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Pentland's Students Manuals.



MANUAL OF ANATOMY.






NUNQUAM AL1U1) NATURA, AL1UD SAP1ENTJA DICtT.



MANUAL



OF



PRACTICAL ANATOMY



BY



D. J. CUNNINGHAM,

M.D. (EDIN. ET DUEL.), D.SC., LL.D., D.C.L. (OXON.), F.R.S.,
PROFESSOR OF ANATOMY AND CHIRURGERY, UNIVERSITY OF DUBLIN



VOLUME FIRST.
UPPER LIMB; LOWER LIMB; ABDOMEN

SECOND EDITION.
ILLUSTRATED WITH ENGRAVINGS.



EDINBURGH AND LONDON:

YOUNG J. PENTLAND.

1896.



EDINBURGH : PRINTED FOR YOUNG J. PENTLAND, II TEVIOT PLACE, AND
38 WEST SMITHFIELD, LONDON, E.G., BY R. AND R. CLARK, LIMITED.



A II rights reserved.



PREFACE.



THE order of dissection which is recommended in this
Manual of Practical Anatomy is much the same as that
which has been followed for many years in the Practical
Anatomy Department of the Edinburgh University, and
in the numerous schools which have been officered from
it. As time has gone by many changes in this method
of dissection have been adopted. As it has been handed
from one teacher to another it has undergone develop-
ment and improvement, so that it differs at the present
day from the practice in the time of the Monros, or
of Goodsir.

The first volume deals with the Limbs and the
Abdomen, the second volume contains the method of
dissection and the description of the Thorax and the
Head and Neck.

Our conception of the topographical anatomy of the
cavities of the body has of late years undergone very con-
siderable modification. This has largely been brought
about by the study of sections of the frozen body, and by
the publication of. the beautiful series of models by
Professor His of Leipzig. In so far as the topography of



vi PREFACE.

the abdomen is concerned, it cannot be too strongly urged
that no two subjects are precisely alike in the relation of
parts ; and, further, that even in the same individual
striking changes are produced during life, both in the
position and in the form of the organs, by different con-
ditions of the hollow viscera. Such being the case, the
author is well aware that in the present state of our
knowledge it is impossible in every case to state dog-
matically the average condition of the various organs and
viscera ; still, in the short description which he has given,
he has striven to approach as nearly as possible to the
truth, by the careful study of specially prepared specimens
and models.

The topographical anatomy of the abdominal cavity
offers at the present moment a most promising field for
research, and the author has little doubt that in a short
time more definite and exact knowledge will be obtained
upon the effect which different degrees of enlargement
or distension of particular organs may exercise upon
neighbouring viscera.

It is right that the student should not lose sight of the
fact that in the course of an ordinary dissection the parts
which are displayed are artificially separated from each
other, and in consequence their true relations are disturbed.
It is necessary to correct, therefore, impressions gained by
dissection by the study of sections of the frozen body.
The one form of study is the complement of the other ;
both are required for the acquisition of a proper knowledge



PREFACE. vii

of topographical anatomy. Sectional anatomy is the true
anatomy, but it can only be appreciated and understood
by the key which is supplied by dissection.

In the present work no attempt is made to deal with
the minute anatomy of the organs. Under ordinary
circumstances the microscope is out of place in the
dissecting-room. It is a matter for regret, however, that
students so very generally neglect the opportunities which
are afforded them during their dissections of gaining a
practical knowledge of the general architecture of the
different organs which come under their notice. The
connecting link between the dissecting-room and the
histological laboratory is thereby lost. The spleen offers
us a good example ; it is only when we deal with such an
organ as a whole, and not with thin slices suited for the
microscope, that we can obtain a proper appreciation of its
framework, and the general disposition of its constituent
parts.

The Committee appointed some years ago by the
Anatomical Society of Germany with the view of obtain-
ing some uniformity in anatomical nomenclature has
recently published its report. Where the terminology
recommended by this Committee differs from that in
common use in this country, the author has, in most
cases, introduced the German terms into the text, within
parentheses.

Most of the illustrations are new, but many have also
been borrowed from the writings of well-known authors.



