Lesson # 1

1. Anatomy of the heart I: location and structure of heart, anatomy of chambers. Systemic and pulmonary circulation

2. Anatomy of the heart II: structure of heart wall, blood supplying and innervation of the heart. Pericardium. Projection of heart on the front thoracic wall

3. Thoracic part of aorta: topography, parietal and visceral branches. System of superior vena cava

Lesson # 31

Theme 1. Anatomy of the heart I: location and structure of heart, anatomy of chambers. Systemic and pulmonary circulation

THE VASCULAR system is divided for descriptive purposes into (a) the blood vascular system, which comprises the heart and bloodvessels for the circulation of the blood; and (b) the lymph vascular system, consisting of lymph glands and lymphatic vessels, through which a colorless fluid, the lymph, circulates. It must be noted, however, that the two systems communicate with each other and are intimately associated developmentally.

The heart is the central organ of the blood vascular system, and consists of a hollow muscle; by its contraction the blood is pumped to all parts of the body through a complicated series of tubes, termed arteries. The arteries undergo enormous ramification in their course throughout the body, and end in minute vessels, called arterioles, which in their turn open into a close-meshed network of microscopic vessels, termed capillaries. After the blood has passed through the capillaries it is collected into a series of larger vessels, called veins, by which it is returned to the heart. The passage of the blood through the heart and blood-vessels constitutes what is termed the circulation of the blood, of which the following is an outline.

The HEART is a hollow muscular organ, which is situated in thoracic cavity in middle mediastinum. It has a heart apex, which is directed down to the left and heart base. Heart has a sternocostal (anterior) surface, diaphragmatic (posterior) surface, right/left pulmonary surfaces. Coronal sulcus passes on diaphragmatic and partially on sternîcostal surfaces, which marks the border between ventricles and atriums. Anterior interventricular sulcus and posterior interventricular sulcus pass from coronal sulcus downward and project borders between right and left ventricles. On heart base right and left auricles are situated, which envelop the great vessels. On heart base at the anterior from right ventricle pulmonary trunk passes, which subdivides into two pulmonary arteries. Aorta

passes behind pulmonary trunk; behind from aorta from right side superior vena cava and inferior vena cava, and to the left four pulmonary veins.



Front view of heart and lungs.

 

Heart cavity subdivides on right and left atriums and right and left ventricles. Left chambers of heart are arterial and in adult do not communicate with right venous half of heart. Exist two blood circles.

Big circle or systemic circulation of the blood starts in left ventricle by aorta and terminates in right atrium by vena cava superior and inferior. Systemic circulation of the blood provides by arterial blood all of organs and tissues.

The small circle or pulmonary circulation of the blood begins by pulmonary trunk from right ventricle and terminates in left atrium by 4 pulmonary veins. Venous blood flows in arteries of pulmonary circulation of which and arterial (oxygenated) blood - in veins.

 

VIDEO

 

Right atrium consists of own atrium and right auricle.

Internal wall is smooth, but in auricle pectinate muscles are situated. Right atrium receives the superior and inferior venae cavae, which open by foramen of inferior vena cava and foramen of superior vena cava. Intervensus tubercle is situated between these foramens. Broadened posterior area, where two venae cavae fall is called as sinus venae cavae. Right atrium is separated from left by interatrial septum, where oval fossa is situated. It is limited by limbus of oval fossa. Atrium communicates by right ventricle through the right atrioventricular ostium. Foramen of coronal sinus situated between last and foramen of inferior vena cava. Alongside are contained foramens of venarum minimarum.

Right ventricle consists of own ventricle and conus arteriosus - superior part, which continues through the ostium of pulmonary trunk into pulmonary trunk. The right and left ventricles are separated by interventricular septum, which has muscular part (greater) and membranous part (lesser). On internal surface of right ventricle are situated the trabeculi carneae, which carry cone-shaped anterior, posterior and septal pappillar muscles. From top of these muscles chordae tendineae start and terminate at cusps of right atrioventricular valve.

Right atrioventricular ostium closes by right atrioventricular (tricuspidal) valve, which consists of anterior cusp, posterior cusp and septal cusp edges of which attach to chordae tendineae. During contraction of atria blood stream presses the cusps to the wall of ventricle. During contraction of ventricles free edges of cusps close up but do not pull out because they are kept by chordae tendineae from ventricle. Ostium of pulmonary trunk closes by valve of pulmonary trunk, which consists of right, left and anterior semilunar valvulae, which have on superior margin the nodules of semilunar valvulae. Nodules assist to compact closing up. Between each semilunar valvula and pulmonary trunk wall sinuses of pulmonary trunk are situated.



Base and diaphragmatic surface of heart.

 

Left atrium has an irregular cube shape; anterior wall forms a left auricle. Internal wall surfaces of left atrium is smooth and only in auricle area pectinate muscles are situated. The ostia of 4 pulmonary veins open into left atrium. Left atrium communicates with left ventricle by the means of left atrioventricular ostium. Oval fossa makes a mark poorly on interatrial septum.

Left ventricle is the largest heart chamber, its wall forms larger part of diaphragmatic surface. Internal surface containes the trabeculi carneae, which attach anterior papillary muscle and posterior papillary muscle. The tops of these muscles by means of cordae tendineae hold the cusps of mitral valve.

Left atrioventricular ostium closes by left atrioventricular (bicuspidal) valve [valve mitralis], which consists of anterior cusp and posterior cusp edges of which attach to chordae tendineae. From left ventricle aorta starts. Aortic ostium closes by aortic valve, which consists of right, left and posterior semilunar valvulae, which have on superior margin the nodules of semilunar valvulae. Between each semilunar valvula and aorta walls are situated aortic sinuses.



Base of ventricles exposed by removal of the atria.

Size.—The heart, in the adult, measures about 12 cm. in length, 8 to 9 cm. in breadth at the broadest part, and 6 cm. in thickness. Its weight, in the male, varies from 280 to 340 grams; in the female, from 230 to 280 grams. The heart continues to increase in weight and size up to an advanced period of life; this increase is more marked in men than in women.

 

Component Parts.—As has already been stated (page 497), the heart is subdivided by septa into right and left halves, and a constriction subdivides each half of the organ into two cavities, the upper cavity being called the atrium, the lower the ventricle. The heart therefore consists of four chambers, viz., right and left atria, and right and left ventricles.

The division of the heart into four cavities is indicated on its surface by grooves. The atria are separated from the ventricles by the coronary sulcus (auriculoventricular groove); this contains the trunks of the nutrient vessels of the heart, and is deficient in front, where it is crossed by the root of the pulmonary artery. The interatrial groove, separating the two atria, is scarcely marked on the posterior surface, while anteriorly it is hidden by the pulmonary artery and aorta. The ventricles are separated by two grooves, one of which, the anterior longitudinal sulcus, is situated on the sternocostal surface of the heart, close to its left margin, the other posterior longitudinal sulcus, on the diaphragmatic surface near the right margin; these grooves extend from the base of the ventricular portion to a notch, the incisura apicis cordis, on the acute margin of the heart just to the right of the apex.

 

The base (basis cordis) (491), directed upward, backward, and to the right, is separated from the fifth, sixth, seventh, and eighth thoracic vertebræ by the esophagus, aorta, and thoracic duct. It is formed mainly by the left atrium, and, to a small extent, by the back part of the right atrium. Somewhat quadrilateral in form, it is in relation above with the bifurcation of the pulmonary artery, and is bounded below by the posterior part of the coronary sulcus, containing the coronary sinus. On the right it is limited by the sulcus terminalis of the right atrium, and on the left by the ligament of the left vena cava and the oblique vein of the left atrium. The four pulmonary veins, two on either side, open into the left atrium, while the superior vena cava opens into the upper, and the anterior vena cava into the lower, part of the right atrium.

 

VIDEO

 

The Apex (apex cordis).—The apex is directed downward, forward, and to the left, and is overlapped by the left lung and pleura: it lies behind the fifth left intercostal space, 8 to 9 cm. from the mid-sternal line, or about 4 cm. below and 2 mm. to the medial side of the left mammary papilla.

The sternocostal surface (492) is directed forward, upward, and to the left. Its lower part is convex, formed chiefly by the right ventricle, and traversed near its left margin by the anterior longitudinal sulcus. Its upper part is separated from the lower by the coronary sulcus, and is formed by the atria; it presents a deep concavity (494), occupied by the ascending aorta and the pulmonary artery.

The diaphragmatic surface (491), directed downward and slightly backward, is formed by the ventricles, and rests upon the central tendon and a small part of the left muscular portion of the diaphragm. It is separated from the base by the posterior part of the coronary sulcus, and is traversed obliquely by the posterior longitudinal sulcus.

The right margin of the heart is long, and is formed by the right atrium above and the right ventricle below. The atrial portion is rounded and almost vertical; it is situated behind the third, fourth, and fifth right costal cartilages about 1.25 cm. from the margin of the sternum. The ventricular portion, thin and sharp, is named the acute margin; it is nearly horizontal, and extends from the sternal end of the sixth right costal cartilage to the apex of the heart.

The left or obtuse margin is shorter, full, and rounded: it is formed mainly by the left ventricle, but to a slight extent, above, by the left atrium. It extends from a point in the second left intercostal space, about 2.5 mm. from the sternal margin, obliquely downward, with a convexity to the left, to the apex of the heart.

Right Atrium (atrium dextrum; right auricle).—The right atrium is larger than the left, but its walls are somewhat thinner, measuring about 2 mm.; its cavity is capable of containing about 57 c.c. It consists of two parts: a principal cavity, or sinus venarum, situated posteriorly, and an anterior, smaller portion, the auricula.

Sinus Venarum (sinus venosus).—The sinus venarum is the large quadrangular cavity placed between the two venæ cavæ. Its walls, which are extremely thin, are connected below with the right ventricle, and medially with the left atrium, but are free in the rest of their extent.

Auricula (auricula dextra; right auricular appendix).—The auricula is a small conical muscular pouch, the margins of which present a dentated edge. It projects from the upper and front part of the sinus forward and toward the left side, overlapping the root of the aorta.



Sternocostal surface of heart.

 

The separation of the auricula from the sinus venarum is indicated externally by a groove, the terminal sulcus, which extends from the front of the superior vena cava to the front of the inferior vena cava, and represents the line of union of the sinus venosus of the embryo with the primitive atrium. On the inner wall of the atrium the separation is marked by a vertical, smooth, muscular ridge, the terminal crest. Behind the crest the internal surface of the atrium is smooth, while in front of it the muscular fibers of the wall are raised into parallel ridges resembling the teeth of a comb, and hence named the musculi pectinati.

