The Netter Collection of Medical Illustrations: Respiratory System: Volume 3

345 Pages·2011·28.67 MB·English

VOLUME 3
The Netter Collection

OF MEDICAL ILLUSTRATIONS:
Respiratory System
Second Edition
David A. Kaminsky, MD
Associate Professor
Pulmonary and Critical Care Medicine
University of Vermont
Burlington, Vermont
Illustrations by
Frank H. Netter, MD, and Carlos A.G. Machado, MD
CONTRIBUTING ILLUSTRATORS
John A. Craig, MD
James A. Perkins, MS, MFA
Kristen Wienandt Marzejon, MS, MFA
Tiff any S. DaVanzo, MA, CMI
Anita Impagliazzo, MA, CMI
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS: ISBN: 978-1-4377-0574-4
RESPIRATORY SYSTEM, Volume 3, Second Edition
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ISBN: 978-1-4377-0595-9
Acquisitions Editor: Elyse O’Grady
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Editorial Assistant: Chris Hazle-Cary
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Last digit is the print number: 9 8 7 6 5 4 3 2 1
ABOUT THE SERIES
Dr. Frank H. Netter exemplifi ed the distinct CUSHING’S SYNDROME IN A PATIENT WITH THE CARNEY COMPLEX
vocations of doctor, artist, and teacher.
Even more important, he unifi ed them. Netter’s
illustrations always began with meticulous
research into the forms of the body, a philoso-
phy that steered his broad and deep medical
understanding. He often said, “Clarifi cation is
the goal. No matter how beautifully it is painted,
a medical illustration has little value if it does Cbya rsnpeoyt tcyo smkipnl epxig ims cehnataraticotne.rized
Pigmented lentigines and blue
not make clear a medical point.” His greatest nevi can be seen on the face–
including the eyelids, vermillion
challenge—and greatest success—was charter- borders of the lips, the
conjunctivae, the sclera–and the
ing a middle course between artistic clarity and labia and scrotum.
instructional complexity. That success is cap-
Additional features of the
tured in this series, beginning in 1948, when Carney complex can include:
the fi rst comprehensive collection of Netter’s Mcuytaxnoemoauss: (cea.rgd.,i aecy ealtirdiu),m,
and mammary
work, a single volume, was published by CIBA
Testicular large-cell
Pharmaceuticals. It met with such success that calcifying Sertoli cell tumors
over the following 40 years the collection was Growth-hormone
secereting pituitary adenomas
expanded into an eight-volume series—each Psammomatous
devoted to a single body system. melanotic schwannomas
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 fi eld-leading doctors
Dr. Frank Netter at work and teachers from world-renowned medical institutions
and supplemented with new illustrations created by
artists working in the Netter tradition. Inside the classic
green covers, students and practitioners will fi nd
PPNAD adrenal glands are usually of normal size and most are
hundreds of original works of art—the human body sntouddudleeds wariet hle bslsa tchka,n b 4ro mwmn, ionr dreiadm neotdeur laensd. Minotestr sopfe trhsee dp iignm theented
in pictures—paired with the latest in expert medical adjacent atrophic cortex.
knowledge and innovation, and anchored in the sublime A brand new illustrated plate painted by Carlos Machado,
style of Frank Netter. MD, for The Endocrine System, Volume 2, ed. 2
Dr. Carlos Machado was chosen by Novartis to be
Dr. Netter’s successor. He continues to be the primary
artist contributing to the Netter family of products. Dr.
Machado says, “For 16 years, in my updating of the
illustrations in the Netter Atlas of Human Anatomy, as
well as many other Netter publications, I have faced
the challenging mission of continuing Dr. Netter’s
The single-volume “blue book” that paved the way for the legacy, of following and understanding his concepts,
multivolume Netter Collection of Medical Illustrations and of reproducing his style by using his favorite
series, aff ectionately known as the “green books.”
techniques.”
Although the science and teaching of medicine
endures changes in terminology, practice, and discov-
ery, 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 imag-
inations for over 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
of Dr. Netter, who is fondly remembered by all who
knew him. 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 at Elsevier, we thank you.
Dr. Carlos Machado at work
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS v
ABOUT THE EDITOR
David A. Kaminsky, MD, is Associate Professor
of Pulmonary and Critical Care Medicine at
the University of Vermont College of Medicine.