Vin PREFA CE.

In every case the source from which the latter have been
obtained is acknowleged in the text. The author has
specially to thank Dr. Symington and Professor Paterson
for the generous manner in which they have supplied him
with original drawings and wood-blocks.



TRINITY COLLEGE, DUBLIN,
2$th December 1895.



CONTENTS.



THE UPPER LIMB.

PAGE

INTRODUCTORY, ..... i

DISSECTION OF THE BACK, ..... 3

PECTORAL REGION AND AXILLARY SPACE, . . -15

THE AXILLA, ....... 23

SCAPULAR REGION, ...... 45

FRONT OF THE ARM, ...... 58

BACK OF THE ARM, ...... 79

SHOULDER JOINT, ...... 84

FOREARM AND HAND, ...... 90

FRONT AND INNER BORDER OF THE FOREARM, . . 94

WRIST AND PALM, . . . . . .106

BACK AND OUTER BORDER OF THE FOREARM, . .129

DORSAL ASPECT OF THE WRIST AND HAND, . . .138

ARTICULATIONS, ...... 145

THE LOWER LIMB.

GLUTEAL REGION, ...... 164

POPLITEAL SPACE, . . . . . .183

BACK OF THE THIGH, ...... 195

FRONT OF THE THIGH, ..... 200

SUPERFICIAL DISSECTION OF THE FRONT OF THE THIGH. . 202

DEEP DISSECTION OF THE FRONT OF THE THIGH, . . 213

INNER SIDE OF THE THIGH, ..... 239

HIP-JOINT, ....... 248

THE LEG, ....... 254



x CONTENTS.

PAGE

ANTERIOR TIBIO-FIBULAR REGION DORSUM OF THE FOOT, . 256
PERONEAL REGION, . . . . . .271

TIBIAL REGION, ...... 273

POSTERIOR TIBIO-FIBULAR REGION, .... 274

SOLE OF THE FOOT, ...... 288

THE KNEE-JOINT, ...... 307

THE ANKLE-JOINT, . . . . .319

TIBIO-FIBULAR JOINTS, . . . . .321

THE ARTICULATIONS OF THE FOOT, .... 324



ABDOMEN.

MALE PERINEUM, ...... 336

RECTAL TRIANGLE, ...... 338

UROGENITAL TRIANGLE, . . . ... 346

THE FEMALE PERINEUM, ..... 364

RECTAL TRIANGLE, ...... 370

UROGENITAL TRIANGLE, . . . . 370

ABDOMINAL WALL, ...... 377

SURGICAL ANATOMY OF THE ABDOMINAL WALL, . . 421

ABDOMINAL CAVITY AND ITS CONTENTS, . . 430

VESSELS ON THE POSTERIOR WALL OF THE ABDOMEN, . 530

FASCIA AND MUSCLES ON THE POSTERIOR WALL OF THE

ABDOMEN, ....... 537

NERVES ON THE POSTERIOR WALL OF THE ABDOMEN, . 540

PELVIS, ........ 546

MALE PELVIS, . . . . . . . 548

PELVIC ARTICULATIONS, ..... 605

FEMALE PELVIS, .... 612



INDEX,



639



LIST OF ILLUSTRATIONS.



PLATE I. Posterior wall of the abdomen after the removal of

viscera. (After GOUBAROFF), . facing page 466

FIG. PAGE

1. Lines of incisions for reflection of skin from dorsal aspect

of subject, ...... 3

2. Cutaneous nerves and superficial muscles of the back, . 5

3. Diagram of the lumbar fascia, . . . .10

4. Lines of incisions for reflection of skin from ventral aspect

of the subject, ...... 17

5. Diagram to show the structure of the mammary gland . 20

6. Section through the axilla of the left side, . . .25

7. Transverse section through the right shoulder, and apex of

the axilla, ...... 27

8. Transverse section through the right axilla, . . 28

9. Diagram illustrating the arrangement of the main branches

of the brachial plexus, ..... 32

10. Diagram of the costo-coracoid membrane, . . -33

11. Diagram of the axillary artery and its branches, . . 37

12. Diagram of the brachial plexus, . . . .40

13. Dissection of the posterior scapular region, . . 48

14. Diagram of the circumflex vessels and nerve, . . 5 1

15. Posterior view of the upper limb, with the elbow-joint fully

extended. (LUSCHKA), . . . -59

16. Posterior view of the upper limb, with the elbow-joint flexed

(LUSCHKA), ' . . . . . -59

17. Diagram of the cutaneous nerves on the front of the upper

limb, ....... 62



xil LIST OF ILLUSTRATIONS.