Its interior (493) presents the following parts for examination:

Openings »

Superior vena cava.

Inferior vena cava.

Coronary sinus.

Valves »

Valve of the inferior vena cava.

Foramina venarum minimarum.

Valve of the coronary sinus.

Atrioventricular.

Fossa ovalis.

Limbus fossæ ovalis.

Intervenous tubercle.

Musculi pectinati.

Crista terminalis.

 

VIDEO

 

The superior vena cava returns the blood from the upper half of the body, and opens into the upper and back part of the atrium, the direction of its orifice being downward and forward. Its opening has no valve.

The inferior vena cava, larger than the superior, returns the blood from the lower half of the body, and opens into the lowest part of the atrium, near the atrial septum, its orifice being directed upward and backward, and guarded by a rudimentary valve, the valve of the inferior vena cava (Eustachian valve). The blood entering the atrium through the superior vena cava is directed downward and forward, i.e., toward the atrioventricular orifice, while that entering through the inferior vena cava is directed upward and backward, toward the atrial septum. This is the normal direction of the two currents in fetal life.

The coronary sinus opens into the atrium, between the orifice of the inferior vena cava and the atrioventricular opening. It returns blood from the substance of the heart and is protected by a semicircular valve, the valve of the coronary sinus (valve of Thebesius).



Interior of right side of heart.

 

The foramina venarum minimarum (foramina Thebesii) are the orifices of minute veins (venœ cordis minimœ), which return blood directly from the muscular substance of the heart.

The atrioventricular opening (tricuspid orifice) is the large oval aperture of communication between the atrium and the ventricle; it will be described with the right ventricle.

The valve of the inferior vena cava (valvula venœ cavœ inferioris [Eustachii]; Eustachian valve) is situated in front of the orifice of the inferior vena cava. It is semilunar in form, its convex margin being attached to the anterior margin of the orifice; its concave margin, which is free, ends in two cornua, of which the left is continuous with the anterior edge of the limbus fossæ ovalis while the right is lost on the wall of the atrium. The valve is formed by a duplicature of the lining membrane of the atrium, containing a few muscular fibers. In the fetus this valve is of large size, and serves to direct the blood from the inferior vena cava, through the foramen ovale, into the left atrium. In the adult it occasionally persists, and may assist in preventing the reflux of blood into the inferior vena cava; more commonly it is small, and may present a cribriform or filamentous appearance; sometimes it is altogether wanting.

The valve of the coronary sinus (valvula sinus coronarii [Thebesii]; Thebesian valve) is a semicircular fold of the lining membrane of the atrium, at the orifice of the coronary sinus. It prevents the regurgitation of blood into the sinus during the contraction of the atrium. This valve may be double or it may be cribriform.

The fossa ovalis is an oval depression on the septal wall of the atrium, and corresponds to the situation of the foramen ovale in the fetus. It is situated at the lower part of the septum, above and to the left of the orifice of the inferior vena cava.

The limbus fossæ ovalis (annulus ovalis) is the prominent oval margin of the fossa ovalis. It is most distinct above and at the sides of the fossa; below, it is deficient. A small slit-like valvular opening is occasionally found, at the upper margin of the fossa, leading upward beneath the limbus, into the left atrium; it is the remains of the fetal aperture between the two atria.

The intervenous tubercle (tuberculum intervenosum; tubercle of Lower) is a small projection on the posterior wall of the atrium, above the fossa ovalis. It is distinct in the hearts of quadrupeds, but in man is scarcely visible. It was supposed by Lower to direct the blood from the superior vena cava toward the atrioventricular opening.

Right Ventricle (ventriculus dexter).—The right ventricle is triangular in form, and extends from the right atrium to near the apex of the heart. Its anterosuperior surface is rounded and convex, and forms the larger part of the sternocostal surface of the heart. Its under surface is flattened, rests upon the diaphragm, and forms a small part of the diaphragmatic surface of the heart. Its posterior wall is formed by the ventricular septum, which bulges into the right ventricle, so that a transverse section of the cavity presents a semilunar outline. Its upper and left angle forms a conical pouch, the conus arteriosus, from which the pulmonary artery arises. A tendinous band, which may be named the tendon of the conus arteriosus, extends upward from the right atrioventricular fibrous ring and connects the posterior surface of the conus arteriosus to the aorta. The wall of the right ventricle is thinner than that of the left, the proportion between them being as 1 to 3; it is thickest at the base, and gradually becomes thinner toward the apex. The cavity equals in size that of the left ventricle, and is capable of containing about 85 c.c.

Its interior (493) presents the following parts for examination:

Openings »

Right atrioventricular.

Valves »

Tricuspid.

Pulmonary artery.

Pulmonary.

Trabeculæ carneæ

Chordæ tendineæ

The right atrioventricular orifice is the large oval aperture of communication between the right atrium and ventricle. Situated at the base of the ventricle, it measures about 4 cm. in diameter and is surrounded by a fibrous ring, covered by the lining membrane of the heart; it is considerably larger than the corresponding aperture on the left side, being sufficient to admit the ends of four fingers. It is guarded by the tricuspid valve.

The opening of the pulmonary artery is circular in form, and situated at the summit of the conus arteriosus, close to the ventricular septum. It is placed above and to the left of the atrioventricular opening, and is guarded by the pulmonary semilunar valves.

 

VIDEO

 

The tricuspid valve (valvula tricuspidalis) (493, 495) consists of three somewhat triangular cusps or segments. The largest cusp is interposed between the atrioventricular orifice and the conus arteriosus and is termed the anterior or infundibular cusp. A second, the posterior or marginal cusp, is in relation to the right margin of the ventricle, and a third, the medial or septal cusp, to the ventricular septum. They are formed by duplicatures of the lining membrane of the heart, strengthened by intervening layers of fibrous tissue: their central parts are thick and strong, their marginal portions thin and translucent, and in the angles between the latter small intermediate segments are sometimes seen. Their bases are attached to a fibrous ring surrounding the atrioventricular orifice and are also joined to each other so as to form a continuous annular membrane, while their apices project into the ventricular cavity. Their atrial surfaces, directed toward the blood current from the atrium, are smooth; their ventricular surfaces, directed toward the wall of the ventricle, are rough and irregular, and, together with the apices and margins of the cusps, give attachment to a number of delicate tendinous cords, the chordæ tendineæ.



Heart seen from above.

 

The trabeculæ carneæ (columnœ carneœ) are rounded or irregular muscular columns which project from the whole of the inner surface of the ventricle, with the exception of the conus arteriosus. They are of three kinds: some are attached along their entire length on one side and merely form prominent ridges, others are fixed at their extremities but free in the middle, while a third set (musculi papillares) are continuous by their bases with the wall of the ventricle, while their apices give origin to the chordæ tendineæ which pass to be attached to the segments of the tricuspid valve. There are two papillary muscles, anterior and posterior: of these, the anterior is the larger, and its chordæ tendineæ are connected with the anterior and posterior cusps of the valve: the posterior papillary muscle sometimes consists of two or three parts; its chordæ tendineæ are connected with the posterior and medial cusps. In addition to these, some chordæ tendineæ spring directly from the ventricular septum, or from small papillary eminences on it, and pass to the anterior and medial cusps. A muscular band, well-marked in sheep and some other animals, frequently extends from the base of the anterior papillary muscle to the ventricular septum. From its attachments it may assist in preventing overdistension of the ventricle, and so has been named the moderator band.

The pulmonary semilunar valves (494) are three in number, two in front and one behind, formed by duplicatures of the lining membrane, strengthened by fibrous tissue. They are attached, by their convex margins, to the wall of the artery, at its junction with the ventricle, their free borders being directed upward into the lumen of the vessel. The free and attached margins of each are strengthened by tendinous fibers, and the former presents, at its middle, a thickened nodule (corpus Arantii). From this nodule tendinous fibers radiate through the segment to its attached margin, but are absent from two narrow crescentic portions, the lunulæ, placed one on either side of the nodule immediately adjoining the free margin. Between the semilunar valves and the wall of the pulmonary artery are three pouches or sinuses (sinuses of Valsalva).

 

Left Atrium (atrium sinistum; left auricle).—The left atrium is rather smaller than the right, but its walls are thicker, measuring about 3 mm.; it consists, like the right, of two parts, a principal cavity and an auricula.

The principal cavity is cuboidal in form, and concealed, in front, by the pulmonary artery and aorta; in front and to the right it is separated from the right atrium by the atrial septum; opening into it on either side are the two pulmonary veins.

 

Auricula (auricula sinistra; left auricular appendix).—The auricula is somewhat constricted at its junction with the principal cavity; it is longer, narrower, and more curved than that of the right side, and its margins are more deeply indented. It is directed forward and toward the right and overlaps the root of the pulmonary artery.



Interior of left side of heart.

 

The interior of the left atrium (496) presents the following parts for examination:

Openings of the four pulmonary veins.

Left atrioventricular opening.

Musculi pectinati.

The pulmonary veins, four in number, open into the upper part of the posterior surface of the left atrium—two on either side of its middle line: they are not provided with valves. The two left veins frequently end by a common opening.

The left atrioventricular opening is the aperture between the left atrium and ventricle, and is rather smaller than the corresponding opening on the right side.

The musculi pectinati, fewer and smaller than in the right auricula, are confined to the inner surface of the auricula.

On the atrial septum may be seen a lunated impression, bounded below by a crescentic ridge, the concavity of which is turned upward. The depression is just above the fossa ovalis of the right atrium.

 

Left Ventricle (ventriculus sinister).—The left ventricle is longer and more conical in shape than the right, and on transverse section its concavity presents an oval or nearly circular outline. It forms a small part of the sternocostal surface and a considerable part of the diaphragmatic surface of the heart; it also forms the apex of the heart. Its walls are about three times as thick as those of the right ventricle.

Its interior (496) presents the following parts for examination:

Openings »

Left atrioventricular.

Valves »

Bicuspid or Mitral.

Aortic.

Aortic.

Trabeculæ carneæ.

Chordæ tendineæ

 

The left atrioventricular opening (mitral orifice) is placed below and to the left of the aortic orifice. It is a little smaller than the corresponding aperture of the opposite side, admitting only two fingers. It is surrounded by a dense fibrous ring, covered by the lining membrane of the heart, and is guarded by the bicuspid or mitral valve.



