LESSON 18

 

Arterial system Systemic and

 pulmonary arteries

 

THE BLOOD VESSELS

You already know that the cardiovascular system is divided into the pulmonary circuit and the systemic circuit. The pulmonary circuit is composed of arteries and veins that transport blood between the heart and the lungs. This circuit begins at the right ventricle and ends at the left atrium. From the left ventricle, the arteries of the systemic circuit transport oxygenated blood and nutrients to all organs and tissues, ultimately returning deoxygenated blood to the right atrium. Figure 21-20 summarizes the primary circulatory routes within the pulmonary and systemic circuits.

In the pages that follow, we shall examine the vessels of the pulmonary and systemic circuits in detail. Two general functional patterns are worth noting at the outset:

1. The peripheral distributions of arteries and veins on the left and right sides are generally identical except near the heart, where the largest vessels connect to the atria or ventricles. For example, there are left and right subclavian, axillary, brachial, and radial arteries whose distribution parallels that of the left and right subclavian, axillary, brachial, and radial veins, respectively.

2. A single vessel may have several different names as it crosses specific anatomical boundaries, making accurate anatomical descriptions possible when the vessel extends far into the periphery. For example, the external iliac artery becomes the femoral artery as it leaves the trunk and enters the lower limb.

The Pulmonary Circulation

Blood entering the right atrium has just returned from the peripheral capillary beds, where oxygen was released and carbon dioxide was absorbed. After traveling through the right atrium and ventricle, blood enters the pulmonary trunk, the start of the pulmonary circuit (Figure 21-21). At the lungs, oxygen will be replenished, carbon dioxide will be released, and the oxygenated blood will be returned to the heart for distribution via the systemic circuit. Compared with the systemic circuit, the pulmonary circuit is relatively short: The base of the pulmonary trunk and the lungs are only about 15 cm (6 in.) apart.

The arteries of the pulmonary circuit differ from those of the systemic circuit in that they carry deoxygenated blood. (For this reason, most color-coded diagrams show the pulmonary arteries in blue, the same color as systemic veins.) As it curves over the superior border of the heart, the pulmonary trunk gives rise to the left and right pulmonary arteries. These large arteries enter the lungs before branching repeatedly, giving rise to smaller and smaller arteries. The smallest branches, the pulmonary arterioles, provide blood to capillary networks that surround alveoli. The walls of these small air pockets are thin enough for gas exchange to occur between the capillary blood and inspired air. As it leaves the alveolar capillaries, oxygenated blood enters venules that in turn unite to form larger vessels carrying blood toward the pulmonary veins. These four veins, two from each lung, empty into the left atrium, completing the pulmonary circuit.

The Systemic Circulation

The systemic circulation supplies the capillary beds in all parts of the body not serviced by the pulmonary circuit. The systemic circuit, which at any given moment contains about 84 percent of the total blood volume, begins at the left ventricle and ends at the right atrium.

Systemic Arteries

Figure 21-22 is an overview of the systemic arterial system. This figure indicates the relative locations of major systemic arteries.

The Ascending Aorta
The ascending aorta begins at the aortic semilunar valve of the left ventricle (Figure 21-23 ). The left and right coronary arteries originate at the base of the ascending aorta, just superior to the aortic semilunar valve. We detailed the distribution of coronary vessels in Chapter 20 and illustrated them in Figure 20-8.

The Aortic Arch
The aortic arch curves like a cane handle across the superior surface of the heart, connecting the ascending aorta with the descending aorta. Three elastic arteries originate along the aortic arch (Figures 21-22, 21-23, and 21-24). These arteries, (1) the brachiocephalic, (2) the left common carotid, and (3) the left subclavian, deliver blood to the head, neck, shoulders, and upper limbs. The brachiocephalic artery, also called the innominate artery (unnamed), ascends for a short distance before branching to form the right subclavian artery and the right common carotid artery.

There is only one brachiocephalic artery, and the left common carotid and left subclavian arteries arise separately from the aortic arch. However, in terms of their peripheral distribution, the vessels on the left side are mirror images of those on the right side. Because the descriptions that follow focus on major branches found on both sides of the body, for clarity we will not use the terms right and left in the following discussion. Figures 21-23 and 21-24 illustrate the major branches of these arteries.

The Subclavian Arteries. The subclavian arteries supply blood to the arms, chest wall, shoulders, back, and CNS (Figures 21-22 and 21-23). Three major branches arise before a subclavian artery leaves the thoracic cavity: (1) the thyrocervical artery, which provides blood to muscles and other tissues of the neck, shoulder, and upper back; (2) the internal thoracic artery, supplying the pericardium and anterior wall of the chest; and (3) the vertebral artery, which provides blood to the brain and spinal cord.

After leaving the thoracic cavity and passing across the superior border of the first rib, the subclavian is called the axillary artery. The axillary artery crosses the axilla to enter the arm, where it becomes the brachial artery. The brachial artery supplies blood to the upper extremity. At the antecubital fossa, the brachial artery divides into the radial artery, which follows the radius, and the ulnar artery, which follows the ulna to the wrist. These arteries supply blood to the forearm. At the wrist, they anastomose to form the superficial palmar arch and the deep palmar arch, which supply blood to the hand and to the digital arteries of the thumb and fingers.

The Carotid Artery and the Blood Supply to the Brain. The common carotid arteries ascend deep in the tissues of the neck. You can usually locate the carotid artery by pressing gently along either side of the windpipe (trachea) until you feel a strong pulse.

Each common carotid artery divides into an external carotid and an internal carotid artery (Figure 21-24). The carotid sinus, located at the base of the internal carotid, may extend along a portion of the common carotid. The external carotids supply blood to the structures of the neck, esophagus, pharynx, larynx, lower jaw, and face. The internal carotids enter the skull through the carotid canals of the temporal bones, delivering blood to the brain (see Figures 7-3e and 7-4b).

The internal carotids ascend to the level of the optic nerves, where each divides into three branches: (1) an ophthalmic artery, which supplies the eyes; (2) an anterior cerebral artery, which supplies the frontal and parietal lobes of the brain; and (3) a middle cerebral artery, which supplies the mesencephalon and lateral surfaces of the cerebral hemispheres (Figures 21-24 and 21-25 ).

The brain is extremely sensitive to changes in its circulatory supply. An interruption of circulation for several seconds will produce unconsciousness, and after 4 minutes there may be some permanent neural damage. Such circulatory crises are rare, because blood reaches the brain through the vertebral arteries as well as by way of the internal carotids. The left and right vertebral arteries arise from the subclavian arteries and ascend within the transverse foramina of the cervical vertebrae. The vertebral arteries enter the cranium at the foramen magnum, where they fuse along the ventral surface of the medulla oblongata to form the basilar artery. The basilar artery continues on the ventral surface along the pons, branching many times before dividing into the posterior cerebral arteries. The posterior communicating arteries branch off the posterior cerebral arteries (Figure 21-25).

The internal carotids normally supply the arteries of the anterior half of the cerebrum, and the rest of the brain receives blood from the vertebral arteries. But this circulatory pattern can easily change, because the internal carotids and the basilar artery are interconnected in a ring-shaped anastomosis called the cerebral arterial circle, or circle of Willis, which encircles the infundibulum of the pituitary gland (Figure 21-25). With this arrangement, the brain can receive blood from either the carotids or the vertebrals, and the chances for a serious interruption of circulation are reduced.

 

Common carotid artery. Vascular nervous bundle of the neck

Brachiocephalic trunk begins from aortic arch on level of right II costal cartilage. It passes upward and to the right of and on level of right sternо-clavicular joint divides into two terminal branches - right common carotid and right subclavianу arteries.

Brachiocephalic trunk 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.

The arch of the aorta, and its branches.

Relations.—Anteriorly, it is separated from the manubrium sterni by the Sternohyoideus and Sternothyreoideus, the remains of the thymus, the left innominate 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 innominate 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 trunk 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 trunk sometimes divides above the level of the sternoclavicular joint, less frequently below it.

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

Superficial dissection of the right side of the neck, showing the carotid and subclavian arteries.

 Collateral Circulation.—Allan Burns demonstrated, on the dead subject, the possibility of the establishment of the collateral circulation after ligature of the brachiocephalic trunk, 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.

 

Common carotid artery passes behind sternocleidomastoid muscle upward on front of transverse processes of cervical vertebrae and does not give off any branches. On the level of upper edge of thyroid cartilage common carotid artery divides into external carotid artery and internal carotid artery. This place called bifurcation of carotid artery. There are carotid sinus and carotid glomus here.

 

The Arteries of the Head and Neck. The principal arteries of supply to the head and neck are the two common carotids; they ascend in the neck and each divides into two branches, viz., (1) the external carotid, supplying the exterior of the head, the face, and the greater part of the neck; (2) the internal carotid, supplying to a great extent the parts within the cranial and orbital cavities.

 

The Common Carotid Artery (A. Carotis Communis)—The common carotid arteries differ in length and in their mode of origin. The right begins at the bifurcation of the brachiocephalic trunk behind the sternoclavicular joint and is confined to the neck. The left springs from the highest part of the arch of the aorta to the left of, and on a plane posterior to the brachiocephalic trunk, and therefore consists of a thoracic and a cervical portion.

