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(cid:37)(cid:85)(cid:82)(cid:90)(cid:86)(cid:72)(cid:3)(cid:82)(cid:88)(cid:85)(cid:3)(cid:70)(cid:82)(cid:80)(cid:83)(cid:79)(cid:72)(cid:87)(cid:72)(cid:3)(cid:70)(cid:82)(cid:79)(cid:79)(cid:72)(cid:70)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:82)(cid:73)(cid:3)(cid:49)(cid:72)(cid:87)(cid:87)(cid:72)(cid:85)(cid:3)(cid:87)(cid:76)(cid:87)(cid:79)(cid:72)(cid:86)(cid:3)(cid:16)(cid:3)(cid:80)(cid:92)(cid:81)(cid:72)(cid:87)(cid:87)(cid:72)(cid:85)(cid:17)(cid:70)(cid:82)(cid:80)(cid:3) VOLUME 4 The Netter Collection OF MEDICAL ILLUSTRATIONS Integumentary System 2nd Edition A compilation of paintings prepared by FRANK H. NETTER, MD Authored by Bryan E. Anderson, MD Associate Professor of Dermatology Pennsylvania State University College of Medicine Hershey, Pennsylvania Additional illustrations by Carlos A. G. Machado, MD CONTRIBUTING ILLUSTRATORS Tiffany S. DaVanzo, MA, CMI John A. Craig, MD James A. Perkins, MS, MFA Anita Impagliazzo, MA, CMI 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 T HE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS: ISBN: 978-1-4377-5654-8 INTEGUMENTARY SYSTEM Copyright © 2012 by Saunders, an imprint of Elsevier Inc. Permissions for Netter Art figures may be sought directly from Elsevier’s Health Science Licensing Department in Philadelphia PA, USA: phone 1-800-523-649, ext. 3276 or (215) 239-3276; or email [email protected]. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission and further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence, or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Anderson, Bryan E. The Netter collection of medical illustrations : integumentary system / Bryan E. Anderson. – 2nd ed. p. cm. ISBN 978-1-4377-5654-8 (hardcover : alk. paper) 1. Skin—Physiology—Atlases. 2. Body covering (Anatomy)—Atlases. 3. Skin—Diseases—Atlases. I. Title. QP88.5.A53 2013 612.7’90222–dc23 2011042444 Content Strategist: Elyse O’Grady Content Development Manager: Marybeth Thiel Publishing Services Manager: Anne Altepeter Senior Project Manager: Doug Turner Designer: Ellen Zanolle Working together to grow libraries in developing countries Printed in the People’s Republic of China www.elsevier.com | www.bookaid.org | www.sabre.org Last digit is the print number: 9 8 7 6 5 4 3 2 1 ABOUT THE SERIES Dr. Frank H. Netter exemplified the CUSHING’S SYNDROME IN A PATIENT WITH THE CARNEY COMPLEX distinct vocations of doctor, artist, and teacher. Even more importantly— he unified them. Netter’s illustrations always began with meticulous research into the forms of the body, a philosophy that steered his broad and deep medical understanding. He once said, “Clarifi­ Carney complex is characterized cation is the goal. No matter how beau­ by spotty skin pigmentation. Pigmented lentigines and blue tifully it is painted, a medical illustration nevi can be seen on the face– including the eyelids, vermillion has little value if it does not make clear bcoonrdjuenrsc otifv athee, tlhipes ,s cthleera–and the a medical point.” His greatest challenge labia and scrotum. and greatest success was charting a Additional features of the middle course between artistic clarity Carney complex can include: Myxomas: cardiac atrium, and instructional complexity. That suc­ cutaneous (e.g., eyelid), and mammary cess is captured in this series, beginning Testicular large-cell in 1948, when the first comprehensive calcifying Sertoli cell tumors Dr. Frank Netter at work collection of Netter’s work, a single Gsercoewretthin-hgo prmituointaery adenomas volume, was published by CIBA Phar­ Psammomatous melanotic schwannomas maceuticals. It met with such success that over the following 40 years the collection was expanded into an eight­volume series—each devoted to a single body system. In this second edition of the legendary series, we are delighted to offer Netter’s timeless work, now arranged and informed by modern text and radiologic imaging contributed by field­leading doctors and teachers from world­renowned medical institutions, and supple­ PPNAD adrenal glands are usually of normal size and most are mented with new illustrations created by artists working sntouddudleeds wariet hle bslsa tchka,n b 4ro mwmn, ionr dreiadm neotdeur laensd. Minotestr sopfe trhsee dp iignm theented adjacent atrophic cortex. in the Netter tradition. Inside the classic green covers, A brand new illustrated plate painted by Carlos Machado, students and practitioners will find hundreds of original MD, for The Endocrine System, vol. 2, 2nd ed. works of art—the human body in pictures—paired with The single-volume “blue book” that paved the way the latest in expert medical knowledge and innovation for the multi-volume Netter Collection of Medical and anchored in the sublime style of Frank Netter. Illustrations series affectionately known as the “green Noted artist­physician, Carlos Machado, MD, the books” primary successor responsible