Aorta laid open to show the semilunar valves.

 

The aortic opening is a circular aperture, in front and to the right of the atrioventricular, from which it is separated by the anterior cusp of the bicuspid valve. Its orifice is guarded by the aortic semilunar valves. The portion of the ventricle immediately below the aortic orifice is termed the aortic vestibule, and possesses fibrous instead of muscular walls.

 

VIDEO

 

The bicuspid or mitral valve (valvula bicuspidalis [metralis]) (495, 496) is attached to the circumference of the left atrioventricular orifice in the same way that the tricuspid valve is on the opposite side. It consists of two triangular cusps, formed by duplicatures of the lining membrane, strengthened by fibrous tissue, and containing a few muscular fibers. The cusps are of unequal size, and are larger, thicker, and stronger than those of the tricuspid valve. The larger cusp is placed in front and to the right between the atrioventricular and aortic orifices, and is known as the anterior or aortic cusp; the smaller or posterior cusp is placed behind and to the left of the opening. Two smaller cusps are usually found at the angles of junction of the larger. The cusps of the bicuspid valve are furnished with chordæ tendineæ, which are attached in a manner similar to those on the right side; they are, however, thicker, stronger, and less numerous.

The aortic semilunar valves (494, 497) are three in number, and surround the orifice of the aorta; two are anterior (right and left) and one posterior. They are similar in structure, and in their mode of attachment, to the pulmonary semilunar valves, but are larger, thicker, and stronger; the lunulæ are more distinct, and the noduli or corpora Arantii thicker and more prominent. Opposite the valves the aorta presents slight dilatations, the aortic sinuses (sinuses of Valsalva), which are larger than those at the origin of the pulmonary artery.

The trabeculæ carneæ are of three kinds, like those upon the right side, but they are more numerous, and present a dense interlacement, especially at the apex, and upon the posterior wall of the ventricle. The musculi papillares are two in number, one being connected to the anterior, the other to the posterior wall; they are of large size, and end in rounded extremities from which the chordæ tendineæ arise. The chordæ tendineæ from each papillary muscle are connected to both cusps of the bicuspid valve.

The course of the blood from the left ventricle through the body generally to the right side of the heart constitutes the greater or systemic circulation, while its passage from the right ventricle through the lungs to the left side of the heart is termed the lesser or pulmonary circulation.

It is necessary, however, to state that the blood which circulates through the spleen, pancreas, stomach, small intestine, and the greater part of the large intestine is not returned directly from these organs to the heart, but is conveyed by the portal vein to the liver. In the liver this vein divides, like an artery, and ultimately ends in capillary-like vessels (sinusoids), from which the rootlets of a series of veins, called the hepatic veins, arise; these carry the blood into the inferior vena cava, whence it is conveyed to the right atrium. From this it will be seen that the blood contained in the portal vein passes through two sets of vessels: (1) the capillaries in the spleen, pancreas, stomach, etc., and (2) the sinusoids in the liver. The blood in the portal vein carries certain of the products of digestion: the carbohydrates, which are mostly taken up by the liver cells and stored as glycogen, and the protein products which remain in solution and are carried into the general circulation to the various tissues and organs of the body.

Speaking generally, the arteries may be said to contain pure and the veins impure blood. This is true of the systemic, but not of the pulmonary vessels, since it has been seen that the impure blood is conveyed from the heart to the lungs by the pulmonary arteries, and the pure blood returned from the lungs to the heart by the pulmonary veins. Arteries, therefore, must be defined as vessels which convey blood from the heart, and veins as vessels which return blood to the heart.

 



Section of the heart showing the ventricular septum.

 

Ventricular Septum (septum ventriculorum; interventricular septum) (498).

 

—The ventricular septum is directed obliquely backward and to the right, and is curved with the convexity toward the right ventricle: its margins correspond with the anterior and posterior longitudinal sulci. The greater portion of it is thick and muscular and constitutes the muscular ventricular septum, but its upper and posterior part, which separates the aortic vestibule from the lower part of the right atrium and upper part of the right ventricle, is thin and fibrous, and is termed the membranous ventricular septum. An abnormal communication may exist between the ventricles at this part owing to defective development of the membranous septum.

THE DISTRIBUTION of the systematic arteries is like a highly ramified tree, the common trunk of which, formed by the aorta, commences at the left ventricle, while the smallest ramifications extend to the peripheral parts of the body and the contained organs. Arteries are found in all parts of the body, except in the hairs, nails, epidermis, cartilages, and cornea; the larger trunks usually occupy the most protected situations, running, in the limbs, along the flexor surface, where they are less exposed to injury.

  There is considerable variation in the mode of division of the arteries: occasionally a short trunk subdivides into several branches at the same point, as may be observed in the celiac artery and the thyrocervical trunk: the vessel may give off several branches in succession, and still continue as the main trunk, as is seen in the arteries of the limbs; or the division may be dichotomous, as, for instance, when the aorta divides into the two common iliacs.

  A branch of an artery is smaller than the trunk from which it arises; but if an artery divides into two branches, the combined sectional area of the two vessels is, in nearly every instance, somewhat greater than that of the trunk; and the combined sectional area of all the arterial branches greatly exceeds that of the aorta; so that the arteries collectively may be regarded as a cone, the apex of which corresponds to the aorta, and the base to the capillary system.

  The arteries, in their distribution, communicate with one another, forming what are called anastomoses, and these communications are very free between the large as well as between the smaller branches. The anastomosis between trunks of equal size is found where great activity of the circulation is requisite, as in the brain; here the two vertebral arteries unite to form the basilar, and the two anterior cerebral arteries are connected by a short communicating trunk; it is also found in the abdomen, where the intestinal arteries have very ample anastomoses between their larger branches. In the limbs the anastomoses are most numerous and of largest size around the joints, the branches of an artery above uniting with branches from the vessels below. These anastomoses are of considerable interest to the surgeon, as it is by their enlargement that a collateral circulation is established after the application of a ligature to an artery. The smaller branches of arteries anastomose more frequently than the larger; and between the smallest twigs these anastomoses become so numerous as to constitute a close network that pervades nearly every tissue of the body.

  Throughout the body generally the larger arterial branches pursue a fairly straight course, but in certain situations they are tortuous. Thus the external maxillary artery in its course over the face, and the arteries of the lips, are extremely tortuous to accommodate themselves to the movements of the parts. The uterine arteries are also tortuous, to accommodate themselves to the increase of size which the uterus undergoes during pregnancy.

  The pulmonary artery conveys the venous blood from the right ventricle of the heart to the lungs. It is a short, wide vessel, about 5 cm. in length and 3 cm. in diameter, arising from the conus arteriosus of the right ventricle. It extends obliquely upward and backward, passing at first in front and then to the left of the ascending aorta, as far as the under surface of the aortic arch, where it divides, about the level of the fibrocartilage between the fifth and sixth thoracic vertebræ, into right and left branches of nearly equal size.

Relations.—The whole of this vessel is contained within the pericardium. It is enclosed with the ascending aorta in a single tube of the visceral layer of the serous pericardium, which is continued upward upon them from the base of the heart. The fibrous layer of the pericardium is gradually lost upon the external coats of the two branches of the artery. In front, the pulmonary artery is separated from the anterior end of the second left intercostal space by the pleura and left lung, in addition to the pericardium; it rests at first upon the ascending aorta, and higher up lies in front of the left atrium on a plane posterior to the ascending aorta. On either side of its origin is the auricula of the corresponding atrium and a coronary artery, the left coronary artery passing, in the first part of its course, behind the vessel. The superficial part of the cardiac plexus lies above its bifurcation, between it and the arch of the aorta.

  The right branch of the pulmonary artery (ramus dexter a. pulmonalis), longer and larger than the left, runs horizontally to the right, behind the ascending aorta and superior vena cava and in front of the right bronchus, to the root of the right lung, where it divides into two branches. The lower and larger of these goes to the middle and lower lobes of the lung; the upper and smaller is distributed to the upper lobe.

  The left branch of the pulmonary artery (ramus sinister a. pulmonalis), shorter and somewhat smaller than the right, passes horizontally in front of the descending aorta and left bronchus to the root of the left lung, where it divides into two branches, one for each lobe of the lung. Above, it is connected to the concavity of the aortic arch by the ligamentum arteriosum, on the left of which is the left recurrent nerve, and on the right the superficial part of the cardiac plexus. Below, it is joined to the upper left pulmonary vein by the ligament of the left vena cava.

  The terminal branches of the pulmonary arteries will be described with the anatomy of the lungs.

Theme 2.  Anatomy of the heart II: structure of heart wall, blood supplying and innervation of the heart. Pericardium. Projection of heart on the front thoracic wall

Wall of heart consists of internal layer - endocardium, muscular layer - myocardium and external layer - epicardium.

Endocardium covers heart cavity from within. Its double sheets forms aortic and pulmonary trunk valves, cusps right and left atrioventricular valves.

Myocardium (middle layer) is formed by muscular tissue, which consists of cardiomyocytes. Muscular fibbers of atria and ventricles start from fibrous tissue, which enters to composition of soft heart skeleton. Last includes right and left fibrous rings, that are situated around right and left atrioventricular ostia, right fibrous triangle and left fibrous triangle, that are situated around valve of aorta and valve of pulmonary trunk, and membranous part of interventricular septum.

Myocardium of atria consists of two layers: superficial, which is common for both of atria and consists of circulation fibres, and deep layer, which consists of longitudinal bundles and is separate each from other.

Myocardium of ventricles consists of three layers: external, middle and internal. External (oblique) layer origins from fibrous annuli, continues downward till apex cordis where forms vortex cordis and passes into internal layer of opposite side with longitudinal fibres. So, external and internal layers are common for both ventricles and middle (circular) layer separate for each ventricle.

External heart membrane epicardium is visceral sheet of serous pericardium. Epicardium covers a heart, initial departments of aorta and pulmonary trunk, and also terminal departments of venae cavae and pulmonary veins. Visceral sheet passes into parietal sheet of serous pericardium on these vessels.

Strucutre.—The heart consists of muscular fibers, and of fibrous rings which serve for their attachment. It is covered by the visceral layer of the serous pericardium (epicardium), and lined by the endocardium. Between these two membranes is the muscular wall or myocardium.