FIG. PAGE

1 8. Diagram of the cutaneous nerves on the posterior aspect of

the upper limb, ...... 64

19. Superficial dissection of the region in front of the right

elbow. (LUSCHKA), ..... 66

20. Diagram to show the arrangement of the intermuscular septa

in the arm. (After TURNER), . . . .68

21. Transverse "section through the lower third of the right

upper arm, ...... 69

22. Transverse section through the right upper arm about its

middle, ....... 71

23. Dissection of the anticubital fossa, . . . .78

24. Coronal or vertical transverse section through the left

shoulder-joint. (Viewed from behind), . . 85

25. Transverse section through the upper third of the left

forearm, ....... 97

26. Diagram to show the relation of the skin markings of the

palm to the arteries and bones of the hand. (TREVES), . 108

27. Diagram of the median and ulnar nerves in the palm, . 115

28. Transverse section through the wrist at the level of the

second row of carpal bones to show the carpal tunnel, . 117

29. Diagram to illustrate the arrangement of the synovial

sheaths around the flexor tendons, . . .120

30. Flexor tendons of the finger, with the vincula accessoria.

(REEVES), . . . . . .122

31. Diagram of the anastomosis around the elbow-joint, . 136

32. Diagrammatic section through the lower end of the forearm

to show the compartments of the posterior annular liga-
ment. (REEVES), ..... 141

33. Arrangement of the flexor and extensor tendons of the

middle finger. (LUSCHKA), .... 142

34. Vertical antero-posterior section through the humerus and

ulna at the elbow-joint, . . . . .145

35. Vertical antero-posterior section through the humerus and

radius at the elbow-joint, .... 147

36. Socket formed by radius and triangular fibro-cartilage for

upper row of carpal bones, . . . .150

37. Vertical section through the flexed wrist-joint in the line of

the middle finger, . . . . .151

38. Coronal section through the carpal joints, . . .157

39. Cutaneous nerves on the back of the lower limb, . .167



LIST OF ILLUSTRATIONS. xill



40. Dissection of the gluteal region, . . . .174

41. Dissection of the right popliteal space, . . . 187

42. Transverse section through the popliteal space of the right

lower limb, . . . . . .188

43. Diagram of the popliteal artery and its branches,' . . 192

44. Dissection of the back of the right thigh, . . .197

45. Diagram of the cutaneous nerves on the front of the lower

limb ....... 208

46. Diagram to show the arrangement of the three intermuscular

septa and the three osteo-fascial compartments of the
thigh. (TURNER), ..... 212

47. Dissection of the femoral sheath and Hunter's canal, . 216

48. Parts which pass behind Poupart's ligament. (LusCHKA), 218

49. Dissection of the femoral sheath and Hunter's canal, . 226

50. Transverse section through Hunter's canal, . . 228

51. Transverse section through the middle of the thigh, . 229

52. Diagram to illustrate the distribution of the obturator nerve

and the general disposition of the adductor muscles of the
thigh. (PATERSON), ..... 244

53. The ilio- femoral band isolated from the capsule of the

hip-joint, .... ' 250

54. Diagrammatic representation of the fascia of the leg, . 260

55. Transverse section through the calf of the leg, . . 263

56. Dissection to show the plantar arterial arch from the dorsal

aspect of the foot, ..... 267

57. Transverse section through the leg immediately above the

ankle-joint, ...... 270

58. Transverse section through the leg immediately above the

ankle-joint, ...... 284

59. Diagrammatic representation of the fascia of the leg, . 285

60. Dissection of the inner ankle, .... 286

61. Diagram to show the different planes occupied by the

external plantar artery. (PATERSON), . . 293

62. Diagram of the accessorius muscle and the tendons of the

flexor longus hallucis and flexor longus digitorum in the

sole of the foot, ...... 297

63. Vertical section through the foot. (LUSCHKA), . . 299

64. Anastomosis on the anterior aspect of the knee-joint, . 305

65. Vertical antero-posterjor section through the knee-joint, . 312

66. Articular surface of the lower end of left femur, with the

crucial ligaments attached, .... 314



xiv LIST OF ILLUSTRATIONS.