  The thoracic portion of the left common carotid artery ascends from the arch of the aorta through the superior mediastinum to the level of the left sternoclavicular joint, where it is continuous with the cervical portion.

 

1. Relations.—In front, it is separated from the manubrium sterni by the Sternohyoideus and Sternothyreoideus, the anterior portions of the left pleura and lung, the left innominate vein, and the remains of the thymus; behind, it lies on the trachea, esophagus, left recurrent nerve, and thoracic duct. To its right side below is the brachiocephalic trunk, and above, the trachea, the inferior thyroid veins, and the remains of the thymus; to its left side are the left vagus and phrenic nerves, left pleura, and lung. The left subclavian artery is posterior and slightly lateral to it.

  The cervical portions of the common carotids resemble each other so closely that one description will apply to both (507). Each vessel passes obliquely upward, from behind the sternoclavicular articulation, to the level of the upper border of the thyroid cartilage, where it divides into the external and internal carotid arteries.

The arteries of the face and scalp.

   At the lower part of the neck the two common carotid arteries are separated from each other by a very narrow interval which contains the trachea; but at the upper part, the thyroid gland, the larynx and pharynx project forward between the two vessels. The common carotid artery is contained in a sheath, which is derived from the deep cervical fascia and encloses also the internal jugular vein and vagus nerve, the vein lying lateral to the artery, and the nerve between the artery and vein, on a plane posterior to both. On opening the sheath, each of these three structures is seen to have a separate fibrous investment.

 

Relations.—At the lower part of the neck the common carotid artery is very deeply seated, being covered by the integument, superficial fascia, Platysma, and deep cervical fascia, the Sternocleidomastoideus, Sternohyoideus, Sternothyreoideus, and Omohyoideus; in the upper part of its course it is more superficial, being covered merely by the integument, the superficial fascia, Platysma, deep cervical fascia, and medial margin of the Sternocleidomastoideus. When the latter muscle is drawn backward, the artery is seen to be contained in a triangular space, the carotid triangle, bounded behind by the Sternocleidomastoideus, above by the Stylohyoideus and posterior belly of the Digastricus, and below by the superior belly of the Omohyoideus. This part of the artery is crossed obliquely, from its medial to its lateral side, by the sternocleidomastoid branch of the superior thyroid artery; it is also crossed by the superior and middle thyroid veins which end in the internal jugular; descending in front of its sheath is the descending branch of the hypoglossal nerve, this filament being joined by one or two branches from the cervical nerves, which cross the vessel obliquely. Sometimes the descending branch of the hypoglossal nerve is contained within the sheath. The superior thyroid vein crosses the artery near its termination, and the middle thyroid vein a little below the level of the cricoid cartilage; the anterior jugular vein crosses the artery just above the clavicle, but is separated from it by the Sternohyoideus and Sternothyreoideus. Behind, the artery is separated from the transverse processes of the cervical vertebræ by the Longus colli and Longus capitis, the sympathetic trunk being interposed between it and the muscles. The inferior thyroid artery crosses behind the lower part of the vessel. Medially, it is in relation with the esophagus, trachea, and thyroid gland (which overlaps it), the inferior thyroid artery and recurrent nerve being interposed; higher up, with the larynx and pharynx. Lateral to the artery are the internal jugular vein and vagus nerve.

  At the lower part of the neck, the right recurrent nerve crosses obliquely behind the artery; the right internal jugular vein diverges from the artery, but the left approaches and often overlaps the lower part of the artery.

  Behind the angle of bifurcation of the common carotid artery is a reddish-brown oval body, known as the glomus caroticum (carotid body). It is similar in structure to the glomus coccygeum (coccygeal body) which is situated on the middle sacral artery.

 

Peculiarities as to Origin.—The right common carotid may arise above the level of the upper border of the sternoclavicular articulation; this variation occurs in about 12 per cent. of cases. In other cases the artery may arise as a separate branch from the arch of the aorta, or in conjunction with the left carotid. The left common carotid varies in its origin more than the right. In the majority of abnormal cases it arises with the brachiocephalic trunk; if that artery is absent, the two carotids arise usually by a single trunk. It is rarely joined with the left subclavian, except in cases of transposition of the aortic arch.

Peculiarities as to Point of Division.—In the majority of abnormal cases this occurs higher than usual, the artery dividing opposite or even above the hyoid bone; more rarely, it occurs below, opposite the middle of the larynx, or the lower border of the cricoid cartilage; one case is related by Morgagni, where the artery was only 4 cm. in length and divided at the root of the neck. Very rarely, the common carotid ascends in the neck without any subdivision, either the external or the internal carotid being wanting; and in a few cases the common carotid has been found to be absent, the external and internal carotids arising directly from the arch of the aorta. This peculiarity existed on both sides in some instances, on one side in others.

Occasional Branches.—The common carotid usually gives off no branch previous to its bifurcation, but it occasionally gives origin to the superior thyroid or its laryngeal branch, the ascending pharyngeal, the inferior thyroid, or, more rarely, the vertebral artery.

Collateral Circulation.—After ligature of the common carotid, the collateral circulation can be perfectly established, by the free communication which exists between the carotid arteries of opposite sides, both without and within the cranium, and by enlargement of the branches of the subclavian artery on the side corresponding to that on which the vessel has been tied. The chief communications outside the skull take place between the superior and inferior thyroid arteries, and the profunda cervicis and ramus descendens of the occipital; the vertebral takes the place of the internal carotid within the cranium.

 

External carotid artery (neck branches)

           External carotid artery starts from common carotid artery in carotid triangle on level of superior margin of thyroid cartilage. On level of mandibular neck this artery divides by its two terminal branches. On its extent external carotid artery gives off branches of anterior, posterior, medial and terminal groups.

Follow arteries belong to anterior  group:

1.     superior thyroid artery supplies thyroid gland and gives off a superior laryngeal artery, which supplies muscles and mucous membrane of the larynx;

2.     lingual artery supplies sublingual salivary gland and gives off dorsal branches and deep lingual artery, which supplies muscles and mucous membrane of the tongue;

3.     facial artery in submandibular triangle gives off the branches to submandibular salivary glands, ascending palatine artery to velum and tonsillar branch to palatine tonsils. Bending over margin of mandible in front of masseter muscle, it gives off on face superior labial artery and inferior labial artery. By terminal branch of facial artery is anglular artery, which passes to medial eye angle and anastomoses with dorsal nasal artery from system of internal carotid artery (ophtalmic artery).

Posterior   group   includes :

1.     sternocleidomastoid branch passes to same named muscle and can start from superior thyroid artery, or from occipital artery;

2.     occipital artery supplies posterior skin occipital region;

3.     posterior auricular artery supplies outer and middle ear (by posterior tympanic artery).

Ascending pharyngel artery belong to medial group. It supplies pharynx, deep neck muscles, cerebral dura mater (posterior meningeal artery and tympanic cavity (by inferior tympanic artery through fossula petrosa).

Follow arteries belong to terminal  branches:

1)    Superficial temporal artery, which is continuation of external carotid artery, passes in front of auricle into temporal area and on level of supraorbital margin of frontal bone subdivides into frontal branch and parietal branch, which feed muscles and skin in frontal and parietal area. On this course superficial temporal artery gives off the branches for parotid salivary gland (r. parotideus), zygomaticoorbital artery, for facial muscles (a. transversa faciei), for auricle (rr. auriculares anteriores) and for temporal muscle (a. temporalis media);

2)    Maxillary artery is a largest branch of external carotid artery. According to topography in it one can pick out a mandibular portion, pterygoid portion and pterygopalatine portion.

a)     The first mandibular portion gives off branches to temporo-mandibular joint

The internal carotid and vertebral arteries. Right side.

b)   

 

·          deep auricular artery supplies external ear also tympanic membrane

·          anterior tympanic artery supplies the tympanic cavity

·          middle meningeal artery passes through spinous foramen into scull and feeds dura mater

·          inferior alveolar artery runs into mandibular canal supplies teeth and gingivae of lower jaw and continue as mental artery in mental region.

b)    The second portion of maxillary artery gives off the branches to masticator and buccal muscles (masseteric, deep temporal arteries, pterygoid branches, and buccal artery).

c)     The third portion of maxillary artery gives off :

·          Posterior superior alveolar arteries pass though alveolar canals of maxilla, supply teeth of upper jaw: molars and premolars with parodont

·          infraorbital artery runs through inferior orbital fissura and infraorbital canal, gives off anterior and middle superior alveolar arteries that supply maxilla, upper teeth and gingivae, face muscles

·          sphenopalatine artery to mucous membrane of the nasal cavity

·          descending palatine artery (for palatine)

·          major and minores palatine arteries (for palatine)

The external carotid artery begins opposite the upper border of the thyroid cartilage, and, taking a slightly curved course, passes upward and forward, and then inclines backward to the space behind the neck of the mandible, where it divides into the superficial temporal and internal maxillary arteries. It rapidly diminishes in size in its course up the neck, owing to the number and large size of the branches given off from it. In the child, it is somewhat smaller than the internal carotid; but in the adult, the two vessels are of nearly equal size. At its origin, this artery is more superficial, and placed nearer the middle line than the internal carotid, and is contained within the carotid triangle.