  The endocardium is a thin, smooth membrane which lines and gives the glistening appearance to the inner surface of the heart; it assists in forming the valves by its reduplications, and is continuous with the lining membrane of the large bloodvessels. It consists of connective tissue and elastic fibers, and is attached to the muscular structure by loose elastic tissue which contains bloodvessels and nerves; its free surface is covered by endothelial cells.

  The fibrous rings surround the atrioventricular and arterial orifices, and are stronger upon the left than on the right side of the heart. The atrioventricular rings serve for the attachment of the muscular fibers of the atria and ventricles, and for the attachment of the bicuspid and tricuspid valves. The left atrioventricular ring is closely connected, by its right margin, with the aortic arterial ring; between these and the right atrioventricular ring is a triangular mass of fibrous tissue, the trigonum fibrosum, which represents the os cordis seen in the heart of some of the larger animals, as the ox and elephant. Lastly, there is the tendinous band, already referred to, the posterior surface of the conus arteriosus.

  The fibrous rings surrounding the arterial orifices serve for the attachment of the great vessels and semilunar valves. Each ring receives, by its ventricular margin, the attachment of some of the muscular fibers of the ventricles; its opposite margin presents three deep semicircular notches, to which the middle coat of the artery is firmly fixed. The attachment of the artery to its fibrous ring is strengthened by the external coat and serous membrane externally, and by the endocardium internally. From the margins of the semicircular notches the fibrous structure of the ring is continued into the segments of the valves. The middle coat of the artery in this situation is thin, and the vessel is dilated to form the sinuses of the aorta and pulmonary artery.

Anastomosing muscular fibers of the heart seen in a longitudinal section. On the right the limits of the separate cells with their nuclei are exhibited somewhat diagrammatically

Purkinje’s fibers from the sheep’s heart. A. In longitudinal section. B. In transverse section.

 

Cardiac Muscular Tissue.—The fibers of the heart differ very remarkably from those of other striped muscles. They are smaller by one-third, and their transverse striæ are by no means so well-marked. They show faint longitudinal striation. The fibers are made up of distinct quadrangular cells, joined end to end so as to form a syncytium (499). Each cell contains a clear oval nucleus, situated near its center. The extremities of the cells have a tendency to branch or divide, the subdivisions uniting with offsets from other cells, and thus producing an anastomosis of the fibers. The connective tissue between the bundles of fibers is much less than in ordinary striped muscle, and no sarcolemma has been proved to exist.

 

Purkinje Fibers (500).—Between the endocardium and the ordinary cardiac muscle are found, imbedded in a small amount of connective tissue, peculiar fibers known as Purkinje fibers. They are found in certain mammals and in birds, and can be best seen in the sheep’s heart, where they form a considerable portion of the moderator band and also appear as gelatinous-looking strands on the inner walls of the atria and ventricles. They also occur in the human heart associated with the terminal distributions of the bundle of His. The fibers are very much larger in size than the cardiac cells and differ from them in several ways. In longitudinal section they are quadrilateral in shape, being about twice as long as they are broad. The central portion of each fiber contains one or more nuclei and is made up of granular protoplasm, with no indication of striations, while the peripheral portion is clear and has distinct transverse striations. The fibers are intimately connected with each other, possess no definite sarcolemma, and do not branch.

  The muscular structure of the heart consists of bands of fibers, which present an exceedingly intricate interlacement. They comprise (a) the fibers of the atria, (b) the fibers of the ventricles, and (c) the atrioventricular bundle of His.

  The fibers of the atria are arranged in two layers—a superficial, common to both cavities, and a deep, proper to each. The superficial fibers are most distinct on the front of the atria, across the bases of which they run in a transverse direction, forming a thin and incomplete layer. Some of these fibers run into the atrial septum. The deep fibers consist of looped and annular fibers. The looped fibers pass upward over each atrium, being attached by their two extremities to the corresponding atrioventricular ring, in front and behind. The annular fibers surround the auriculæ, and form annular bands around the terminations of the veins and around the fossa ovalis.

  The fibers of the ventricles are arranged in a complex manner, and various accounts have been given of their course and connections; the following description is based on the work of McCallum. 94 They consist of superficial and deep layers, all of which, with the exception of two, are inserted into the papillary muscles of the ventricles. The superficial layers consist of the following: (a) Fibers which spring from the tendon of the conus arteriosus and sweep downward and toward the left across the anterior longitudinal sulcus and around the apex of the heart, where they pass upward and inward to terminate in the papillary muscles of the left ventricle; those arising from the upper half of the tendon of the conus arteriosus pass to the anterior papillary muscle, those from the lower half to the posterior papillary muscle and the papillary muscles of the septum. (b) Fibers which arise from the right atrioventricular ring and run diagonally across the diaphragmatic surface of the right ventricle and around its right border on to its costosternal surface, where they dip beneath the fibers just described, and, crossing the anterior longitudinal sulcus, wind around the apex of the heart and end in the posterior papillary muscle of the left ventricle. (c) Fibers which spring from the left atrioventricular ring, and, crossing the posterior longitudinal sulcus, pass successively into the right ventricle and end in its papillary muscles. The deep layers are three in number; they arise in the papillary muscles of one ventricle and, curving in an S-shaped manner, turn in at the longitudinal sulcus and end in the papillary muscles of the other ventricle. The layer which is most superficial in the right ventricle lies next the lumen of the left, and vice versa. Those of the first layer almost encircle the right ventricle and, crossing in the septum to the left, unite with the superficial fibers from the right atrioventricular ring to form the posterior papillary muscle. Those of the second layer have a less extensive course in the wall of the right ventricle, and a correspondingly greater course in the left, where they join with the superficial fibers from the anterior half of the tendon of the conus arteriosus to form the papillary muscles of the septum. Those of the third layer pass almost entirely around the left ventricle and unite with the superficial fibers from the lower half of the tendon of the conus arteriosus to form the anterior papillary muscle. Besides the layers just described there are two bands which do not end in papillary muscles. One springs from the right atrioventricular ring and crosses in the atrioventricular septum; it then encircles the deep layers of the left ventricle and ends in the left atrioventricular ring. The second band is apparently confined to the left ventricle; it is attached to the left atrioventricular ring, and encircles the portion of the ventricle adjacent to the aortic orifice.

  The atrioventricular bundle of His (501), is the only direct muscular connection known to exist between the atria and the ventricles. Its cells differ from ordinary cardiac muscle cells in being more spindle-shaped. They are, moreover, more loosely arranged and have a richer vascular supply than the rest of the heart muscle. It arises in connection with two small collections of spindle-shaped cells, the sinoatrial and atrioventricular nodes. The sinoatrial node is situated on the anterior border of the opening of the superior vena cava; from its strands of fusiform fibers run under the endocardium of the wall of the atrium to the atrioventricular node. The atrioventricular node lies near the orifice of the coronary sinus in the annular and septal fibers of the right atrium; from it the atrioventricular bundle passes forward in the lower part of the membranous septum, and divides into right and left fasciculi. These run down in the right and left ventricles, one on either side of the ventricular septum, covered by endocardium. In the lower parts of the ventricles they break up into numerous strands which end in the papillary muscles and in the ventricular muscle generally. The greater portion of the atrioventricular bundle consists of narrow, somewhat fusiform fibers, but its terminal strands are composed of Purkinje fibers.

  Dr. A. Morison 95 has shown that in the sheep and pig the atrioventricular bundle “is a great avenue for the transmission of nerves from the auricular to the ventricular heart; large and numerous nerve trunks entering the bundle and coursing with it.” From these, branches pass off and form plexuses around groups of Purkinje cells, and from these plexuses fine fibrils go to innervate individual cells.

  Clinical and experimental evidence go to prove that this bundle conveys the impulse to systolic contraction from the atrial septum to the ventricles.


Schematic representation of the atrioventricular bundle of His. The bundle, represented in red originates near the orifice of the coronary sinus, undergoes slight enlargement to form a node, passes forward to the ventricular septum, and divides into two limbs. The ultimate distribution cannot be completely shown in this diagram.

 

Vessels and Nerves.—The arteries supplying the heart are the right and left coronary from the aorta; the veins end in the right atrium.

Structure of Arteries—The arteries are composed of three coats: an internal or endothelial coat (tunica intima of Kölliker); a middle or muscular coat (tunica media); and an external or connective-tissue coat (tunica adventitia). The two inner coats together are very easily separated from the external, as by the ordinary operation of tying a ligature around an artery. If a fine string be tied forcibly upon an artery and then taken off, the external coat will be found undivided, but the two inner coats are divided in the track of the ligature and can easily be further dissected from the outer coat.

The arteries, in their distribution throughout the body, are included in thin fibro-areolar investments, which form their sheaths. The vessel is loosely connected with its sheath by delicate areolar tissue; and the sheath usually encloses the accompanying veins, and sometimes a nerve. Some arteries, as those in the cranium, are not included in sheaths.

All the larger arteries, like the other organs of the body, are supplied with bloodvessels. These nutrient vessels, called the vasa vasorum, arise from a branch of the artery, or from a neighboring vessel, at some considerable distance from the point at which they are distributed; they ramify in the loose areolar tissue connecting the artery with its sheath, and are distributed to the external coat, but do not, in man, penetrate the other coats; in some of the larger mammals a few vessels have been traced into the middle coat. Minute veins return the blood from these vessels; they empty themselves into the vein or veins accompanying the artery. Lymphatic vessels are also present in the outer coat.

Arteries are also supplied with nerves, which are derived from the sympathetic, but may pass through the cerebrospinal nerves. They form intricate plexuses upon the surfaces of the larger trunks, and run along the smaller arteries as single filaments, or bundles of filaments which twist around the vessel and unite with each other in a plexiform manner. The branches derived from these plexuses penetrate the external coat and are distributed principally to the muscular tissue of the middle coat, and thus regulate, by causing the contraction and relaxation of this tissue the amount of blood sent to any part.

The Capillaries.—The smaller arterial branches (excepting those of the cavernous structure of the sexual organs, of the splenic pulp, and of the placenta) terminate in net-works of vessels which pervade nearly every tissue of the body. These vessels, from their minute size, are termed capillaries. They are interposed between the smallest branches of the arteries and the commencing veins, constituting a net-work, the branches of which maintain the same diameter throughout; the meshes of the net-work are more uniform in shape and size than those formed by the anastomoses of the small arteries and veins.