67. Upper articular surface of right tibia showing attachments

of semilunar cartilages and crucial ligaments, . . 318

68. Socket for the astragalus, ..... 320

69. Vertical section through the foot. (LuscHKA), . . 324

70. Outlet of pelvis, ...... 337

71. Lines of incisions for reflection of skin in the dissection of

the perineum, . . . . . . 339

72. Diagram of the pelvic fascia, .... 342

73. Dissection of the perineum, ..... 345

74. Diagram of the three parts of the penis, and their relation

to the pubic arch and the triangular ligament, . . 350

75. Deep dissection of the perineum, .... 354

76. Diagram of the triangular ligament, . . . 355
77- ,,,,,, ,,.... 356

78. Vertical transverse section through the pubic arch to show

the two perineal compartments and their contents, . 360

79. Deep dissection of the perineum. (GRAY), . . 362

80. Outlet of pelvis, ...... 365

81. External genitalia of the female. (SYMINGTON), . . 367

82. The clitoris and the bulb of the vestibule. (GEGENBAUR), 374

83. Lines of incision for reflection of skin from the ventral aspect

of the subject, ...... 379

84. Superficial dissection of abdominal wall, . . . 383

85. Diagram to show the connections of the lower part of the

aponeurosis of the external oblique muscle, . . 388

86. The obliquus abdominis internus. (HEITZMANN), . . 393

87. Diagram to illustrate the relation of the lower border of the

internal oblique muscle, ..... 394

88. Diagram of the muscles and apbneuroses of the abdominal wall, 398

89. Dissection of the abdominal wall. (HEITZMANN),. . 399

90. Diagram of the muscles and aponeuroses of the abdominal wall, 402

91. Diagram of the aponeuroses in the lower part of the front

wall of the abdomen, ..... 403

92. Diagram to illustrate the relation of the lower portions of

the internal oblique and transversalis muscles to the in-
guinal canal, ...... 404

93. Diagrams illustrating the descent of the testicle and the

derivation of the tunica vaginalis from the peritoneal
lining of the abdominal cavity, . . . .412

94. Transverse section through the left side of the scrotum and

the left testicle, . . . . . .416



LIST OF ILLUSTRATIONS. xv

FIG. PAGE

95. Diagram illustrating the structure of the testicle. (GEGEN-

BAUR), . . 419

96. Diagram to show the different peritoneal relations in an

ordinary inguinal hernia and a congenital inguinal
hernia ....... 424

97. Diagram to illustrate the four different varieties of infantile

hernia. (After LOCKWOOD), .... 426

98. Outline of the abdominal cavity as seen in mesial section, . 432

99. Subdivision of the abdominal cavity, . . . 433

100. Diagram showing the exact portions of the liver in the

different sections of the costal zone, . . . 437

101. Anterior surface of the liver from the model by His, . 439

102. The form of the spleen as seen from its visceral aspect, . 442

103. Position of viscera as seen in a female subject, . . 444

104. The recess or space in the abdominal cavity which is

occupied by the stomach, .... 445

105. Position of viscera in relation to the under surface of the

diaphragm. (BRAUNE), .... 448

1 06. From a tracing of a transverse section through the abdomen,

at the level of the fourth lumbar vertebra, . -453

107. Diagram to illustrate the continuity of the peritoneum in

the vertical direction, ..... 456

1 08. Section through the peritoneal cavity at the level of the

foramen of Winslow, ..... 460

109. Section at the level of the umbilicus through the inter-

vertebral disc between the third and fourth lumbar
vertebrae, . . . . . .461

no. Section through the abdominal cavity of a young subject at
the upper border of the twelfth dorsal vertebra, above the
level of the foramen of Winslow. (LusCHKA), . . 462