He received his undergraduate degree from Yale
University, and medical degree from University of
Massachusetts Medical School. He completed his
residency training in Internal Medicine at Columbia
Presbyterian Medical Center in New York City, and
fellowship training in Pulmonary and Critical Care
Medicine at the University of Colorado Health Sci-
ences Center in Denver. He joined the faculty of the
University of Vermont College of Medicine in 1995
and continues to work as a clinician, researcher, and
educator. Dr. Kaminsky is the Clinical Director of
the Pulmonary Function Lab, Program Director for
the Fellowship Training Program in Pulmonary and
Critical Care, and Associate Chair of the Institutional
Review Board at University of Vermont. His areas of
research interest include pulmonary physiology, lung
mechanics, asthma, and COPD. His work has been
funded by the National Institutes of Health, the Ameri-
can Lung Association, the Whittaker Foundation, and
other agencies. Dr. Kaminsky has published nearly 40
original papers and a dozen book chapters and reviews.
He lives in the Burlington, Vermont, area with his wife
and two children, two cats, and dog. He enjoys many
outdoor activities, including running, hiking, sailing,
rowing, and ice hockey.
vi THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS
PREFACE
It has been an honor to be the editor of the second am indebted to the many outstanding contributors to
edition—fi rst major revision in 30 years—of Netter’s this edition, who are each international experts in their
Respiratory System. The changes that have occurred fi eld. Without their input, it would have been impos-
over the past 3 decades in pulmonary medicine have sible to ensure that the most up-to-date, accurate infor-
been profound. The challenge of editing this edition mation would be provided to bring Netter’s Respiratory
has therefore been to include these updates while at the Disease into the 21st century. I would like to thank
same time preserving the unique nature and artistic especially those contributors who have been my teach-
beauty of Netter’s classic depiction of human health ers and mentors over the years: Drs. David Badesch,
and disease. In addition to ensuring the accuracy and Jason Bates, Gerry Davis, Barry Make, Ted Marcy,
relevance of the timeless topics of anatomy and physio- Polly Parsons, Charlie Irvin, Richard Irwin, Mike
logy, we have signifi cantly revised the sections on Iseman, and Talmadge King. Special thanks also go to
airways, parenchymal and pleural diseases, lung cancer, Dr. Jeffrey Klein, who made extra efforts to provide
infectious diseases, thromboembolic disease, inhala- radiographic images for many different sections of the
tional diseases, acute respiratory distress syndrome, book. Finally, I want to dedicate this work to my grand-
pharmacotherapy, radiology, mechanical ventilation, father, Dr. Edward Budnitz, who shared with me his
and trauma and surgery. New sections have been love of medicine and inspired me to pursue a career as
created on pulmonary immunology, pulmonary hyper- a physician.
tension, lung manifestations of systemic disease, sleep
medicine, exhaled breath analysis, endobronchial ultra- David Kaminsky
sound, video-assisted thoracoscopic ultrasound, lung Burlington, Vermont
volume reduction surgery, and lung transplantation. I November 2010
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS vii
ABOUT THE ARTIST FROM THE FIRST EDITION
undiminished. He is usually in his studio by in medical school, however, he found that because of
7:00 am, where he concentrates on the project his graphic training he could learn his subjects best by
before him until about two o’clock. The making drawings. So his early medical illustrations were
afternoons are mostly devoted to golf, to made for his own education. But it was not long before
swimming in the sea or pool, to fi shing, to his drawings caught the eyes of his professors, who then
time with his family or friends, or to other kept him busy in what little spare time he had making
diversions. At times he takes a “postman’s illustrations for their books and articles. Netter gradu-
holiday” to paint a landscape or a portrait just ated from New York University School of Medicine
for the fun of it. and completed his internship and surgical residency at
But not all of Dr. Netter’s work is done at Bellevue Hospital in the depths of the great depression.
the drawing board. Much of it consists of It soon became evident that his art commissions from
intensive study and wide reading, observation publishers and pharmaceutical manufacturers were a
of physicians at work in the clinic, hospital better source of income than his depression-stifl ed
or laboratory, and long hours of discussion medical practice, and he made the decision to be a full-
with a collaborator. Even during his hours of time medical artist.