The diameters of the capillaries vary in the different tissues of the body, the usual size being about 8μ. The smallest are those of the brain and the mucous membrane of the intestines; and the largest those of the skin and the marrow of bone, where they are stated to be as large as 20μ in diameter. The form of the capillary net varies in the different tissues, the meshes being generally rounded or elongated.

The rounded form of mesh is most common, and prevails where there is a dense network, as in the lungs, in most glands and mucous membranes, and in the cutis; the meshes are not of an absolutely circular outline, but more or less angular, sometimes nearly quadrangular, or polygonal, or more often irregular.

Elongated meshes are observed in the muscles and nerves, the meshes resembling parallelograms in form, the long axis of the mesh running parallel with the long axis of the nerve or muscle. Sometimes the capillaries have a looped arrangement; a single vessel projecting from the common net-work and returning after forming one or more loops, as in the papillæ of the tongue and skin.

The number of the capillaries and the size of the meshes determine the degree of vascularity of a part. The closest network and the smallest interspaces are found in the lungs and in the choroid coat of the eye. In these situations the interspaces are smaller than the capillary vessels themselves. In the intertubular plexus of the kidney, in the conjunctiva, and in the cutis, the interspaces are from three to four times as large as the capillaries which form them; and in the brain from eight to ten times as large as the capillaries in their long diameters, and from four to six times as large in their transverse diameters. In the adventitia of arteries the width of the meshes is ten times that of the capillary vessels. As a general rule, the more active the function of the organ, the closer is its capillary net and the larger its supply of blood; the meshes of the network are very narrow in all growing parts, in the glands, and in the mucous membranes, wider in bones and ligaments which are comparatively inactive; bloodvessels are nearly altogether absent in tendons, in which very little organic change occurs after their formation. In the liver the capillaries take a more or less radial course toward the intralobular vein, and their walls are incomplete, so that the blood comes into direct contact with the liver cells. These vessels in the liver are not true capillaries but “sinusoids;” they are developed by the growth of columns of liver cells into the blood spaces of the embryonic organ.

Structure.—The wall of a capillary consists of a fine transparent endothelial layer, composed of cells joined edge to edge by an interstitial cement substance, and continuous with the endothelial cells which line the arteries and veins. When stained with nitrate of silver the edges which bound the epithelial cells are brought into view. These cells are of large size and of an irregular polygonal or lanceolate shape, each containing an oval nucleus which may be displayed by carmine or hematoxylin. Between their edges, at various points of their meeting, roundish dark spots are sometimes seen, which have been described as stomata, though they are closed by intercellular substance. They have been believed to be the situations through which the colorless corpuscles of the blood, when migrating from the bloodvessels, emerge; but this view, though probable, is not universally accepted.

  The lymphatics end in the thoracic and right lymphatic ducts.

  The nerves are derived from the cardiac plexus, which are formed partly from the vagi, and partly from the sympathetic trunks. They are freely distributed both on the surface and in the substance of the heart, the separate nerve filaments being furnished with small ganglia.

 

The Cardiac Cycle and the Actions of the Valves.—By the contractions of the heart the blood is pumped through the arteries to all parts of the body. These contractions occur regularly and at the rate of about seventy per minute. Each wave of contraction or period of activity is followed by a period of rest, the two periods constituting what is known as a cardiac cycle.

  Each cardiac cycle consists of three phases, which succeed each other as follows: (1) a short simultaneous contraction of both atria, termed the atrial systole, followed, lowed, after a slight pause, by (2) a simultaneous, but more prolonged, contraction of both ventricles, named the ventricular systole, and (3) a period of rest, during which the whole heart is relaxed. The atrial contraction commences around the venous openings, and sweeping over the atria forces their contents through the atrioventricular openings into the ventricles, regurgitation into the veins being prevented by the contraction of their muscular coats. When the ventricles contract, the tricuspid and bicuspid valves are closed, and prevent the passage of the blood back into the atria; the musculi papillares at the same time are shortened, and, pulling on the chordæ tendineæ, prevent the inversion of the valves into the atria. As soon as the pressure in the ventricles exceeds that in the pulmonary artery and aorta, the valves guarding the orifices of these vessels are opened and the blood is driven from the right ventricle into the pulmonary artery and from the left into the aorta. The moment the systole of the ventricles ceases, the pressure of the blood in the pulmonary artery and aorta closes the pulmonary and aortic semilunar valves to prevent regurgitation of blood into the ventricles, the valves remaining shut until reopened by the next ventricular systole. During the period of rest the tension of the tricuspid and bicuspid valves is relaxed, and blood is flowing from the veins into the atria, being aspirated by negative intrathoracic pressure, and slightly also from the atria into the ventricles. The average duration of a cardiac cycle is about 8/10 of a second, made up as follows:

Atrial systole, 1/10.

Atrial diastole, 7/10.

Ventricular systole, 3/10.

Ventricular diastole, 5/10.

Total systole, 4/10.

Complete diastole, 4/10.

  The rhythmical action of the heart is muscular in origin—that is to say, the heart muscle itself possesses the inherent property of contraction apart from any nervous stimulation. The more embryonic the muscle the better is it able to initiate and propagate the contraction wave; this explains why the normal systole of the heart starts at the entrance of the veins, for there the muscle is most embryonic in nature. At the atrioventricular junction there is a slight pause in the wave of muscular contraction. To obviate this so far as possible a peculiar band of marked embryonic type passes across the junction and so carries on the contraction wave to the ventricles. This band, composed of special fibers, is the atrioventricular bundle of His (p. 537). The nerves, although not concerned in originating the contractions of the heart muscle, play an important role in regulating their force and frequency in order to subserve the physiological needs of the organism.

Conducting heart system consists of atypical muscular fibres, which have ability to carry impulses from nerves of heart to myocardium of atria and ventricles. Centre of conducting heart system includes two ganglia:

1.               Sinoatrial ganglion (Kiss-Fleck) disposed in wall of right atrium between foramen of superior vena cava and right auricle. This ganglion gives off the branches to myocardium of atria and directs a heart contraction rhythm.

2.               Atrioventricular ganglion (Ashoff-Tavar) lies in thickness of inferior department of interatrial septum. This ganglion continues in atrioventricular fascicle (Giss) which communicates myocardium of atria and ventricles. Fascicle subdivides on right leg and left leg in muscular part of interventricular septum, the terminal branches of which (Purkinje fibres) terminate in ventricles myocardium.

Blood supplying of the heart realizes by means of right coronal artery and left coronal artery, which take its beginning from aorta bulb in suitable its sinuses. Right coronal artery passes to the right under right auricle, lies into coronal sulcus and passes on posterior interventricular sulcus, where anastomose with circumflex branch of left coronal artery. Branches of right coronal artery supply wall of right ventricle and atrium, back portion of interventricular septum, papillary muscles of right ventricle and ganglia of conducting heart system. Left coronal artery passes under left auricle where divides into two branches: anterior interventricular branch and circumflex branch. Last rounds a heart in coronal sulcus and passes on posterior surface where anastomoses with right coronal artery, forming circular arterial anastomose of arterial heart vessels. Anterior interventricular branch passes on same name heart sulcus to the apex, where anastomoses with terminal portion of right coronal artery, forming longitudinal arterial heart anastomose. Left coronal artery supplies wall of left ventricle, anterior wall of right ventricle, wall of left atrium and larger half of interventricular septum.

VIDEO

Venous system of the heart carries largest part of deoxygenated blood into coronal sinus. Some veins empty in it:

-         greater cardiac vein [vena cordis magna], which passes in anterior interventricular sulcus and coronal sulcus;

-         lesser cardiac vein [vena cordis parva], which passes in right part of coronal sulcus;

-         middle cardiac vein [vena cordis media] passes in posterior interventricular sulcus;

-         posterior vein of left ventricle;

-         oblique vein of left atrium.

There are venae minimae (Tebezia) and anterior venae, positioned in myocardium of right atrium.

Innervation of the Heart. Sympathetic fibres pass from sympathetic trunk and form the superior, middle and inferior cervical cardiac nerves. Also thoracic department of sympathetic trunk gives off the thoracic cardiac sympathetic nerves. They hasten cardiac contractions and add their amplitude, broaden the coronal vessels. The parasympathetic fibres pass in composition of superior, inferior and thoracic cardiac branches of vagus nerve. They slow a rhythm of cardiac contractions, reduce their amplitude and narrow space of coronal arteries. The sensory fibres from heart wall receptor pass in composition of cardiac nerves and cardiac branches to spinal cord.

The heart nerves form superficial extraorgan cardiac plexus and deep extraorgan cardiac plexus. The branches of extraorgan cardiac plexus continue into one intraorgan cardiac plexus, which conventionally subdivides on subepicardial plexus, intramuscular plexus and subendocardial plexus. Subepicardial plexus is reach developed.

Topography of the heart. Heart is situated in thoracic cavity; two thirds are disposed to the left from middle line and one third on the right side. From sides a heart is covered by pleural sacs, and lesser its front surface adjoins to sternum and costal cartilages.

Superior heart border passes on line, which connects upper margins of third costal cartilages. Right heart boundary path passes from ²²² right costal superior margin to V right costal cartilage. Inferior heart border passes on line, which passes from right V right costal cartilage to apex cordis. Apex cordis projects into left V intercostal space 1-1,5 cm medially from medioclavicular line. Left heart boundary path lies through superior margin of left ²²² costal cartilage to apex cordis. Palpitation sound of bicuspidal valve is listened in apex cordis area. Aortic valve is listened into second intercostal space to the right from sternum. Valve of pulmonary trunk - into ²² intercostal space to the left from sternum. Right atrioventricular (tricuspidal) valve is listened by base xyphoid process of sternum to the right (joint of ²V costal cartilage with sternum).

Heart is enveloped by pericardium, which consists of fibrous and serous portions. Fibrous pericardium near base of big vessels passes into their external membrane. Serous pericardium has parietal lamina that covers fibrous pericardium from within and visceral lamina that covers surface of the heart and is known as epicardium. Parietal lamina passes into visceral lamina closely the base of heart. There is space like fissure between two laminae – pericardial cavity with small amount of serous liquid that prevents friction during palpitation. There are two deepening in pericardial cavity: transverse sinus and oblique sinus. Transverse sinus is bordered in front by aorta and pulmonary trunk, behind by superior vena cava. Oblique pericardial sinus is situated on the diaphragmatic surface between pulmonary veins on the left and inferior vena cava on the right.

Theme 3.  Thoracic aorta: topography, parietal and visceral branches. System of superior vena cava

AORTA is the largest arterial vessel of systemic circulation. It subdivides on ascending part of aorta, aortic arch and descending part of aorta, which has thoracic and abdominal portions of aorta.

Ascending part of aorta leave the left ventricle behind left margin of sternum on level III intercostal space. In initial department it has expansion is aorta bulb, in which three aortic sinuses are contained. Ascending part of aorta lies behind and a little to the right  from pulmonary trunk, rises up and to level of second right costal cartilage passes into arc.

The Arch of the Aorta turns posteriorly to the left from second costal cartilage to left side of fourth thoracic vertebral body, where passes into descending aorta. Between concave aortic arch surface and pulmonary trunk on beginning of left pulmonary artery is situated obliterated arterial Botali duct. From convex aortic arch surface starts to from the right to the left: brachiocephalic trunk, left common carotid and left subclavian artery.


The arch of the aorta, and its branches.

The Arch of the Aorta (Arcus AortÆ; Transverse Aorta) (505).—The arch of the aorta begins at the level of the upper border of the second sternocostal articulation of the right side, and runs at first upward, backward, and to the left in front of the trachea; it is then directed backward on the left side of the trachea and finally passes downward on the left side of the body of the fourth thoracic vertebra, at the lower border of which it becomes continuous with the descending aorta. It thus forms two curvatures: one with its convexity upward, the other with its convexity forward and to the left. Its upper border is usually about 2.5 cm. below the superior border to the manubrium sterni.

 

Relations.—The arch of the aorta is covered anteriorly by the pleuræ and anterior margins of the lungs, and by the remains of the thymus. As the vessel runs backward its left side is in contact with the left lung and pleura. Passing downward on the left side of this part of the arch are four nerves; in order from before backward these are, the left phrenic, the lower of the superior cardiac branches of the left vagus, the superior cardiac branch of the left sympathetic, and the trunk of the left vagus. As the last nerve crosses the arch it gives off its recurrent branch, which hooks around below the vessel and then passes upward on its right side. The highest left intercostal vein runs obliquely upward and forward on the left side of the arch, between the phrenic and vagus nerves. On the right are the deep part of the cardiac plexus, the left recurrent nerve, the esophagus, and the thoracic duct; the trachea lies behind and to the right of the vessel. Above are the brachiocephalic, left common carotid, and left subclavian arteries, which arise from the convexity of the arch and are crossed close to their origins by the left brachiocephalic vein. Below are the bifurcation of the pulmonary artery, the left bronchus, the ligamentum arteriosum, the superficial part of the cardiac plexus, and the left recurrent nerve. As already stated, the ligamentum arteriosum connects the commencement of the left pulmonary artery to the aortic arch.

  Between the origin of the left subclavian artery and the attachment of the ductus arteriosus the lumen of the fetal aorta is considerably narrowed, forming what is termed the aortic isthmus, while immediately beyond the ductus arteriosus the vessel presents a fusiform dilation which His has named the aortic spindle—the point of junction of the two parts being marked in the concavity of the arch by an indentation or angle. These conditions persist, to some extent, in the adult, where His found that the average diameter of the spindle exceeded that of the isthmus by 3 mm.

  Distinct from this diffuse and moderate stenosis at the isthmus is the condition known as coarctation of the aorta, or marked stenosis often amounting to complete obliteration of its lumen, seen in adults and occuring at or near, oftenest a little below, the insertion of the ligamentum arteriosum into the aorta. According to Bonnet 96 this coarctation is never found in the fetus or at birth, and is due to an abnormal extension of the peculiar tissue of the ductus into the aortic wall, which gives rise to a simultaneous stenosis of both vessels as it contracts after birth—the ductus is usually obliterated in these cases. An extensive collateral circulation is set up, by the costocervicals, internal mammaries, and the descending branches of the transverse cervical above the stenosis, and below it by the first four aortic intercostals, the pericardiaco-phrenics, and the superior and inferior epigastrics.

 

Peculiarities.—The height to which the aorta rises in the thorax is usually about 2.5 cm. below the upper border of the sternum; but it may ascend nearly to the top of the bone. Occasionally it is found 4 cm., more rarely from 5 to 8 cm. below this point. Sometimes the aorta arches over the root of the right lung (right aortic arch) instead of over that of the left, and passes down on the right side of the vertebral column, a condition which is found in birds. In such cases all the thoracic and abdominal viscera are transposed. Less frequently the aorta, after arching over the root of the right lung, is directed to its usual position on the left side of the vertebral column; this peculiarity is not accompanied by transposition of the viscera. The aorta occasionally divides, as in some quadrupeds, into an ascending and a descending trunk, the former of which is directed vertically upward, and subdivides into three branches, to supply the head and upper extremities. Sometimes the aorta subdivides near its origin into two branches, which soon reunite. In one of these cases the esophagus and trachea were found to pass through the interval between the two branches; this is the normal condition of the vessel in the reptilia.

 

Branches (505, 506).—The branches given off from the arch of the aorta are three in number: the brachiocephalic, the left common carotid, and the left subclavian.

 

Peculiarities.Position of the Branches.—The branches, instead of arising from the highest part of the arch, may spring from the commencement of the arch or upper part of the ascending aorta; or the distance between them at their origins may be increased or diminished, the most frequent change in this respect being the approximation of the left carotid toward the brachiocephalic artery.

  The number of the primary branches may be reduced to one, or more commonly two; the left carotid arising from the brachiocephalic artery; or (more rarely) the carotid and subclavian arteries of the left side arising from a left brachiocephalic artery. But the number may be increased to four, from the right carotid and subclavian arteries arising directly from the aorta, the brachiocephalic being absent. In most of these latter cases the right subclavian has been found to arise from the left end of the arch; in other cases it is the second or third branch given off, instead of the first. Another common form in which there are four primary branches is that in which the left vertebral artery arises from the arch of the aorta between the left carotid and subclavian arteries. Lastly, the number of trunks from the arch may be increased to five or six; in these instances, the external and internal carotids arise separately from the arch, the common carotid being absent on one or both sides. In some few cases six branches have been found, and this condition is associated with the origin of both vertebral arteries from the arch.

 

Number Usual, Arrangement Different.—When the aorta arches over to the right side, the three branches have an arrangement the reverse of what is usual; the brachiocephalic artery is a left, one, and the right carotid and subclavian arise separately. In other cases, where the aorta takes its usual course, the two carotids may be joined in a common trunk, and the subclavians arise separately from the arch, the right subclavian generally arising from the left end of the arch.

  In some instances other arteries spring from the arch of the aorta. Of these the most common are the bronchial, one or both, and the thyreoidea ima; but the internal mammary and the inferior thyroid have been seen to arise from this vessel.

 

The Brachiocephalic Artery (A. Anonyma; Brachiocephalic Artery) (505).—The brachiocephalic artery is the largest branch of the arch of the aorta, and is from 4 to 5 cm. in length. It arises, on a level with the upper border of the second right costal cartilage, from the commencement of the arch of the aorta, on a plane anterior to the origin of the left carotid; it ascends obliquely upward, backward, and to the right to the level of the upper border of the right sternoclavicular articulation, where it divides into the right common carotid and right subclavian arteries.

 

Relations.Anteriorly, it is separated from the manubrium sterni by the Sternohyoideus and Sternothyreoideus, the remains of the thymus, the left brachiocephalic and right inferior thyroid veins which cross its root, and sometimes the superior cardiac branches of the right vagus. Posterior to it is the trachea, which it crosses obliquely. On the right side are the right brachiocephalic vein, the superior vena cava, the right phrenic nerve, and the pleura; and on the left side, the remains of the thymus, the origin of the left common carotid artery, the inferior thyroid veins, and the trachea.

 

Branches.—The brachiocephalic artery usually gives off no branches; but occasionally a small branch, the thyreoidea ima, arises from it. Sometimes it gives off a thymic or bronchial branch.

  The thyreoidea ima (a. thyreoidea ima) ascends in front of the trachea to the lower part of the thyroid gland, which it supplies. It varies greatly in size, and appears to compensate for deficiency or absence of one of the other thyroid vessels. It occasionally arises from the aorta, the right common carotid, the subclavian or the internal mammary.

 

Point of Division.—The brachiocephalic artery sometimes divides above the level of the sternoclavicular joint, less frequently below it.

 

Position.—When the aortic arch is on the right side, the brachiocephalic is directed to the left side of the neck.

 

Collateral Circulation.—Allan Burns demonstrated, on the dead subject, the possibility of the establishment of the collateral circulation after ligature of the brachiocephalic artery, by tying and dividing that artery. He then found that “Even coarse injection, impelled into the aorta, passed freely by the anastomosing branches into the arteries of the right arm, filling them and all the vessels of the head completely.” 97 The branches by which this circulation would be carried on are very numerous; thus, all the communications across the middle line between the branches of the carotid arteries of opposite sides would be available for the supply of blood to the right side of the head and neck; while the anastomosis between the costocervical of the subclavian and the first aortic intercostal (see infra on the collateral circulation after obliteration of the thoracic aorta) would bring the blood, by a free and direct course, into the right subclavian. The numerous connections, also, between the intercostal arteries and the branches of the axillary and internal mammary arteries would, doubtless, assist in the supply of blood to the right arm, while the inferior epigastric from the external iliac would, by means of its anastomosis with the internal mammary, compensate for any deficiency in the vascularity of the wall of the chest.

Descending aorta has thoracic part of aorta, which passes in posterior mediastinum and lies to the left from bodies of thoracic vertebrae and abdominal part of aorta, which starts on level of Õ²² thoracic vertebra, passes through aortic hiatus of diaphragm, and extends to level of ²V lumbar vertebra. Abdominal part of aorta is disposed front of anterior surface of lumbar vertebrae to the left from midiane line. Here abdominal aorta gives off the pair parietal branches, pair and odd visceral branches and finishes in bifurcation, dividing into two common iliac arteries.

Branches of thoracic part of aorta

Parietal branches and visceral branches there distinguish in thoracic part of aorta.

Follow arteries belong to parietal branches of thoracic part of aorta:

-         superior phrenic arteries are pair, pass to lumbar part of diaphragm;

-         posterior intercostal arteries are 10 pairs in number, which pass in ²²²-X² intercostal spaces and supply intercostal muscles, ribs, skin, breasts. Lower posterior intercostal arteries supply also muscles of anterior abdominal wall. X posterior intercostal artery is situated under posterior margin of X²² rib and has a name of subcostal artery. From each posterior intercostal artery move away the sprigs to muscles and posterior skin, to membranes of spinal cord and lateral and medial cutane³ branches to breasts skin and abdominal, sprigs to mammary gland.

Follow arteries belong to visceral branches of thoracic part of aorta:

-         bronchial branches - to trachea, bronch³ and lung;

-         esophageal branches to esophagus;

-         pericardial branches to posterior part of pericardium;

-         mediastinal branches supply connective tissue and lymphatic nodes in posterior mediastinum.

The thoracic aorta (530) is contained in the posterior mediastinal cavity. It begins at the lower border of the fourth thoracic vertebra where it is continuous with the aortic arch, and ends in front of the lower border of the twelfth at the aortic hiatus in the diaphragm. At its commencement, it is situated on the left of the vertebral column; it approaches the median line as it descends; and, at its termination, lies directly in front of the column. The vessel describes a curve which is concave forward, and as the branches given off from it are small, its diminution in size is inconsiderable.


The thoracic aorta, viewed from the left side.

 

 

Relations.—It is in relation, anteriorly, from above downward, with the root of the left lung, the pericardium, the esophagus, and the diaphragm; posteriorly, with the vertebral column and the hemiazygos veins; on the right side, with the azygos vein and thoracic duct; on the left side, with the left pleura and lung. The esophagus, with its accompanying plexus of nerves, lies on the right side of the aorta above; but at the lower part of the thorax it is placed in front of the aorta, and, close to the diaphragm, is situated on its left side.

 

Peculiarities.—The aorta is occasionally found to be obliterated at the junction of the arch with the thoracic aorta, just below the ductus arteriosus. Whether this is the result of disease, or of congenital malformation, is immaterial to our present purpose; it affords an interesting opportunity of observing the resources of the collateral circulation. The course of the anastomosing vessels, by which the blood is brought from the upper to the lower part of the artery, will be found well described in an account of two cases in the Pathological Transactions, vols. viii and x. In the former, Sydney Jones thus sums up the detailed description of the anastomosing vessels: The principal communications by which the circulation was carried on were: (1) The internal mammary, anastomosing with the intercostal arteries, with the inferior phrenic of the abdominal aorta by means of the musculophrenic and pericardiacophrenic, and largely with the inferior epigastric. (2) The costocervical trunk, anastomosing anteriorly by means of a large branch with the first aortic intercostal, and posteriorly with the posterior branch of the same artery. (3) The inferior thyroid, by means of a branch about the size of an ordinary radial, forming a communication with the first aortic intercostal. (4) The transverse cervical, by means of very large communications with the posterior branches of the intercostals. (5) The branches (of the subclavian and axillary) going to the side of the chest were large, and anastomosed freely with the lateral branches of the intercostals. In the second case Wood describes the anastomoses in a somewhat similar manner, adding the remark that “the blood which was brought into the aorta through the anastomosis of the intercostal arteries appeared to be expended principally in supplying the abdomen and pelvis; while the supply to the lower extremities had passed through the internal mammary and epigastrics.”

  In a few cases an apparently double descending thoracic aorta has been found, the two vessels lying side by side, and eventually fusing to form a single tube in the lower part of the thorax or in the abdomen. One of them is the aorta, the other represents a dissecting aortic aneurism which has become canalized; opening above and below into the true aorta, and at first sight presenting the appearances of a proper bloodvessel.

 

Branches of the Thoracic Aorta.

Visceral    

Pericardial.

Parietal   

Intercostal.

Bronchial.

Subcostal.

Esophageal.

Superior Phrenic.

Mediastinal.

  The pericardial branches (rami pericardiaci) consist of a few small vessels which are distributed to the posterior surface of the pericardium.

  The bronchial arteries (aa. bronchiales) vary in number, size, and origin. There is as a rule only one right bronchial artery, which arises from the first aortic intercostal, or from the upper left bronchial artery. The left bronchial arteries are usually two in number, and arise from the thoracic aorta. The upper left bronchial arises opposite the fifth thoracic vertebra, the lower just below the level of the left bronchus. Each vessel runs on the back part of its bronchus, dividing and subdividing along the bronchial tubes, supplying them, the areolar tissue of the lungs, the bronchial lymph glands, and the esophagus.

  The esophageal arteries (aa. æsophageæ) four or five in number, arise from the front of the aorta, and pass obliquely downward to the esophagus, forming a chain of anastomoses along that tube, anastomosing with the esophageal branches of the inferior thyroid arteries above, and with ascending branches from the left inferior phrenic and left gastric arteries below.

  The mediastinal branches (rami mediastinales) are numerous small vessels which supply the lymph glands and loose areolar tissue in the posterior mediastinum.

 

Intercostal Arteries (aa. intercostales).—There are usually nine pairs of aortic intercostal arteries. They arise from the back of the aorta, and a redistributed to the lower nine intercostal spaces, the first two spaces being supplied by the highest intercostal artery, a branch of the costocervical trunk of the subclavian. The right aortic intercostals are longer than the left, on account of the position of the aorta on the left side of the vertebral column; they pass across the bodies of the vertebræ behind the esophagus, thoracic duct, and vena azygos, and are covered by the right lung and pleura. The left aortic intercostals run backward on the sides of the vertebræ and are covered by the left lung and pleura; the upper two vessels are crossed by the highest left intercostal vein, the lower vessels by the hemiazygos veins. The further course of the intercostal arteries is practically the same on both sides. Opposite the heads of the ribs the sympathetic trunk passes downward in front of them, and the splanchnic nerves also descend in front by the lower arteries. Each artery then divides into an anterior and a posterior ramus.

  The Anterior Ramus crosses the corresponding intercostal space obliquely toward the angle of the upper rib, and thence is continued forward in the costal groove. It is placed at first between the pleura and the posterior intercostal membrane, then it pierces this membrane, and lies between it and the Intercostalis externus as far as the angle of the rib; from this onward it runs between the Intercostales externus and internus, and anastomoses in front with the intercostal branch of the internal mammary or musculophrenic. Each artery is accompanied by a vein and a nerve, the former being above and the latter below the artery, except in the upper spaces, where the nerve is at first above the artery. The first aortic intercostal artery anastomoses with the intercostal branch of the costocervical trunk, and may form the chief supply of the second intercostal space. The lower two intercostal arteries are continued anteriorly from the intercostal spaces into the abdominal wall, and anastomose with the subcostal, superior epigastric, and lumbar arteries.

 

Branches.—The anterior rami give off the following branches:

Collateral Intercostal.

Lateral Cutaneous.

Muscular.

Mammary.

  The collateral intercostal branch comes off from the intercostal artery near the angle of the rib, and descends to the upper border of the rib below, along which it courses to anastomose with the intercostal branch of the internal mammary.

  Muscular branches are given to the Intercostales and Pectorales and to the Serratus anterior; they anastomose with the highest and lateral thoracic branches of the axillary artery.

  The lateral cutaneous branches accompany the lateral cutaneous branches of the thoracic nerves.

  Mammary branches are given off by the vessels in the third, fourth, and fifth spaces. They supply the mamma, and increase considerably in size during the period of lactation.

  The Posterior Ramus runs backward through a space which is bounded above and below by the necks of the ribs, medially by the body of a vertebra, and laterally by an anterior costotransverse ligament. It gives off a spinal branch which enters the vertebral canal through the intervertebral foramen and is distributed to the medulla spinalis and its membranes and the vertebræ. It then courses over the transverse process with the posterior division of the thoracic nerve, supplies branches to the muscles of the back and cutaneous branches which accompany the corresponding cutaneous branches of the posterior division of the nerve.

  The subcostal arteries, so named because they lie below the last ribs, constitute the lowest pair of branches derived from the thoracic aorta, and are in series with the intercostal arteries. Each passes along the lower border of the twelfth rib behind the kidney and in front of the Quadratus lumborum muscle, and is accompanied by the twelfth thoracic nerve. It then pierces the posterior aponeurosis of the Transversus abdominis, and, passing forward between this muscle and the Obliquus internus, anastomoses with the superior epigastric, lower intercostal, and lumbar arteries. Each subcostal artery gives off a posterior branch which has a similar distribution to the posterior ramus of an intercostal artery.

  The superior phrenic branches are small and arise from the lower part of the thoracic aorta; they are distributed to the posterior part of the upper surface of the diaphragm, and anastomose with the musculophrenic and pericardiacophrenic arteries.

  A small aberrant artery is sometimes found arising from the right side of the thoracic aorta near the origin of the right bronchial. It passes upward and to the right behind the trachea and the esophagus, and may anastomose with the highest right intercostal artery. It represents the remains of the right dorsal aorta, and in a small proportion of cases is enlarged to form the first part of the right subclavian artery.

Superior vena cava is generated by reason of confluence of right and left brachiocephalic veins behind joint of cartilage of first right rib with sternum. Superior vena cava on level of third right cartilage empties into right atrium. Azygos vein empties into superior vena cava from right side.

Brachiocephalic veins form by the confluence of subclavian vein, internal jugular and sometimes External jugular vein. This place is called as venous angle, where thoracic lymphatic duct empties (left side), and right lymphatic duct (right side). Inferior thyroid veins from thyroid plexus, inferior laryngeal vein and thymic vein, pericardial veins from pericardium, bronchic veins and esophageal veins from esophagus fall into brachiocephalic veins.

Azygos vein continues into thoracic cavity from right ascending lumbar vein. Azygos vein receives posterior intercostal veins, esophageal veins, bronchic veins, pericardial veins and mediastinal veins, also hemizygos vein.

  The Veins of the Thorax The brachiocephalic veins (vv. anonymæ; brachiocephalic veins) are two large trunks, placed one on either side of the root of the neck, and formed by the union of the internal jugular and subclavian veins of the corresponding side; they are devoid of valves.

  The Right Brachiocephalic Vein (v. anonyma dextra) is a short vessel, about 2.5 cm. in length, which begins behind the sternal end of the clavicle, and, passing almost vertically downward, joins with the left brachiocephalic vein just below the cartilage of the first rib, close to the right border of the sternum, to form the superior vena cava. It lies in front and to the right of the brachiocephalic artery; on its right side are the phrenic nerve and the pleura, which are interposed between it and the apex of the lung. This vein, at its commencement, receives the right vertebral vein; and, lower down, the right internal mammary and right inferior thyroid veins, and sometimes the vein from the first intercostal space.