in. Diagram of the peritoneal ligaments of the liver, . . 465

112. Diagram of the superior mesenteric artery and its branches.

(GRAY), . .471

113. Diagram of the inferior mesenteric artery and its branches.

(GRAY), .... . 475

114. The cceliac axis and its branches. (GRAY), . . 484

115. The splenic artery and vein. (GRAY), . . . 487

1 1 6. The duodenum, pancreas, kidneys, etc., from the model

by His, . . . . . . -491

117. Position of duodenum, with reference to kidney in three

different subjects. (BROOKS), . . . 492



xvi LIST OF ILL USTRA TIONS.

FIG. PAGE

1 1 8. The pancreas as seen in a subject in which the abdominal

viscera were hardened by repeated injections of Mtiller's

fluid and spirit, ...... 495

119. The pyloric orifice of a child in which the sphincter is

tightly contracted, . . . 503

1 20. Peritoneal and muscular coats removed from the pylorus

and upper part of duodenum to show the constriction and
Brunner's glands. (GEGENBAUR), . . . 504

121. Inferior surface of the liver, from the model by His, . 507

122. Posterior surface of the liver, from the model by His, . 509

123. Liver, right kidney, spleen, and stomach, as seen from

behind, . . . . . . .510

124. Lower and posterior surfaces of a liver which has lost its

proper form from being placed on a plane surface.
(GRAY), . .... 511

125. Cystic and hepatic ducts. (GEGENBAUR), . . 512

126. Section through abdomen at the level of the second lumbar

vertebra, . . . . . 517

/'A. Anterior surface of a model of the right kidney of a
J27 J child of two years old, .... 519

I B. Anterior surface of a model of the left kidney of a

child of two years old, . . . 519

128. Transverse section through abdomen at the level of the

first lumbar vertebra, . . . . .520

129. Peritoneal relations of the kidneys, . . . 521

130. Two different forms of the pelvis of the ureter. (GEGENBAUR), 522

131. Two renal papillae. (LUSCHKA), .... 522

132. Posterior surface of the anterior wall of the thorax and

abdomen, to show the costal and sternal origins of the

diaphragm on the left side. (LUSCHKA), . . 526

133. Diagram of the lumbar plexus, .... 543

134. The lumbar plexus, . . . 545

135. Side view of pelvic viscera. (WiLSON), . . . 549

136. Diagram of the pelvic fascia .... 552

137. Dissection to expose pelvic fascia from the outer side, . 553

138. Dissection of the pelvic fascia . . . -554

139. Relation of blood-vessels, etc., to the parietal pelvic fascia, 558

140. Diagram of the pelvic fascia as seen in a vertical transverse

section through the pubic arch, . . . -559

141. Diagram of the pelvic fascia, .... 560
H2. ,, .... 561



US T OF ILL US TRA TIONS. x vii

FIG. PAGE

143. Diagram representing the pelvic fascia in antero-posterior

section, ....... 562

144. Dissection of the rectum, from behind, by Mr. C. Paton, . 566

145. Coronal section through the whole length of the anal canal.

(SYMINGTON), ...... 569

146. Mesial section through the pelvis of an adult male, . 572

147. Mesial section through a male pelvis, in which the bladder

is greatly distended, ..... 574

148. Mesial section through pelvis of a newly-born full-time

male infant, ...... 575

149. Seminal vesicle and vas deferens on the base of the bladder.

(GEGENBAUR), ..... 578

150. View of the posterior aspect of the anterior wall of the

abdomen and pelvis of a foetus, to show the hypogastric
artery. (LUSCHKA), ..... 580