relaxation the concept of the illustrations is Dr. Netter’s association with the CIBA Pharmaceuti-
germinating in his mind. After these prelimi- cal Company began in 1938 with his creation of a folder
naries he makes pencil sketches, composing cut out in the shape of a heart. Paintings of the anterior
The medical paintings of Dr. Frank Netter have the details and layout of the various elements of the and posterior (basal) surface of the heart were printed
received such wide acclaim from physicians the illustrations, positioning x-rays and photomicrographs, on the front and back and sections of the internal
world over for so long that the image of the man himself and determining the exact dimensions and placing of anatomy were depicted on the inside. An advertising
has begun to take on mythical proportions. And, indeed, the legends in order to achieve the maximum teaching message was overprinted both inside and out. The
it is easy to understand how such a transformation could effect. Only after the sketches are checked, double immediate response of physicians to this piece was to
take place. Yet, Dr. Netter is a real human being who checked, and revised for accuracy and detail does he request that it be produced without the advertising
breathes, eats and carries on a daily routine just like the proceed with the fi nished painting. Most of his paint- message. This was done to great success, and thus was
rest of us and who, for that matter, stands a little in awe ings are in water color, but at times he has used other born a series of anatomy and pathology illustration
of the image which is so often ascribed to him. media including casein paint, chalks, acrylics or oils. projects, the demand for which was so great that it
In order to help affi rm his reality as a man, we asked He maintains, however, that the medium is not very eventually led, in 1948, to the publication of the fi rst
Dr. Netter to make the accompanying self-portrait of important. Good pictures can be made in any medium. book of The Ciba Collection of Medical Illustra-
himself at work in his studio. The sketch portrays a He prefers water color only because through long use tions. The year 1978, then, is not only the year of
number of elements which may be familiar to those who he feels more at home with it and because he can introduction of Volume 7, Respiratory System, but is
have seen photographs of Dr. Netter’s studio in previ- express himself more directly and work more rapidly also the thirtieth anniversary of the fi rst book of The
ous volumes of The Ciba Collection of Medical with it. Ciba Collection of Medical Illustrations. Coinci-
Illustrations or in other publications—the man Dr. Netter’s great facility and skill at representative dentally, it is also the thirtieth anniversary of the fi rst
himself, the drawing board, the paints, the brushes, the painting, gift though it may be, did not come to fruition issue of the Ciba Clinical Symposia series.
skeleton and other accoutrements. The difference is without dedicated study and training—not only in Dr. Netter is still preparing well over 100 paintings
in the background. No longer is it the skyline of drawing and painting but in graphic design, composi- a year for The Ciba Collection of Medical Illustra-
New York, which could be seen from his former tion and layout as well. From the time he was a little tions and Clinical Symposia. Even now he is well into
studio window. Now it is the open sunny landscape of boy he wanted to be an artist. He studied intensively at the task of illustrating a new atlas on the musculo-
southern Florida, with waving palm trees and a boat the National Academy of Design, the Art Students skeletal system. Much has been said and written in the
traversing the waters of the intracoastal waterway. League of New York and other outstanding schools as past about the Netter “genius.” Perhaps the most
Nevertheless, the Netters’ move south from their well as with private teachers. He won many honors and, impressive aspect of all is not his “genius,” but the use
long established New York home does not signify an indeed, became a successful commercial artist in the this remarkable artist-physician-teacher makes of his
intention to wind down a highly productive work heyday of that profession. But then, partly because of gifts. His collective works are monumental, and they
schedule. Florida has meant a change in location and his own interest and partly because of urging by his continue to grow.
climate, but the intensity of Frank Netter’s commit- family to do “something more serious” he decided to
ment to what has become his life’s work continues give up art and initiate a new career in medicine. Once Philip B. Flagler
viii THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS
INTRODUCTION TO THE FIRST EDITION
Whenever a new atlas of mine appears, I feel as a manifestations of pulmonary vascular obstruction have
woman must feel when she has just had a baby. been more clearly defi ned.
The tediousness and travail of the long pregnancy and In light of the foregoing examples of the changing
the pain of delivery are over, and it remains to be seen emphasis in the fi eld of pulmonary medicine, to which
how my offspring will fare in the world. many more could be added, I have tried in this atlas to
In this case, there were a number of problems during give to each topic its proper emphasis in relation to the
the gestation. One of these was that interest in the subject as a whole, in accord with current concepts. In
respiratory system and its diseases has not only greatly doing this, much consideration had to be given to space
increased in recent years but that its focus has been availability. A good public speaker must deliver the
radically altered. The reasons for these changes are essentials of his message within the time allotted to him
manifold. They include the great differences which for if he rambles on and on, his audience is lost and his
have come about in the incidence of various lung dis- message ineffective. So, too, the artist must portray
eases; the advent and better utilization of antibiotics; his subject matter as effectively as possible within the
advances in radiologic technique and interpretation; the allotted pages. What to leave out becomes, at times, as
development of additional diagnostic techniques such important as what to include. Without such considera-
as radioactive isotope scanning; expansion in the study tions, this volume might have grown to twice or three
of pulmonary physiology and application of pulmonary times its size and become unbalanced, or become so
function tests; progress in understanding of pulmonary crowded with minutiae as to be dull and boring. In
pathology; increased facility in thoracic surgery and the either event, the utility of the book would have been
development of methods for predetermining operabil- greatly impaired.