for continuing the Netter tradition, has particular appreciation for the Green Book series. “The Reproductive System is of special signifi­ cance for those who, like me, deeply admire Dr. Netter’s work. In this volume, he masters the representation of textures of different surfaces, which I like to call ‘the rhythm of the brush,’ since it is the dimension, the direc­ tion of the strokes, and the interval separating them that create the illusion of given textures: organs have their external surfaces, the surfaces of their cavities, and texture of their parenchyma realistically represented. It set the style for the subsequent volumes of Netter’s Collection—each an amazing combination of painting masterpieces and precise scientific information.” Though the science and teaching of medicine endures changes in terminology, practice, and discovery, some things remain the same. A patient is a patient. A teacher is a teacher. And the pictures of Dr. Netter—he called them pictures, never paintings—remain the same blend of beautiful and instructional resources that have guided physicians’ hands and nurtured their imaginations for more than half a century. The original series could not exist without the dedi­ cation of all those who edited, authored, or in other ways contributed, nor, of course, without the excellence Dr. Carlos Machado at work of Dr. Netter. For this exciting second edition, we also owe our gratitude to the authors, editors, advisors, and artists whose relentless efforts were instrumental in adapting these timeless works into reliable references for today’s clinicians in training and in practice. From all of us with the Netter Publishing Team at Elsevier, we thank you. THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS v ABOUTTHEAUTHOR Bryan E. Anderson, MD, is Associate Professor of Dermatology at the Pennsylvania State University College of Medicine. He is proud to have received both his undergraduate and medical degrees from The Ohio State University. He completed his internship and Dermatology residency at the Pennsylvania State Uni- versity College of Medicine in Hershey, Pennsylvania, where, upon completion thereof, he joined the faculty in the Department of Dermatology in 2002. There he works as a clinician, educator, and researcher. Dr. Anderson is currently the Dermatology Residency Program Director and Director of a multidisciplinary outpatient specialty clinic. He is also a part of the Hershey Medical Centers Cancer Institute’s Multidis- ciplinary Skin Oncology Clinic. His areas of interest and research include resident education and cutaneous malignancies, with an emphasis on melanoma. He is an active member in his state medical society, the American Academy of Dermatology, and the American Contact Dermatitis Society. He has written numerous journal articles and book chapters and is coeditor of a large online dermatology resource. He currently lives in Hershey with his wife, Susan, and two daughters, Rachel and Sarah. In his leisure time he enjoys wood- working, cheering on his alma mater, and spending time with this family. vi THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS PREFACE It has been both an honor and a challenge to serve Jeffrey Miller, MD, Warren Heymann, MD, the late as the author of The Netter Collection: Integumentary John Stang, MD, and James Marks, MD—your impact System. I am honored to have contributed to the legacy on my career has been immeasurable. Certainly, this list that The Netter Collection so deserves with its timeless is not exhaustive. I have had the pleasure of crossing quality and continued contribution to medical educa­ paths with so many fine people—sadly, too many to list. tion. Of course, the challenge was in determining that A special thank you goes to Ruth Howe and Cheryl which would and should be included in the volume, in Hermanson, whose help was simply incredible; I truly keeping with the tradition of relevance of the series. My appreciate all you did. Additionally, I would like to hope is that this volume is appreciated by those with thank my colleagues at the Milton S. Hershey Medical vast experience as well as those individuals just begin­ Center, whose encouragement and support have always ning their journey of lifelong learning, which I feel so been a part of our culture. accurately describes the medical world. Finally, I would like to recognize and express appre­ My sincerest gratitude is extended to people behind ciation for my family: my parents, sisters, Uncle Lou, the scenes at Elsevier, specifically Marybeth Thiel, as and my loving Grandmother Ermandina. Your encour­ well as the artists who were able to bring the slightest agement and support is the foundation from which I nuance to life for the benefit of clinician and patient draw my confidence to tackle a project such as this. At alike. Although no volume exclusively dedicated to the the time of this writing, my wife, Susan, is in a select