 

Relations.—The external carotid artery is covered by the skin, superficial fascia, Platysma, deep fascia, and anterior margin of the Sternocleidomastoideus; it is crossed by the hypoglossal nerve, by the lingual, ranine, common facial, and superior thyroid veins; and by the Digastricus and Stylohyoideus; higher up it passes deeply into the substance of the parotid gland, where it lies deep to the facial nerve and the junction of the temporal and internal maxillary veins. Medial to it are the hyoid bone, the wall of the pharynx, the superior laryngeal nerve, and a portion of the parotid gland. Lateral to it, in the lower part of its course, is the internal carotid artery. Posterior to it, near its origin, is the superior laryngeal nerve; and higher up, it is separated from the internal carotid by the Styloglossus and Stylopharyngeus, the glossopharyngeal nerve, the pharyngeal branch of the vagus, and part of the parotid gland.

 Branches.—The branches of the external carotid artery may be divided into four sets.

Anterior.

Posterior.

Ascending.

Terminal.

Superior Thyroid.

Occipital.

Ascending

Superficial Temporal.

Lingual.

Posterior Auricular.

Pharyngeal.

Maxillary.

  1. The superior thyroid artery (a. thyreoidea superior) (507) arises from the external carotid artery just below the level of the greater cornu of the hyoid bone and ends in the thyroid gland.

 Relations.—From its origin under the anterior border of the Sternocleidomastoideus it runs upward and forward for a short distance in the carotid triangle, where it is covered by the skin, Platysma, and fascia; it then arches downward beneath the Omohyoideus, Sternohyoideus, and Sternothyreoideus. To its medial side are the Constrictor pharyngis inferior and the external branch of the superior laryngeal nerve.

Branches.—It distributes twigs to the adjacent muscles, and numerous branches to the thyroid gland, anastomosing with its fellow of the opposite side, and with the inferior thyroid arteries. The branches to the gland are generally two in number; one, the larger, supplies principally the anterior surface; on the isthmus of the gland it anastomoses with the corresponding artery of the opposite side: a second branch descends on the posterior surface of the gland and anastomoses with the inferior thyroid artery.

  Besides the arteries distributed to the muscles and to the thyroid gland, the branches of the superior thyroid are:

Hyoid.

Superior Laryngeal.

Sternocleidomastoid.

Cricothyroid.

  The Hyoid Branch (ramus hyoideus; infrahyoid branch) is small and runs along the lower border of the hyoid bone beneath the Thyreohyoideus and anastomoses with the vessel of the opposite side.

  The Sternocleidomastoid Branch (ramus sternocleidomastoideus; sternomastoid branch) runs downward and lateralward across the sheath of the common carotid artery, and supplies the Sternocleidomastoideus and neighboring muscles and integument; it frequently arises as a separate branch from the external carotid.

  The Superior Laryngeal Artery (a. laryngea superior), larger than either of the preceding, accompanies the internal laryngeal branch of the superior laryngeal nerve, beneath the Thyreohyoideus; it pierces the hyothyroid membrane, and supplies the muscles, mucous membrane, and glands of the larynx, anastomosing with the branch from the opposite side.

  The Cricothyroid Branch (ramus cricothyreoideus) is small and runs transversely across the cricothyroid membrane, communicating with the artery of the opposite side.

  2. The lingual artery (a. lingualis) (513) arises from the external carotid between the superior thyroid and external maxillary; it first runs obliquely upward and medialward to the greater cornu of the hyoid bone; it then curves downward and forward, forming a loop which is crossed by the hypoglossal nerve, and passing beneath the Digastricus and Stylohyoideus it runs horizontally forward, beneath the Hyoglossus, and finally, ascending almost perpendicularly to the tongue, turns forward on its lower surface as far as the tip, under the name of the profunda linguæ.

Relations.—Its first, or oblique, portion is superficial, and is contained within the carotid triangle; it rests upon the Constrictor pharyngis medius, and is covered by the Platysma and the fascia of the neck. Its second, or curved, portion also lies upon the Constrictor pharyngis medius, being covered at first by the tendon of the Digastricus and by the Stylohyoideus, and afterward by the Hyoglossus. Its third, or horizontal, portion lies between the Hyoglossus and Genioglossus. The fourth, or terminal part, under the name of the profunda linguæ (ranine artery) runs along the under surface of the tongue to its tip; here it is superficial, being covered only by the mucous membrane; above it is the Longitudinalis inferior, and on the medial side the Genioglossus. The hypoglossal nerve crosses the first part of the lingual artery, but is separated from the second part by the Hyoglossus.

 

Branches.—The branches of the lingual artery are:

Hyoid.

Sublingual.

Dorsales linguæ.

Profunda linguæ.

 

  The Hyoid Branch (ramus hyoideus; suprahyoid branch) runs along the upper border of the hyoid bone, supplying the muscles attached to it and anastomosing with its fellow of the opposite side.

  The Arteriæ Dorsales Linguæ (rami dorsales linguæ) consist usually of two or three small branches which arise beneath the Hyoglossus; they ascend to the back part of the dorsum of the tongue, and supply the mucous membrane in this situation, the glossopalatine arch, the tonsil, soft palate, and epiglottis; anastomosing with the vessels of the opposite side.

  The Sublingual Artery (a. sublingualis) arises at the anterior margin of the Hyoglossus, and runs forward between the Genioglossus and Mylohyoideus to the sublingual gland. It supplies the gland and gives branches to the Mylohyoideus and neighboring muscles, and to the mucous membrane of the mouth and gums. One branch runs behind the alveolar process of the mandible in the substance of the gum to anastomose with a similar artery from the other side; another pierces the Mylohyoideus and anastomoses with the submental branch of the external maxillary artery.

  The Arteria Profunda Linguæ (ranine artery; deep lingual artery) is the terminal portion of the lingual artery; it pursues a tortuous course and runs along the under surface of the tongue, below the Longitudinalis inferior, and above the mucous membrane; it lies on the lateral side of the Genioglossus, accompanied by the lingual nerve. At the tip of the tongue, it is said to anastomose with the artery of the opposite side, but this is denied by Hyrtl. In the mouth, these vessels are placed one on either side of the frenulum linguæ.

  3. The facial artery (a. maxillaris externa; facial artery) (508), arises in the carotid triangle a little above the lingual artery and, sheltered by the ramus of the mandible, passes obliquely up beneath the Digastricus and Stylohyoideus, over which it arches to enter a groove on the posterior surface of the submaxillary gland. It then curves upward over the body of the mandible at the antero-inferior angle of the Masseter; passes forward and upward across the cheek to the angle of the mouth, then ascends along the side of the nose, and ends at the medial commissure of the eye, under the name of the angular artery. This vessel, both in the neck and on the face, is remarkably tortuous: in the former situation, to accommodate itself to the movements of the pharynx in deglutition; and in the latter, to the movements of the mandible, lips, and cheeks.

 

Relations.—In the neck, its origin is superficial, being covered by the integument, Platysma, and fascia; it then passes beneath the Digastricus and Stylohyoideus muscles and part of the submaxillary gland, and frequently beneath the hypoglossal nerve. It lies upon the Constrictores pharyngis medius and superior, the latter of which separates it, at the summit of its arch, from the lower and back part of the tonsil. On the face, where it passes over the body of the mandible, it is comparatively superficial, lying immediately beneath the Platysma. In its course over the face, it is covered by the integument, the fat of the cheek, and, near the angle of the mouth, by the Platysma, Risorius, and Zygomaticus. It rests on the Buccinator and Caninus, and passes either over or under the infraorbital head of the Quadratus labii superioris. The anterior facial vein lies lateral to the artery, and takes a more direct course across the face, where it is separated from the artery by a considerable interval. In the neck it lies superficial to the artery. The branches of the facial nerve cross the artery from behind forward.

The arteries of the face and scalp.

Branches.—The branches of the artery may be divided into two sets: those given off in the neck (cervical), and those on the face (facial).

Cervical Branches.

Facial Branches.

Ascending Palatine.

Inferior Labial.

Tonsillar.

Superior Labial.

Glandular.

Lateral Nasal.

Submental.

Angular.

Muscular.

Muscular.

  The Ascending Palatine Artery (a. palatina ascendens) (513) arises close to the origin of the external maxillary artery and passes up between the Styloglossus and Stylopharyngeus to the side of the pharynx, along which it is continued between the Constrictor pharyngis superior and the Pterygoideus internus to near the base of the skull. It divides near the Levator veli palatini into two branches: one follows the course of this muscle, and, winding over the upper border of the Constrictor pharyngis superior, supplies the soft palate and the palatine glands, anastomosing with its fellow of the opposite side and with the descending palatine branch of the internal maxillary artery; the other pierces the Constrictor pharyngis superior and supplies the palatine tonsil and auditory tube, anastomosing with the tonsillar and ascending pharyngeal arteries.

The internal carotid and vertebral arteries. Right side.

  The Tonsillar Branch (ramus tonsillaris) (513) ascends between the Pterygoideus internus and Styloglossus, and then along the side of the pharynx, perforating the Constrictor pharyngis superior, to ramify in the substance of the palatine tonsil and root of the tongue.

  The Glandular Branches (rami glandulares; submaxillary branches) consist of three or four large vessels, which supply the submaxillary gland, some being prolonged to the neighboring muscles, lymph glands, and integument.

  The Submental Artery (a. submentalis) the largest of the cervical branches, is given off from the facial artery just as that vessel quits the submaxillary gland: it runs forward upon the Mylohyoideus, just below the body of the mandible, and beneath the Digastricus. It supplies the surrounding muscles, and anastomoses with the sublingual artery and with the mylohyoid branch of the inferior alveolar; at the symphysis menti it turns upward over the border of the mandible and divides into a superficial and a deep branch. The superficial branch passes between the integument and Quadratus labii inferioris, and anastomoses with the inferior labial artery; the deep branch runs between the muscle and the bone, supplies the lip, and anastomoses with the inferior labial and mental arteries.

  The Inferior Labial Artery (a. labialis inferior; inferior coronary artery) arises near the angle of the mouth; it passes upward and forward beneath the Triangularis and, penetrating the Orbicularis oris, runs in a tortuous course along the edge of the lower lip between this muscle and the mucous membrane. It supplies the labial glands, the mucous membrane, and the muscles of the lower lip; and anastomoses with the artery of the opposite side, and with the mental branch of the inferior alveolar artery.

  The Superior Labial Artery (a. labialis superior; superior coronary artery) is larger and more tortuous than the inferior. It follows a similar course along the edge of the upper lip, lying between the mucous membrane and the Orbicularis oris, and anastomoses with the artery of the opposite side. It supplies the upper lip, and gives off in its course two or three vessels which ascend to the nose; a septal branch ramifies on the nasal septum as far as the point of the nose, and an alar branch supplies the ala of the nose.

  The Lateral Nasal branch is derived from the external maxillary as that vessel ascends along the side of the nose. It supplies the ala and dorsum of the nose, anastomosing with its fellow, with the septal and alar branches, with the dorsal nasal branch of the ophthalmic, and with the infraorbital branch of the internal maxillary.

  The Angular Artery (a. angularis) is the terminal part of the external maxillary; it ascends to the medial angle of the orbit, imbedded in the fibers of the angular head of the Quadratus labii superioris, and accompanied by the angular vein. On the cheek it distributes branches which anastomose with the infraorbital; after supplying the lacrimal sac and Orbicularis oculi, it ends by anastomosing with the dorsal nasal branch of the ophthalmic artery.

  The Muscular Branches in the neck are distributed to the Pterygoideus internus and Stylohyoideus, and on the face to the Masseter and Buccinator. The anastomoses of the external maxillary artery are very numerous, not only with the vessel of the opposite side, but, in the neck, with the sublingual branch of the lingual, with the ascending pharyngeal, and by its ascending palatine and tonsillar branches with the palatine branch of the internal maxillary; on the face, with the mental branch of the inferior alveolar as it emerges from the mental foramen, with the transverse facial branch of the superficial temporal, with the infraorbital branch of the internal maxillary, and with the dorsal nasal branch of the ophthalmic.

 

Peculiarities.—The external maxillary artery not infrequently arises in common with the lingual. It varies in its size and in the extent to which it supplies the face; it occasionally ends as the submental, and not infrequently extends only as high as the angle of the mouth or nose. The deficiency is then compensated for by enlargement of one of the neighboring arteries.

  4. The occipital artery (a. occipitalis) (508) arises from the posterior part of the external carotid, opposite the external maxillary, near the lower margin of the posterior belly of the Digastricus, and ends in the posterior part of the scalp.

Course and Relations.—At its origin, it is covered by the posterior belly of the Digastricus and the Stylohyoideus, and the hypoglossal nerve winds around it from behind forward; higher up, it crosses the internal carotid artery, the internal jugular vein, and the vagus and accessory nerves. It next ascends to the interval between the transverse process of the atlas and the mastoid process of the temporal bone, and passes horizontally backward, grooving the surface of the latter bone, being covered by the Sternocleidomastoideus, Splenius capitis, Longissimus capitis, and Digastricus, and resting upon the Rectus capitis lateralis, the Obliquus superior, and Semispinalis capitis. It then changes its course and runs vertically upward, pierces the fascia connecting the cranial attachment of the Trapezius with the Sternocleidomastoideus, and ascends in a tortuous course in the superficial fascia of the scalp, where it divides into numerous branches, which reach as high as the vertex of the skull and anastomose with the posterior auricular and superficial temporal arteries. Its terminal portion is accompanied by the greater occipital nerve.

 Branches.—The branches of the occipital artery are:

Muscular.

Sternocleidomastoid.

Auricular.

Meningeal.

Descending.

  The Muscular Branches (rami musculares) supply the Digastricus, Stylohyoideus, Splenius, and Longissimus capitis.

  The Sternocleidomastoid Artery (a. sternocleidomastoidea; sternomastoid artery) generally arises from the occipital close to its commencement, but sometimes springs directly from the external carotid. It passes downward and backward over the hypoglossal nerve, and enters the substance of the muscle, in company with the accessory nerve.

  The Auricular Branch (ramus auricularis) supplies the back of the concha and frequently gives off a branch, which enters the skull through the mastoid foramen and supplies the dura mater, the diploë, and the mastoid cells; this latter branch sometimes arises from the occipital artery, and is then known as the mastoid branch.

  The Meningeal Branch (ramus meningeus; dural branch) ascends with the internal jugular vein, and enters the skull through the jugular foramen and condyloid canal, to supply the dura mater in the posterior fossa.

  The Descending Branch (ramus descendens; arteria princeps cervicis) (513), the largest branch of the occipital, descends on the back of the neck, and divides into a superficial and deep portion. The superficial portion runs beneath the Splenius, giving off branches which pierce that muscle to supply the Trapezius and anastomose with the ascending branch of the transverse cervical: the deep portion runs down between the Semispinales capitis and colli, and anastomoses with the vertebral and with the a. profunda cervicalis, a branch of the costocervical trunk. The anastomosis between these vessels assists in establishing the collateral circulation after ligature of the common carotid or subclavian artery.

  The terminal branches of the occipital artery are distributed to the back of the head: they are very tortuous, and lie between the integument and Occipitalis, anastomosing with the artery of the opposite side and with the posterior auricular and temporal arteries, and supplying the Occipitalis, the integument, and pericranium. One of the terminal branches may give off a meningeal twig which passes through the parietal foramen.

  5. The posterior auricular artery (a. auricularis posterior) (508) is small and arises from the external carotid, above the Digastricus and Stylohyoideus, opposite the apex of the styloid process. It ascends, under cover of the parotid gland, on the styloid process of the temporal bone, to the groove between the cartilage of the ear and the mastoid process, immediately above which it divides into its auricular and occipital branches.

 

Branches.—Besides several small branches to the Digastricus, Stylohyoideus, and Sternocleidomastoideus, and to the parotid gland, this vessel gives off three branches:

Stylomastoid.

Auricular.

Occipital.

 

  The Stylomastoid Artery (a. stylomastoidea) enters the stylomastoid foramen and supplies the tympanic cavity, the tympanic antrum and mastoid cells, and the semicircular canals. In the young subject a branch from this vessel forms, with the anterior tympanic artery from the internal maxillary, a vascular circle, which surrounds the tympanic membrane, and from which delicate vessels ramify on that membrane. It anastomoses with the superficial petrosal branch of the middle meningeal artery by a twig which enters the hiatus canalis facialis.

  The Auricular Branch (ramus auricularis) ascends behind the ear, beneath the Auricularis posterior, and is distributed to the back of the auricula, upon which it ramifies minutely, some branches curving around the margin of the cartilage, others perforating it, to supply the anterior surface. It anastomoses with the parietal and anterior auricular branches of the superficial temporal.

  The Occipital Branch (ramus occipitalis) passes backward, over the Sternocleidomastoideus, to the scalp above and behind the ear. It supplies the Occipitalis and the scalp in this situation and anastomoses with the occipital artery.

  6. The ascending pharyngeal artery (a. pharyngea ascendens) (513), the smallest branch of the external carotid, is a long, slender vessel, deeply seated in the neck, beneath the other branches of the external carotid and under the Stylopharyngeus. It arises from the back part of the external carotid, near the commencement of that vessel, and ascends vertically between the internal carotid and the side of the pharynx, to the under surface of the base of the skull, lying on the Longus capitis.

 Branches.—Its branches are:

Pharyngeal.

Prevertebral.

Palatine.

Inferior Tympanic.

Posterior Meningeal.

  The Pharyngeal Branches (rami pharyngei) are three or four in number. Two of these descend to supply the Constrictores pharyngis medius and inferior and the Stylopharyngeus, ramifying in their substance and in the mucous membrane lining them.

  The Palatine Branch varies in size, and may take the place of the ascending palatine branch of the facial artery, when that vessel is small. It passes inward upon the Constrictor pharyngis superior, sends ramifications to the soft palate and tonsil, and supplies a branch to the auditory tube.

  The Prevertebral Branches are numerous small vessels, which supply the Longi capitis and colli, the sympathetic trunk, the hypoglossal and vagus nerves, and the lymph glands; they anastomose with the ascending cervical artery.

  The Inferior Tympanic Artery (a. tympanica inferior) is a small branch which passes through a minute foramen in the petrous portion of the temporal bone, in company with the tympanic branch of the glossopharyngeal nerve, to supply the medial wall of the tympanic cavity and anastomose with the other tympanic arteries.

  The Meningeal Branches are several small vessels, which supply the dura mater. One, the posterior meningeal, enters the cranium through the jugular foramen; a second passes through the foramen lacerum; and occasionally a third through the canal for the hypoglossal nerve.

  7. The superficial temporal artery (a. temporalis superficialis) (508), the smaller of the two terminal branches of the external carotid, appears, from its direction, to be the continuation of that vessel. It begins in the substance of the parotid gland, behind the neck of the mandible, and corsses over the posterior root of the zygomatic process of the temporal bone; about 5 cm. above this process it divides into two branches, a frontal and a parietal.

Relations.—As it crosses the zygomatic process, it is covered by the Auricularis anterior muscle, and by a dense fascia; it is crossed by the temporal and zygomatic branches of the facial nerve and one or two veins, and is accompanied by the auriculotemporal nerve, which lies immediately behind it.

Branches.—Besides some twigs to the parotid gland, to the temporomandibular joint, and to the Masseter muscle, its branches are:

Transverse Facial.

Anterior Auricular.

Middle Temporal.

Frontal.

Parietal.

  The Transverse Facial Artery (a. transversa faciei) is givien off from the superficial temporal before that vessel quits the parotid gland; running forward through the substance of the gland, it passes transversely across the side of the face, between the parotid duct and the lower border of the zygomatic arch, and divides into numerous branches, which supply the parotid gland and duct, the Masseter, and the integument, and anastomose with the external maxillary, masseteric, buccinator, and infraorbital arteries. This vessel rests on the Masseter, and is accompanied by one or two branches of the facial nerve.

  The Middle Temporal Artery (a. temporalis media) arises immediately above the zygomatic arch, and, perforating the temporal fascia, gives branches to the Temporalis, anastomosing with the deep temporal branches of the internal maxillary. It occasionally gives off a zygomaticoörbital branch, which runs along the upper border of the zygomatic arch, between the two layers of the temporal fascia, to the lateral angle of the orbit. This branch, which may arise directly from the superficial temporal artery, supplies the Orbicularis oculi, and anastomoses with the lacrimal and palpebral branches of the ophthalmic artery.

  The Anterior Auricular Branches (rami auriculares anteriores) are distributed to the anterior portion of the auricula, the lobule, and part of the external meatus, anastomosing with the posterior auricular.

  The Frontal Branch (ramus frontalis; anterior temporal) runs tortuously upward and forward to the forehead, supplying the muscles, integument, and pericranium in this region, and anastomosing with the supraorbital and frontal arteries.

  The Parietal Branch (ramus parietalis; posterior temporal) larger than the frontal, curves upward and backward on the side of the head, lying superficial to the temporal fascia, and anastomosing with its fellow of the opposite side, and with the posterior auricular and occipital arteries.

  8. The maxillary artery (a. maxillaris) (510), the larger of the two terminal branches of the external carotid, arises behind the neck of the mandible, and is at first imbedded in the substance of the parotid gland; it passes forward between the ramus of the mandible and the sphenomandibular ligament, and then runs, either superficial or deep to the Pterygoideus externus, to the pterygopalatine fossa. It supplies the deep structures of the face, and may be divided into mandibular, pterygoid, and pterygopalatine portions.

  The first or mandibular portion passes horizontally forward, between the ramus of the mandible and the sphenomandibular ligament, where it lies parallel to and a little below the auriculotemporal nerve; it crosses the inferior alveolar nerve, and runs along the lower border of the Pterygoideus externus.

  The second or pterygoid portion runs obliquely forward and upward under cover of the ramus of the mandible and insertion of the Temporalis, on the superficial (very frequently on the deep) surface of the Pterygoideus externus; it then passes between the two heads of origin of this muscle and enters the fossa.

  The third or pterygopalatine portion lies in the pterygopalatine fossa in relation with the sphenopalatine ganglion.

  The branches of this vessel may be divided into three groups (511), corresponding with its three divisions.

 Branches of the First or Mandibular Portions.

Anterior Tympanic.

Middle Meningeal.

Deep Auricular.

Accessory Meningeal

Inferior Alveolar.

  The Anterior Tympanic Artery (a. tympanica anterior; tympanic artery) passes upward behind the temporomandibular articulation, enters the tympanic cavity through the petrotympanic fissure, and ramifies upon the tympanic membrane, forming a vascular circle around the membrane with the stylomastoid branch of the posterior auricular, and anastomosing with the artery of the pterygoid canal and with the caroticotympanic branch from the internal carotid.

Plan of branches of maxillary artery.

  The Deep Auricular Artery (a. auricularis profunda) often arises in common with the preceding. It ascends in the substance of the parotid gland, behind the temporomandibular articulation, pierces the cartilaginous or bony wall of the external acoustic meatus, and supplies its cuticular lining and the outer surface of the tympanic membrane. It gives a branch to the temporomandibular joint.

  The Middle Meningeal Artery (a. meningea media;

 medidural artery) is the largest of the arteries which supply the dura mater. It ascends between the sphenomandibular ligament and the Pterygoideus externus, and between the two roots of the auriculotemporal nerve to the foramen spinosum of the sphenoid bone, through which it enters the cranium; it then runs forward in a groove on the great wing of the sphenoid bone, and divides into two branches, anterior and posterior. The anterior branch, the larger, crosses the great wing of the sphenoid, reaches the groove, or canal, in the sphenoidal angle of the parietal bone, and then divides into branches which spread out between the dura mater and internal surface of the cranium, some passing upward as far as the vertex, and others backward to the occipital region. The posterior branch curves backward on the squama of the temporal bone, and, reaching the parietal some distance in front of its mastoid angle, divides into branches which supply the posterior part of the dura mater and cranium. The branches of the middle meningeal artery are distributed partly to the dura mater, but chiefly to the bones; they anastomose with the arteries of the opposite side, and with the anterior and posterior meningeal.

  The middle meningeal on entering the cranium gives off the following branches: (1) Numerous small vessels supply the semilunar ganglion and the dura mater in this situation. (2) A superficial petrosal branch enters the hiatus of the facial canal, supplies the facial nerve, and anastomoses with the stylomastoid branch of the posterior auricular artery. (3) A superior tympanic artery runs in the canal for the Tensor tympani, and supplies this muscle and the lining membrane of the canal. (4) Orbital branches pass through the superior orbital fissure or through separate canals in the great wing of the sphenoid, to anastomose with the lacrimal or other branches of the ophthalmic artery. (5) Temporal branches pass through foramina in the great wing of the sphenoid, and anastomose in the temporal fossa with the deep temporal arteries.

  The Accessory Meningeal Branch (ramus meningeus accessorius; small meningeal or parvidural branch) is sometimes derived from the preceding. It enters the skull through the foramen ovale, and supplies the semilunar ganglion and dura mater.

  The Inferior Alveolar Artery (a. alveolaris inferior; inferior dental artery) descends with the inferior alveolar nerve to the mandibular foramen on the medial surface of the ramus of the mandible. It runs along the mandibular canal in the substance of the bone, accompanied by the nerve, and opposite the first premolar tooth divides into two branches, incisor and mental. The incisor branch is continued forward beneath the incisor teeth as far as the middle line, where it anastomoses with the artery of the opposite side; the mental branch escapes with the nerve at the mental foramen, supplies the chin, and anastomoses with the submental and inferior labial arteries. Near its origin the inferior alveolar artery gives off a lingual branch which descends with the lingual nerve and supplies the mucous membrane of the mouth. As the inferior alveolar artery enters the foramen, it gives off a mylohyoid branch which runs in the mylohyoid groove, and ramifies on the under surface of the Mylohyoideus. The inferior alveolar artery and its incisor branch during their course through the substance of the bone give off a few twigs which are lost in the cancellous tissue, and a series of branches which correspond in number to the roots of the teeth: these enter the minute apertures at the extremities of the roots, and supply the pulp of the teeth.

 Branches of the Second or Pterygoid Portion.—

Deep Temporal.

Masseteric.

Pterygoid.

Buccinator.

  The Deep Temporal Branches, two in number, anterior and posterior, ascend between the Temporalis and the pericranium; they supply the muscle, and anastomose with the middle temporal artery; the anterior communicates with the lacrimal artery by means of small branches which perforate the zygomatic bone and great wing of the sphenoid.

  The Pterygoid Branches (rami pterygoidei), irregular in their number and origin, supply the Pterygoidei.

  The Masseteric Artery (a. masseterica) is small and passes lateralward through the mandibular notch to the deep surface of the Masseter. It supplies the muscle, and anastomoses with the masseteric branches of the external maxillary and with the transverse facial artery.

  The Buccinator Artery (a. buccinatoria; buccal artery) is small and runs obliquely forward, between the Pterygoideus internus and the insertion of the Temporalis, to the outer surface of the Buccinator, to which it is distributed, anastomosing with branches of the external maxillary and with the infraorbital.

 Branches of the Third or Pterygopalatine Portion.—

Posterior Superior Alveolar.

Artery of the Pterygoid Canal.

Infraorbital.

Pharyngeal.

Descending Palatine.

Sphenopalatine.

  The Posterior Superior Alveolar Artery (a. alveolaris superior posterior; alveolar or posterior dental artery) is given off from the internal maxillary, frequently in conjunction with the infraorbital just as the trunk of the vessel is passing into the pterygopalatine fossa. Descending upon the tuberosity of the maxilla, it divides into numerous branches, some of which enter the alveolar canals, to supply the molar and premolar teeth and the lining of the maxillary sinus, while others are continued forward on the alveolar process to supply the gums.

  The Infraorbital Artery (a. infraorbitalis) appears, from its direction, to be the continuation of the trunk of the internal maxillary, but often arises in conjunction with the posterior superior alveolar. It runs along the infraorbital groove and canal with the infraorbital nerve, and emerges on the face through the infraorbital foramen, beneath the infraorbital head of the Quadratus labii superioris. While in the canal, it gives off (a) orbital branches which assist in supplying the Rectus inferior and Obliquus inferior and the lacrimal sac, and (b) anterior superior alveolar branches which descend through the anterior alveolar canals to supply the upper incisor and canine teeth and the mucous membrane of the maxillary sinus. On the face, some branches pass upward to the medial angle of the orbit and the lacrimal sac, anastomosing with the angular branch of the external maxillary artery; others run toward the nose, anastomosing with the dorsal nasal branch of the ophthalmic; and others descend between the Quadratus labii superioris and the Caninus, and anastomose with the external maxillary, transverse facial, and buccinator arteries. The four remaining branches arise from that portion of the internal maxillary which is contained in the pterygopalatine fossa.

  The Descending Palatine Artery (a. palatina descendens) descends through the pterygopalatine canal with the anterior palatine branch of the sphenopalatine ganglion, and, emerging from the greater palatine foramen, runs forward in a groove on the medial side of the alveolar border of the hard palate to the incisive canal; the terminal branch of the artery passes upward through this canal to anastomose with the sphenopalatine artery. Branches are distributed to the gums, the palatine glands, and the mucous membrane of the roof of the mouth; while in the pterygopalatine canal it gives off twigs which descend in the lesser palatine canals to supply the soft palate and palatine tonsil, anastomosing with the ascending palatine artery.

  The Artery of the Pterygoid Canal (a. canalis pterygoidei; Vidian artery) passes backward along the pterygoid canal with the corresponding nerve. It is distributed to the upper part of the pharynx and to the auditory tube, sending into the tympanic cavity a small branch which anastomoses with the other tympanic arteries.

  The Pharyngeal Branch is very small; it runs backward through the pharyngeal canal with the pharyngeal nerve, and is distributed to the upper part of the pharynx and to the auditory tube.

  The Sphenopalatine Artery (a. sphenopalatina; nasopalatine artery) passes through the sphenopalatine foramen into the cavity of the nose, at the back part of the superior meatus. Here it gives off its posterior lateral nasal branches which spread forward over the conchæ and meatuses, anastomose with the ethmoidal arteries and the nasal branches of the descending palatine, and assist in supplying the frontal, maxillary, ethmoidal, and sphenoidal sinuses. Crossing the under surface of the sphenoid the sphenopalatine artery ends on the nasal septum as the posterior septal branches; these anastomose with the ethmoidal arteries and the septal branch of the superior labial; one branch descends in a groove on the vomer to the incisive canal and anastomoses with the descending palatine artery.

 

Internal carotid artery. Blood vessels of orbit

Internal carotid artery disposes at first laterally and behind then medially from external carotid artery, passes vertically upward [cervical portion] and get into external foramen of carotid canal (temporal pyramid). Passing in carotid canal [petrosal portion], it gives off the caroticotympanic arteries for tympanic cavity. After passing out from the internal foramen of canal internal carotid artery lies into carotid sulcus of sphenoid bone, passes through the cavernous sinus [cavernous portion of artery], on level of optic canal gives off an ophthalmic artery and divides into branches: anterior cerebral artery and middle cerebral artery, posterior communicating artery.

VIDEO

It supplies the anterior part of the brain, the eye and its appendages, and sends branches to the forehead and nose. Its size, in the adult, is equal to that of the external carotid, though, in the child, it is larger than that vessel. It is remarkable for the number of curvatures that it presents in different parts of its course. It occasionally has one or two flexures near the base of the skull, while in its passage through the carotid canal and along the side of the body of the sphenoid bone it describes a double curvature and resembles the italic letter S.

 

Superficial dissection of the right side of the neck, showing the carotid and subclavian arteries.

 

Course and Relations.—In considering the course and relations of this vessel it may be divided into four portions: cervical, petrous, cavernous, and cerebral.

Cervical Portion.—This portion of the internal carotid begins at the bifurcation of the common carotid, opposite the upper border of the thyroid cartilage, and runs perpendicularly upward, in front of the transverse processes of the upper three cervical vertebræ, to the carotid canal in the petrous portion of the temporal bone. It is comparatively superficial at its commencement, where it is contained in the carotid triangle, and lies behind and lateral to the external carotid, overlapped by the Sternocleidomastoideus, and covered by the deep fascia, Platysma, and integument: it then passes beneath the parotid gland, being crossed by the hypoglossal nerve, the Digastricus and Stylohyoideus, and the occipital and posterior auricular arteries. Higher up, it is separated from the external carotid by the Styloglossus and Stylopharyngeus, the tip of the styloid process and the stylohyoid ligament, the glossopharyngeal nerve and the pharyngeal branch of the vagus. It is in relation, behind, with the Longus capitis, the superior cervical ganglion of the sympathetic trunk, and the superior laryngeal nerve; laterally, with the internal jugular vein and vagus nerve, the nerve lying on a plane posterior to the artery; medially, with the pharynx, superior laryngeal nerve, and ascending pharyngeal artery. At the base of the skull the glossopharyngeal, vagus, accessory, and hypoglossal nerves lie between the artery and the internal jugular vein.

 

Petrous Portion.—When the internal carotid artery enters the canal in the petrous portion of the temporal bone, it first ascends a short distance, then curves forward and medialward, and again ascends as it leaves the canal to enter the cavity of the skull between the lingula and petrosal process of the sphenoid. The artery lies at first in front of the cochlea and tympanic cavity; from the latter cavity it is separated by a thin, bony lamella, which is cribriform in the young subject, and often partly absorbed in old age. Farther forward it is separated from the semilunar ganglion by a thin plate of bone, which forms the floor of the fossa for the ganglion and the roof of the horizontal portion of the canal. Frequently this bony plate is more or less deficient, and then the ganglion is separated from the artery by fibrous membrane. The artery is separated from the bony wall of the carotid canal by a prolongation of dura mater, and is surrounded by a number of small veins and by filaments of the carotid plexus, derived from the ascending branch of the superior cervical ganglion of the sympathetic trunk.

 

Cavernous Portion.—In this part of its course, the artery is situated between the layers of the dura mater forming the cavernous sinus, but covered by the lining membrane of the sinus. It at first ascends toward the posterior clinoid process, then passes forward by the side of the body of the sphenoid bone, and again curves upward on the medial side of the anterior clinoid process, and perforates the dura mater forming the roof of the sinus. This portion of the artery is surrounded by filaments of the sympathetic nerve, and on its lateral side is the abducent nerve.

 

Cerebral Portion.—Having perforated the dura mater on the medial side of the anterior clinoid process, the internal carotid passes between the optic and oculomotor nerves to the anterior perforated substance at the medial extremity of the lateral cerebral fissure, where it gives off its terminal or cerebral branches.

 

Peculiarities.—The length of the internal carotid varies according to the length of the neck, and also according to the point of bifurcation of the common carotid. It arises sometimes from the arch of the aorta; in such rare instances, this vessel has been found to be placed nearer the middle line of the neck than the external carotid, as far upward as the larynx, when the latter vessel crossed the internal carotid. The course of the artery, instead of being straight, may be very tortuous. A few instances are recorded in which this vessel was altogether absent; in one of these the common carotid passed up the neck, and gave off the usual branches of the external carotid; the cranial portion of the internal carotid was replaced by two branches of the internal maxillary, which entered the skull through the foramen rotundum and foramen ovale, and joined to form a single vessel.

 

Branches.—The cervical portion of the internal carotid gives off no branches. Those from the other portions are:

From the Petrous Portion

Caroticotympanic.

Artery of the Pterygoid Canal.

From the Cavernous Portion

Cavernous.

Hypophyseal.

Semilunar.

Anterior Meningeal.

Ophthalmic.

From the Cerebral Portion

Anterior Cerebral.

Middle Cerebral.

Posterior Communicating.

Choroidal.

  1. The caroticotympanic branch (ramus caroticotympanicus; tympanic branch) is small; it enters the tympanic cavity through a minute foramen in the carotid canal, and anastomoses with the anterior tympanic branch of the internal maxillary, and with the stylomastoid artery.

  2. The artery of the pterygoid canal (a. canilis pterygoidei [Vidii]; Vidian artery) is a small, inconstant branch which passes into the pterygoid canal and anastomoses with a branch of the internal maxillary artery.

  3. The cavernous branches are numerous small vessels which supply the hypophysis, the semilunar ganglion, and the walls of the cavernous and inferior petrosal sinuses. Some of them anastomose with branches of the middle meningeal.

  4. The hypophyseal branches are one or two minute vessels supplying the hypophysis.

  5. The semilunar branches are small vessels to the semilunar ganglion.

  6. The anterior meningeal branch (a. meningea anterior) is a small branch which passes over the small wing of the sphenoid to supply the dura mater of the anterior cranial fossa; it anastomoses with the meningeal branch from the posterior ethmoidal artery.

  7. The ophthalmic artery (a. ophthalmica)

The ophthalmic artery and its branches.

 

  The Supraorbital Artery (a. supraorbitalis) springs from the ophthalmic as that vessel is crossing over the optic nerve. It passes upward on the medial borders of the Rectus superior and Levator palpebræ, and meeting the supraorbital nerve accompanies it between the periosteum and Levator palpebræ to the supraorbital foramen; passing through this it divides into a superficial and a deep branch, which supply the integument, the muscles, and the pericranium of the forehead, anastomosing with the frontal, the frontal branch of the superficial temporal, and the artery of the opposite side. This artery in the orbit supplies the Rectus superior and the Levator palpebræ, and sends a branch across the pulley of the Obliquus superior, to supply the parts at the medial palpebral commissure. At the supraorbital foramen it frequently transmits a branch to the diploë.

  The Ethmoidal Arteries are two in number: posterior and anterior. The posterior ethmoidal artery, the smaller, passes through the posterior ethmoidal canal, supplies the posterior ethmoidal cells, and, entering the cranium, gives off a meningeal branch to the dura mater, and nasal branches which descend into the nasal cavity through apertures in the cribriform plate, anastomosing with branches of the sphenopalatine. The anterior ethmoidal artery accompanies the nasociliary nerve through the anterior ethmoidal canal, supplies the anterior and middle ethmoidal cells and frontal sinus, and, entering the cranium, gives off a meningeal branch to the dura mater, and nasal branches; these latter descend into the nasal cavity through the slit by the side of the crista galli, and, running along the groove on the inner surface of the nasal bone, supply branches to the lateral wall and septum of the nose, and a terminal branch which appears on the dorsum of the nose between the nasal bone and the lateral cartilage.

  The Medial Palpebral Arteries (aa. palpebrales mediales; internal palpebral arteries), two in number, superior and inferior, arise from the ophthalmic, opposite the pulley of the Obliquus superior; they leave the orbit to encircle the eyelids near their free margins, forming a superior and an inferior arch, which lie between the Orbicularis oculi and the tarsi. The superior palpebral anastomoses, at the lateral angle of the orbit, with the zygomaticoörbital branch of the temporal artery and with the upper of the two lateral palpebral branches from the lacrimal artery; the inferior palpebral anastomoses, at the lateral angle of the orbit, with the lower of the two lateral palpebral branches from the lacrimal and with the transverse facial artery, and, at the medial part of the lid, with a branch from the angular artery. From this last anastomoses a branch passes to the nasolacrimal duct, ramifying in its mucous membrane, as far as the inferior meatus of the nasal cavity.

  The Frontal Artery (a. frontalis), one of the terminal branches of the ophthalmic, leaves the orbit at its medial angle with the supratrochlear nerve, and, ascending on the forehead, supplies the integument, muscles, and pericranium, anastomosing with the supraorbital artery, and with the artery of the opposite side.

  The Dorsal Nasal Artery (a. dorsalis nasi; nasal artery), the other terminal branch of the ophthalmic, emerges from the orbit above the medial palpebral ligament, and, after giving a twig to the upper part of the lacrimal sac, divides into two branches, one of which crosses the root of the nose, and anastomoses with the angular artery, the other runs along the dorsum of the nose, supplies its outer surface; and anastomoses with the artery of the opposite side, and with the lateral nasal branch of the external maxillary.

  The Central Artery of the Retina (a. centralis retinœ) is the first and one of the smallest branches of the ophthalmic artery. It runs for a short distance within the dural sheath of the optic nerve, but about 1.25 cm. behind the eyeball it pierces the nerve obliquely, and runs forward in the center of its substance to the retina. Its mode of distribution will be described with the anatomy of the eye.

  The Ciliary Arteries (aa. ciliares) are divisible into three groups, the long and short, posterior, and the anterior. The short posterior ciliary arteries from six to twelve in number, arise from the ophthalmic, or its branches; they pass forward around the optic nerve to the posterior part of the eyeball, pierce the sclera around the entrance of the nerve, and supply the choroid and ciliary processes. The long posterior ciliary arteries, two in number, pierce the posterior part of the sclera at some little distance from the optic nerve, and run forward, along either side of the eyeball, between the sclera and choroid, to the ciliary muscle, where they divide into two branches; these form an arterial circle, the circulus arteriosus major, around the circumference of the iris, from which numerous converging branches run, in the substance of the iris, to its pupillary margin, where they form a second arterial circle, the circulus arteriosus minor. The anterior ciliary arteries are derived from the muscular branches; they run to the front of the eyeball in company with the tendons of the Recti, form a vascular zone beneath the conjunctiva, and then pierce the sclera a short distance from the cornea and end in the circulus arteriosus major.

  The Muscular Branches, (rami musculares), two in number, superior and inferior, frequently spring from a common trunk. The superior, often wanting, supplies the Levator palpebræ superioris, Rectus superior, and Obliquus superior. The inferior, more constantly present, passes forward between the optic nerve and Rectus inferior, and is distributed to the Recti lateralis, medialis, and inferior, and the Obliquus inferior. This vessel gives off most of the anterior ciliary arteries. Additional muscular branches are given off from the lacrimal and supraorbital arteries, or from the trunk of the ophthalmic.

  8. The anterior cerebral artery (a. cerebri anterior) (517,

The arteries of the base of the brain. The tempora pole of the cerebrum and a portion of the cerebellar hemisphere have been removed on the right side.

  The Anterior Communicating Artery (a. communicans anterior) connects the two anterior cerebral arteries across the commencement of the longitudinal fissure. Sometimes this vessel is wanting, the two arteries joining together to form a single trunk, which afterward divides; or it may be wholly, or partially, divided into two. Its length averages about 4 mm., but varies greatly. It gives off some of the antero-medial ganglionic vessels, but these are principally derived from the anterior cerebral.

  9. The middle cerebral artery (a. cerebri media) (517), the largest branch of the internal carotid, runs at first lateralward in the lateral cerebral or Sylvian fissure and then backward and upward on the surface of the insula, where it divides into a number of branches which are distributed to the lateral surface of the cerebral hemisphere.

 

Branches.—The branches of this vessel are the:

Antero-lateral Ganglionic.

Ascending Parietal.

Inferior Lateral Frontal.

Parietotemporal.

Ascending Frontal.

Temporal.

 

Medial surface of cerebral hemisphere, showing areas supplied by cerebral arteries.

 

  The Antero-lateral Ganglionic Branches, a group of small arteries which arise at the commencement of the middle cerebral artery, are arranged in two sets: one, the internal striate, passes upward through the inner segments of the lentiform nucleus, and supplies it, the caudate nucleus, and the internal capsule; the other, the external striate, ascends through the outer segment of the lentiform nucleus, and supplies the caudate nucleus and the thalamus. One artery of this group is of larger size than the rest, and is of special importance, as being the artery in the brain most frequently ruptured; it has been termed by Charcot the artery of cerebral hemorrhage. It ascends between the lentiform nucleus and the external capsule, and ends in the caudate nucleus. The inferior lateral frontal supplies the inferior frontal gyrus (Broca’s convolution) and the lateral part of the orbital surface of the frontal lobe. The ascending frontal supplies the anterior central gyrus. The ascending parietal is distributed to the posterior central gyrus and the lower part of the superior parietal lobule. The parietotemporal supplies the supramarginal and angular gyri, and the posterior parts of the superior and middle temporal gyri. The temporal branches, two or three in number, are distributed to the lateral surface of the temporal lobe.

  10. The posterior communicating artery (a. communicans posterior) 516,

Diagram of the arterial circulation at the base of the brain. A.L. Antero-lateral. A.M. Antero-medial. P.L. Postero-lateral. P.M. Posteromedial ganglionic branches.

 

  The three trunks which together supply each cerebral hemisphere arise from the arterial circle of Willis. From its anterior part proceed the two anterior cerebrals, from its antero-lateral parts the middle cerebrals, and from its posterior part the posterior cerebrals. Each of these principal arteries gives origin to two different systems of secondary vessels. One of these is named the ganglionic system, and the vessels belonging to it supply the thalami and corpora striata; the other is the cortical system, and its vessels ramify in the pia mater and supply the cortex and subjacent brain substance. These two systems do not communicate at any point of their peripheral distribution, but are entirely independent of each other, and there is between the parts supplied by the two systems a borderland of diminished nutritive activity, where, it is said, softening is especially liable to occur in the brains of old people.