ity, such as mediastinoscopy; the design or improve- As in the preparation of all my previous atlases, my
ment of technical and diagnostic mechanisms such as major efforts in this work were again necessarily
oxygen and aerosol apparatus, mechanical ventilators, directed towards gathering, absorbing and digesting the
more effi cient spirometers and surgical staplers; and information about each subject so that I might properly
alterations in the personal habits, environment and portray it. Thus study, learning and analysis of the
average age of the population. subject matter became as time consuming, or more so,
All these factors, as well as others, are, however, than the actual painting of the pictures. One cannot
interactive. For example, the great decrease in inci- intelligently portray a subject unless one understands it.
dence of pulmonary tuberculosis is related to the advent My goal was to picture or diagram the essence of each
of antibiotics: but it is also a consequence of improve- subject, avoiding the incidental or inconsequential. In
ment in living standards and habits, as well as of some instances I have, however, included topics which,
improved early diagnosis. These factors may also be at present, do not seem to have great practical applica-
responsible for the lesser incidence and morbidity of tion but which, in the future, may give important clues
pneumococcal pneumonia. Whereas in former years to pathogenesis, diagnosis or treatment. All this was
these two diseases were major concerns of the chest greatly facilitated, indeed made possible, through the
physician, they are nowadays of much less signifi cance. devoted cooperation of the many distinguished consult-
But this, on the other hand, has allowed more time and ants who are listed individually on other pages of this
effort to be diverted to other lung disorders. The volume. I herewith express my appreciation to each and
greatly increased incidence of lung cancer appears to every one of them for the time, effort and guidance
have resulted in considerable measure from changes which they gave me, and for the knowledge which they
in personal habits (such as smoking), environmental imparted to me. I also thank the many others who,
pollution and occupational activity, and possibly also although not offi cially consultants, nevertheless helped
change in population age. But earlier discovery of me with advice or information or by supplying refer-
tumors through greater public awareness and improved ence material to me. They are also credited elsewhere
diagnosis, plus greater surgical facility, have led to in this book. I especially thank Dr. Matthew B. Divertie
increased interest in operability, and this in turn has for his careful and thorough review of both the pictorial
stimulated study of pathologic classifi cation in relation and text material and for his many constructive
to malignancy. The increase in chronic bronchitis and suggestions.
emphysema, while largely real and attributable to the The production of this book involved a tremendous
same etiologic factors as cancer, may to some extent be amount of organizational work, such as assembling and
only apparent—due to better diagnostic methods and compiling the material as it grew in volume, correlating
utilization of pulmonary function studies. But recogni- illustrations and text, grammatical checking, reference
tion of some of the etiologic factors and better under- checking, type specifi cation, page layout, proofreading,
standing of the underlying pathologic processes, and a multitude of mechanical and practical details inci-
coupled with availability and utilization of such meas- dental to publication. I tremendously admire the effi -
ures as aerosol medication, improved equipment for ciency with which these matters were handled by Mr.
oxygen administration and mechanical ventilation, and Philip Flagler and his staff at CIBA, including Ms. Gina
postural drainage have greatly modifi ed for the better Dingle, Ms. Barbara Bekiesz, Ms. Kristine Bean and
the management of these distressing disorders. The Mr. Pierre Lair. Finally, I once more give praise to the
current relatively high incidence of occupational dis- CIBA Pharmaceutical Company and its executives for
eases may likewise to some extent be only apparent, their vision in sponsoring this project and for the free
because of greater awareness and better diagnosis. Pul- hand they have given me in executing it. I have tried to
monary embolus and infarction have also received do justice to it.
increased attention in recent years as the common
sources of emboli have been identifi ed, and as the FRANK H. NETTER, MD
THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS ix