integumentary system existed, I attempted to incorpo­ group of people who have read, literally, every word of rate as many of Frank Netter’s depictions as possible. text in this volume. I cannot thank Susan enough for In several instances however, this simply was not pos­ her supportive nature, patience, and love; you are the sible, and I therefore had the pleasure and privilege of gem of my life. Lastly, I need to acknowledge my working with Carlos Machado, MD, and Tiffany S. daughters, Rachel and Sarah, of whom I am so proud. DaVanzo, MA, CMI, whose talent deserves to be The sacrifice of your evenings for more than a year so formally recognized. Their artwork captures the sub­ that I could work in an environment that was produc­ tleties of the integumentary system. For that I am tive and conducive to concentration will forever be forever grateful. appreciated. I would like to thank all those who have positively influenced, taught, and mentored me, specifically, Bryan E. Anderson, MD THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS vii ABOUTTHEARTIST Frank H. Netter, MD (1906-1991) “The Medical Michelangelo” Celebrated as the foremost medical illustrator of that artists led a very dissolute life, which of course was back asking for more heart flyers—without the advertis- the human body and how it works, Dr. Frank H. really not true.” ing copy. Dr. Netter went on to design similar product Netter began his career as a medical illustrator in To find a more “dependable” career, Dr. Netter advertisements depicting other organs, and all were the 1930s when the CIBA Pharmaceutical Company entered New York University Medical School. But even extremely well received. After that project was con- commissioned him to prepare illustrations of the major as he pursued his training as a surgeon, Dr. Netter cluded, Dr. Netter was commissioned to prepare small organs and their pathology. Dr. Netter’s incredibly found that it was easier for him to take notes in pictures folders of pathology plates that were later collected into detailed, lifelike renderings were so well received by the than in words. “Mine was a graphic viewpoint. My the first CIBA Collection of Medical Illustrations. medical community that CIBA published them in a notebooks were crammed with illustrations. It was the Following the success of these endeavors, Dr. Netter book. This first successful publication in 1948 was fol- only way I could remember things.” Soon faculty was asked to illustrate a series of atlases that became his lowed by the series of volumes that now carry the members recognized his artistic talents, and Dr. Netter life’s work. They are a group of volumes individually Netter name, The Netter Collection of Medical Illustra- began to pay for part of his medical education by illus- devoted to each organ system and cover human ana- tions. Even years after his death, Dr. Netter is still trating lectures and textbooks. tomy, embryology, physiology, pathology, and pertinent acknowledged as the foremost master of medical illus- Starting out as a young physician during the Depres- clinical features of the diseases arising in each system. tration. His anatomical drawings are the benchmark by sion, Dr. Netter found that there was more interest in Dr. Netter has completed volumes on the nervous which all other medical art is measured and judged. his medical artwork than his surgical capabilities. “I system, reproductive system, lower and upper diges- “As far back as I can remember, ever since I was little thought I could do drawings until I had my practice on tive tracts, liver, biliary tract and pancreas, endocrine tot, I studied art,” said Dr. Netter during an interview its feet,” he recalled, “but the demand for my pictures system, kidney, ureters, urinary bladder, respiratory in 1986. At the time he was hailed by the New York grew much faster than the demand for my surgery. As system, and musculoskeletal system. Times as “The Medical Michelangelo.” “All I wanted to a result, I gave up my practice entirely.” Dr. Netter’s beautifully rendered volumes are now to do was to make pictures,” he reflected. Born in New In 1938, Dr. Netter was hired by the CIBA Pharma- be found in every medical school library in the country, York in 1906, Dr. Netter had already established himself ceutical Company to work on a promotional flyer for a as well as in many doctors’ offices around the world, as a successful commercial artist in the 1920s when, at heart medication. He designed a folder cut in the shape and his work has helped to educate and enlighten gen- the advice of his parents, he changed careers. “I gave of and elaborately depicting a heart, which was sent to erations of physicians. In 1988, the New York Times up art at the urging of my family,” he said. “They felt physicians. Surprisingly, many of the doctors wrote called Netter “an artist who has probably contributed viii THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS