were somewhat daunting, seeming to demand
the teaching staff at St George’s, Henry Vandyke Carter, in November much nose-to-the-grindstone effort from the reader.
1855. Carter was from a family of Scarborough artists, and was himself The planned new textbook’s dimensions and character were serious
a clever artist and microscopist. He had produced fine illustrations for matters. Pocket manuals were commercially successful because they
Gray’s scientific publications before, but could see that this idea was a appealed to students by offering much knowledge in a small compass.
much more complex project. Carter recorded in his diary: But pocket-sized books had button-sized illustrations. Knox’s Manual
of Human Anatomy, for example, was a good book, but was only 6 inches
Little to record. Gray made proposal to assist by drawings in bringing
by 4 (15 × 10 cm) and few of its illustrations occupied more than one-
out a Manual for students: a good idea but did not come to any plan …
third of a page. Gray and Carter must have discussed this matter between
too exacting, for would not be a simple artist (Carter 1855).
themselves, and with Gray’s publisher, JW Parker & Son, before deci-
Neither of these young men was interested in producing a pretty book, sions were taken about the size and girth of the new book, and espe-
or an expensive one. Their purpose was to supply an affordable, accurate cially the size of its illustrations. While Gray and Carter were working
teaching aid for people like their own students, who might soon be on the book, a new edition of Quain’s was published; this time it was