The venæ cavæ and azygos veins, with their tributaries.

 

  The Left Brachiocephalic Vein (v. anonyma sinistra), about 6 cm. in length, begins behind the sternal end of the clavicle and runs obliquely downward and to the right behind the upper half of the manubrium sterni to the sternal end of the first right costal cartilage, where it unites with the right brachiocephalic vein to form the superior vena cava. It is separated from the manubrium sterni by the Sternohyoideus and Sternothyreoideus, the thymus or its remains, and some loose areolar tissue. Behind it are the three large arteries, brachiocephalic, left common carotid, and left subclavian, arising from the aortic arch, together with the vagus and phrenic nerves. The left brachiocephalic vein may occupy a higher level, crossing the jugular notch and lying directly in front of the trachea.

 

Tributaries.—Its tributaries are the left vertebral, left internal mammary, left inferior thyroid, and the left highest intercostal veins, and occasionally some thymic and pericardiac veins.

 

Peculiarities.—Sometimes the brachiocephalic veins open separately into the right atrium; in such cases the right vein takes the ordinary course of the superior vena cava; the left vein—left superior vena cava, as it is then termed—which may communicate by a small branch with the right one, passes in front of the root of the left lung, and, turning to the back of the heart, ends in the right atrium. This occasional condition in the adult is due to the persistence of the early fetal condition, and is the normal state of things in birds and some mammalia.

  The internal mammary veins (vv. mammariæ internæ) are venæ comitantes to the lower half of the internal mammary artery, and receive tributaries corresponding to the branches of the artery. They then unite to form a single trunk, which runs up on the medial side of the artery and ends in the corresponding brachiocephalic vein. The superior phrenic vein, i.e., the vein accompanying the pericardiacophrenic artery, usually opens into the internal mammary vein.

  The inferior thyroid veins (vv. thyreoideæ inferiores) two, frequently three or four, in number, arise in the venous plexus on the thyroid gland, communicating with the middle and superior thyroid veins. They form a plexus in front of the trachea, behind the Sternothyreoidei. From this plexus, a left vein descends and joins the left brachiocephalic trunk, and a right vein passes obliquely downward and to the right across the brachiocephalic artery to open into the right brachiocephalic vein, just at its junction with the superior vena cava; sometimes the right and left veins open by a common trunk in the latter situation. These veins receive esophageal tracheal, and inferior laryngeal veins, and are provided with valves at their terminations in the brachiocephalic veins.

  The highest intercostal vein (v. intercostalis suprema; superior intercostal veins) (right and left) drain the blood from the upper three or four intercostal spaces. The right vein (v. intercostalis suprema dextra) passes downward and opens into the vena azygos; the left vein (v. intercostalis suprema sinistra) runs across the arch of the aorta and the origins of the left subclavian and left common carotid arteries and opens into the left brachiocephalic vein. It usually receives the left bronchial vein, and sometimes the left superior phrenic vein, and communicates below with the accessory hemiazygos vein.

  The superior vena cava (v. cava superior) drains the blood from the upper half of the body. It measures about 7 cm. in length, and is formed by the junction of the two brachiocephalic veins. It begins immediately below the cartilage of the right first rib close to the sternum, and, descending vertically behind the first and second intercostal spaces, ends in the upper part of the right atrium opposite the upper border of the third right costal cartilage: the lower half of the vessel is within the pericardium. In its course it describes a slight curve, the convexity of which is to the right side.

 

Relations.In front are the anterior margins of the right lung and pleura with the pericardium intervening below; these separate it from the first and second intercostal spaces and from the second and third right costal cartilages; behind it are the root of the right lung and the right vagus nerve. On its right side are the phrenic nerve and right pleura; on its left side, the commencement of the brachiocephalic artery and the ascending aorta, the latter overlapping it. Just before it pierces the pericardium, it receives the azygos vein and several small veins from the pericardium and other contents of the mediastinal cavity. The portion contained within the pericardium is covered, in front and laterally, by the serous layer of the membrane. The superior vena cava has no valves.

  The azygos vein (v. azygos; vena azygos major) begins opposite the first or second lumbar vertebra, by a branch, the ascending lumbar vein (page 678); sometimes by a branch from the right renal vein, or from the inferior vena cava. It enters the thorax through the aortic hiatus in the diaphragm, and passes along the right side of the vertebral column to the fourth thoracic vertebra, where it arches forward over the root of the right lung, and ends in the superior vena cava, just before that vessel pierces the pericardium. In the aortic hiatus, it lies with the thoracic duct on the right side of the aorta; in the thorax it lies upon the intercostal arteries, on the right side of the aorta and thoracic duct, and is partly covered by pleura.

 

Tributaries.—It receives the right subcostal and intercostal veins, the upper three or four of these latter opening by a common stem, the highest superior intercostal vein. It receives the hemiazygos veins, several esophageal, mediastinal, and pericardial veins, and, near its termination, the right bronchial vein. A few imperfect valves are found in the azygos vein; but its tributaries are provided with complete valves.

  The intercostal veins on the left side, below the upper three intercostal spaces, usually form two trunks, named the hemiazygos and accessory hemiazygos veins.

  The Hemiazygos Vein (v. hemiazygos; vena azygos minor inferior) begins in the left ascending lumbar or renal vein. It enters the thorax, through the left crus of the diaphragm, and, ascending on the left side of the vertebral column, as high as the ninth thoracic vertebra, passes across the column, behind the aorta, esophagus, and thoracic duct, to end in the azygos vein. It receives the lower four or five intercostal veins and the subcostal vein of the left side, and some esophageal and mediastinal veins.

  The Accessory Hemiazygos Vein (v. hemiazygos accessoria; vena azygos minor superior) descends on the left side of the vertebral column, and varies inversely in size with the highest left intercostal vein. It receives veins from the three or four intercostal spaces between the highest left intercostal vein and highest tributary of the hemiazygos; the left bronchial vein sometimes opens into it. It either crosses the body of the eighth thoracic vertebra to join the azygos vein or ends in the hemiazygos. When this vein is small, or altogether wanting, the left highest intercostal vein may extend as low as the fifth or sixth intercostal space.

  In obstruction of the superior vena cava, the azygos and hemiazygos veins are one of the principal means by which the venous circulation is carried on, connecting as they do the superior and inferior venæ cavæ, and communicating with the common iliac veins by the ascending lumbar veins and with many of the tributaries of the inferior vena cava.

  The Bronchial Veins (vv. bronchiales) return the blood from the larger bronchi, and from the structures at the roots of the lungs; that of the right side opens into the azygos vein, near its termination; that of the left side, into the highest left intercostal or the accessory hemiazygos vein. A considerable quantity of the blood which is carried to the lungs through the bronchial arteries is returned to the left side of the heart through the pulmonary veins.

 

The Veins of the Vertebral Column

  The veins which drain the blood from the vertebral column, the neighboring muscles, and the meninges of the medulla spinalis form intricate plexuses extending along the entire length of the column; these plexuses may be divided into two groups, external and internal, according to their positions inside or outside the vertebral canal. The plexuses of the two groups anastomose freely with each other and end in the intervertebral veins.

  The external vertebral venous plexuses (plexus venosi vertebrales externi; extraspinal veins) best marked in the cervical region, consist of anterior and posterior plexuses which anastomose freely with each other. The anterior external plexuses lie in front of the bodies of the vertebræ, communicate with the basivertebral and intervertebral veins, and receive tributaries from the vertebral bodies. The posterior external plexuses are placed partly on the posterior surfaces of the vertebral arches and their processes, and partly between the deep dorsal muscles. They are best developed in the cervical region, and there anastomose with the vertebral, occipital, and deep cervical veins.


Transverse section of a thoracic vertebra, showing the vertebral venous plexuses.


Median sagittal section of two thoracic vertebræ, showing the vertebral venous plexuses.

 

  The internal vertebral venous plexuses (plexus venosi vertebrales interni; intraspinal veins) lie within the vertebral canal between the dura mater and the vertebræ, and receive tributaries from the bones and from the medulla spinalis. They form a closer net-work than the external plexuses, and, running mainly in a vertical direction, form four longitudinal veins, two in front and two behind; they therefore may be divided into anterior and posterior groups. The anterior internal plexuses consist of large veins which lie on the posterior surfaces of the vertebral bodies and intervertebral fibrocartilages on either side of the posterior longitudinal ligament; under cover of this ligament they are connected by transverse branches into which the basivertebral veins open. The posterior internal plexuses are placed, one on either side of the middle line in front of the vertebral arches and ligamenta flava, and anastomose by veins passing through those ligaments with the posterior external plexuses. The anterior and posterior plexuses communicate freely with one another by a series of venous rings (retia venosa vertebrarum), one opposite each vertebra. Around the foramen magnum they form an intricate net-work which opens into the vertebral veins and is connected above with the occipital sinus, the basilar plexus, the condyloid emissary vein, and the rete canalis hypoglossi.

  The basivertebral veins (vv. basivertebrales) emerge from the foramina on the posterior surfaces of the vertebral bodies. They are contained in large, tortuous channels in the substance of the bones, similar in every respect to those found in the diploë of the cranial bones. They communicate through small openings on the front and sides of the bodies of the vertebræ with the anterior external vertebral plexuses, and converge behind to the principal canal, which is sometimes double toward its posterior part, and open by valved orifices into the transverse branches which unite the anterior internal vertebral plexuses. They become greatly enlarged in advanced age.

  The intervertebral veins (vv. intervertebrales) accompany the spinal nerves through the intervertebral foramina; they receive the veins from the medulla spinalis, drain the internal and external vertebral plexuses and end in the vertebral, intercostal, lumbar, and lateral sacral veins, their orifices being provided with valves.

  The veins of the medulla spinalis (vv. spinales; veins of the spinal cord) are situated in the pia mater and form a minute, tortuous, venous plexus. They emerge chiefly from the median fissures of the medulla spinalis and are largest in the lumbar region. In this plexus there are (1) two median longitudinal veins, one in front of the anterior fissure, and the other behind the posterior sulcus of the cord, and (2) four lateral longitudinal veins which run behind the nerve roots. They end in the intervertebral veins. Near the base of the skull they unite, and form two or three small trunks, which communicate with the vertebral veins, and then end in the inferior cerebellar veins, or in the inferior petrosal sinuses.

Prepared by

Galytsa-Harhalis O.Ya.