151. Sacral and sacro-coccygeal plexuses as seen from behind.

(EISLER), ...... 588

152. Mucous membrane lining the anal canal. (LuscHKA), . 595

153. Diagram of the urethra and bladder, . . . 599

154. Section through the sacro-iliac joint. (LUSCHKA), . 608

155. Horizontal section through the symphysis pubis. (LuscHKA), 610

156. Mesial section through the pel vis of a virgin. (LEGENDRE), 613

157. Horizontal section through the urethra, vagina, and anal

canal, a short distance above their terminations. (HENLE), 614

158. The uterus, with the broad ligament stretching out from

either side of it. (GEGENBAUR), . . 615

159. Two forms of the empty female bladder as seen in mesial

section. (DissE), . . . . .618

1 60. Mesial section through a female pelvis, . .619

161. Vertical section through the female pelvis ; bladder dis-

tended. (PlROGOFF), ..... 620

162. Diagram of the vulva, vagina, and uterus with its append-

ages. (SYMINGTON), ..... 625

163. The uterus, with the broad ligament stretching out from

either side of it. (GEGENBAUR), . . . 626

164. Sagittal section through the pelvis of a female child two

years old, ...... 628

165. The ampulla and fimbriated end of the Fallopian tube ;

the ovary and the parovarium. (GEGENBAUR), . 630

166. Interior of the uterus. (LuscHKA), . . . 635



MANUAL OF ANATOMY.



MANUAL



OF



PRACTICAL ANATOMY.



THE UPPER LIMB.

dissector of the upper limb begins work on the
third day after the subject has been placed in
the dissecting-room. He will then find the subject
stretched out at full length upon its face, with the pelvis
and chest supported by blocks (Fig. i) ; and while the
body remains in this position he must examine those
structures which connect the limb to the posterior aspect
of the trunk.

Surface Anatomy. Before proceeding to the actual
dissection of any region, the student should make it
an invariable rule to familiarise himself with the bony
prominences within its area. It is by using these as
landmarks that the surgeon is enabled to establish the
position of the component parts of the body in the
living subject. Their importance can hardly be ex-
aggerated. In the middle line of the back there will
be little difficulty in recognising the spines of the
vertebrae, which foil .<v each other in consecutive order.
If the finger be p, jsed over them, it will be observed
that they do not, in every case, occupy the mesial plane ;
VOL. i. i



2 THE UPPER LIMB,

some of them may be deflected, in a slight degree, to
one side or the other. The spines of the vertebrae are
the only parts of the vertebral column which come to
the surface ; they alone yield direct information, by touch*,
to the surgeon as to the condition of the spine. At the
lower end of the neck, the spine of the seventh cervical
vertebra (vertebra prominens] makes a visible projection;
and the spines of the first two dorsal vertebrae are like-
wise very prominent. As a rule, the most evident of the
three is that of the first dorsal vertebra. At a lower
level, in subjects of good muscular development, a mesial
furrow is produced by the prominence of the erector
spinae muscle on each side, and the spines of the vertebrae
may be felt at the bottom of this groove. It attains its
greatest depth in the upper part of the lumbar region,
and it fades away below at the level of the spine of the
third sacral vertebra. The finger should next be passed
along the crest of the ilium as it pursues its sigmoid
course forwards and outwards. Note that the posterior
superior spine of the ilium lies in a slight depression on
a level with the second sacral spine. The scapula is for
the most part thickly covered by muscles ; but, in spite
of this, its general outline can be made out. The scapula
covers a considerable area on the upper portion of the
chest on its posterior aspect. With the hand by the
side its superior angle corresponds with the second
intercostal space, whilst its inferior angle reaches down
as far as the seventh, or even the eighth, rib. It is
very mobile moving more or less with every movement
of the limb. The spine and acromion process of the
scapula will be seen to be subcutaneous throughout. It
is important to make out accurately the angle which is
formed by the meeting of the lower border of the spine
with the outer margin of the acromion. This very
apparent bony point is selected by the surgeon as the
upper limit in making measurements of the limb.



DISSECTION OF THE BACK.



DISSECTION OF THE BACK.

In this dissection the following are the parts which
require to be examined :

1. The cutaneous vessels and nerves of the back.

2. The trapezia's muscle.

3. The latissimus dorsi muscle.

4. The rhomboid muscles and their nerve of supply.

5. The levator anguli scapulce muscle.

6. The spinal accessory nerve and the nerves from the cervical

plexus which supply the trapezius.



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