 

The Ganglionic System.—All the vessels of this system are given off from the arterial circle of Willis, or from the vessels close to it. They form six principal groups: (I) the antero-medial group, derived from the anterior cerebrals and anterior communicating; (II) the postero-medial group, from the posterior cerebrals and posterior communicating; (III and IV) the right and left antero-lateral groups, from the middle cerebrals; and (V and VI) the right and left postero-lateral groups, from the posterior cerebrals, after they have wound around the cerebral peduncles. The vessels of this system are larger than those of the cortical system, and are what Cohnheim designated terminal arteries—that is to say, vessels which from their origin to their termination neither supply nor receive any anastomotic branch, so that, through any one of the vessels only a limited area of the thalamus or corpus striatum can be injected, and the injection cannot be driven beyond the area of the part supplied by the particular vessel which is the subject of the experiment.

 

The Cortical Arterial System.—The vessels forming this system are the terminal branches of the anterior, middle, and posterior cerebral arteries. They divide and ramify in the substance of the pia mater, and give off branches which penetrate the brain cortex, perpendicularly. These branches are divisible into two classes, long and short. The long, or medullary arteries, pass through the gray substance and penetrate the subjacent white substance to the depth of 3 or 4 cm., without intercommunicating otherwise than by very fine capillaries, and thus constitute so many independent small systems. The short vessels are confined to the cortex, where they form with the long vessels a compact net-work in the middle zone of the gray substance, the outer and inner zones being sparingly supplied with blood. The vessels of the cortical arterial system are not so strictly “terminal” as those of the ganglionic system, but they approach this type very closely, so that injection of one area from the vessel of another area, though possible, is frequently very difficult, and is only effected through vessels of small caliber. As a result of this, obstruction of one of the main branches, or its divisions, may have the effect of producing softening in a limited area of the cortex.

Internal thoracic artery begins from inferior surface of subclavian artery and passes along І-VII cartilages of ribs near sternum, where disintegrates on two terminal branches are musculо-phrenic artery and superior epigastric artery. Internal thoracic artery gives off rami for thymus, bronchі, pericardium and sternum. Also from this artery moves away rami mammarii, tracheal rami, anterior intercostal branches, which supply intercostal muscles. Superior epigastric artery gets into sheath of rectus abdominal muscle, supplies this muscle and anastomoses with inferior epigastric artery on navel level.

Thyro-cervical trunk is has length 1-2 cm and subdivides into four branches: inferior thyroid artery, (supplies thyroid gland, cervical esophagus department, cervical trachea portion and inferior laryngeal artery reaches mucous membrane of the to larynx), ascending cervical artery (to neck muscles), superficial cervical artery (to trapezius, rhomboid and other neck muscles) and suprascapular artery (for supraspinatus and infraspinatus muscles).

In interscalenus space subclavian artery gives off costo-cervical trunk, which ramifies into deep cervical artery, which supplies semispinalis capitis and cervicis muscles and suprema intercostal artery, which ramifies into I and ІІ intercostal spaces, supplying intercostal muscles.

After interscalenus space space subclavian artery gives off

transverse colli artery, which continues into dorsal scapulae artery. They supply rhomboid, levator scapulae and shoulder girdle muscles.

The artery which supplies the upper extremity continues as a single trunk from its commencement down to the elbow; but different portions of it have received different names, according to the regions through which they pass. That part of the vessel which extends from its origin to the outer border of the first rib is termed the subclavian; beyond this point to the lower border of the axilla it is named the axillary; and from the lower margin of the axillary space to the bend of the elbow it is termed brachial; here the trunk ends by dividing into two branches the radial and ulnar.

The internal mammary artery and its branches.

 

 

         The Subclavian Artery (a. Subclavia).

—On the right side the subclavian artery arises from the innominate artery behind the right sternoclavicular articulation; on the left side it springs from the arch of the aorta. The two vessels, therefore, in the first part of their course, differ in length, direction, and relation with neighboring structures.

  In order to facilitate the description, each subclavian artery is divided into three parts. The first portion extends from the origin of the vessel to the medial border of the Scalenus anterior; the second lies behind this muscle; and the third extends from the lateral margin of the muscle to the outer border of the first rib, where it becomes the axillary artery. The first portions of the two vessels require separate descriptions; the second and third parts of the two arteries are practically alike.

 

 

 

      First Part of the Right Subclavian Artery.—The first part of the right subclavian artery arises from the innominate artery, behind the upper part of the right sternoclavicular articulation, and passes upward and lateralward to the medial margin of the Scalenus anterior. It ascends a little above the clavicle, the extent to which it does so varying in different cases.

 

      Relations.—It is covered, in front, by the integument, superficial fascia, Platysma, deep fascia, the clavicular origin of the Sternocleidomastoideus, the Sternohyoideus, and Sternothyreoideus, and another layer of the deep fascia. It is crossed by the internal jugular and vertebral veins, by the vagus nerve and the cardiac branches of the vagus and sympathetic, and by the subclavian loop of the sympathetic trunk which forms a ring around the vessel. The anterior jugular vein is directed lateralward in front of the artery, but is separated from it by the Sternohyoideus and Sternothyreoideus. Below and behind the artery is the pleura, which separates it from the apex of the lung; behind is the sympathetic trunk, the Longus collie and the first thoracic vertebra. The right recurrent nerve winds around the lower and back part of the vessel.

 

First Part of the Left Subclavian Artery .—The first part of the left subclavian artery arises from the arch of the aorta, behind the left common carotid, and at the level of the fourth thoracic vertebra; it ascends in the superior mediastinal cavity to the root of the neck and then arches lateralward to the medial border of the Scalenus anterior.

 

Relations.—It is in relation, in front, with the vagus, cardiac, and phrenic nerves, which lie parallel with it, the left common carotid artery, left internal jugular and vertebral veins, and the commencement of the left innominate vein, and is covered by the Sternothyreoideus, Sternohyoideus, and Sternocleidomastoideus; behind, it is in relation with the esophagus, thoracic duct, left recurrent nerve, inferior cervical ganglion of the sympathetic trunk, and Longus colli; higher up, however, the esophagus and thoracic duct lie to its right side; the latter ultimately arching over the vessel to join the angle of union between the subclavian and internal jugular veins. Medial to it are the esophagus, trachea, thoracic duct, and left recurrent nerve; lateral to it, the left pleura and lung.

 

       Second and Third Parts of the Subclavian Artery .—The second portion of the subclavian artery lies behind the Scalenus anterior; it is very short, and forms the highest part of the arch described by the vessel.

 

      Relations.—It is covered, in front, by the skin, superficial fascia, Platysma, deep cervical fascia, Sternocleidomastoideus, and Scalenus anterior. On the right side of the neck the phrenic nerve is separated from the second part of the artery by the Scalenus anterior, while on the left side it crosses the first part of the artery close to the medial edge of the muscle. Behind the vessel are the pleura and the Scalenus medius; above, the brachial plexus of nerves; below, the pleura. The subclavian vein lies below and in front of the artery, separated from it by the Scalenus anterior.

  The third portion of the subclavian artery runs downward and lateralward from the lateral margin of the Scalenus anterior to the outer border of the first rib, where it becomes the axillary artery. This is the most superficial portion of the vessel, and is contained in the subclavian triangle.

 

      Relations.—It is covered, in front, by the skin, the superficial fascia, the Platysma, the supraclavicular nerves, and the deep cervical fascia. The external jugular vein crosses its medial part and receives the transverse scapular, transverse cervical, and anterior jugular veins, which frequently form a plexus in front of the artery. Behind the veins, the nerve to the Subclavius descends in front of the artery. The terminal part of the artery lies behind the clavicle and the Subclavius and is crossed by the transverse scapular vessels. The subclavian vein is in front of and at a slightly lower level than the artery. Behind, it lies on the lowest trunk of the brachial plexus, which intervenes between it and the Scalenus medius. Above and to its lateral side are the upper trunks of the brachial plexus and the Omohyoideus. Below, it rests on the upper surface of the first rib.

 

       Peculiarities.—The subclavian arteries vary in their origin, their course, and the height to which they rise in the neck.

  The origin of the right subclavian from the innominate takes place, in some cases, above the sternoclavicular articulation, and occasionally, but less frequently, below that joint. The artery may arise as a separate trunk from the arch of the aorta, and in such cases it may be either the first, second, third, or even the last branch derived from that vessel; in the majority, however, it is the first or last, rarely the second or third. When it is the first branch, it occupies the ordinary position of the innominate artery; when the second or third, it gains its usual position by passing behind the right carotid; and when the last branch, it arises from the left extremity of the arch, and passes obliquely toward the right side, usually behind the trachea, esophagus, and right carotid, sometimes between the esophagus and trachea, to the upper border of the first rib, whence it follows its ordinary course. In very rare instances, this vessel arises from the thoracic aorta, as low down as the fourth thoracic vertebra. Occasionally, it perforates the Scalenus anterior; more rarely it passes in front of that muscle. Sometimes the subclavian vein passes with the artery behind the Scalenus anterior. The artery may ascend as high as 4 cm. above the clavicle, or any intermediate point between this and the upper border of the bone, the right subclavian usually ascending higher than the left.

  The left subclavian is occasionally joined at its origin with the left carotid.

  The left subclavian artery is more deeply placed than the right in the first part of its course, and, as a rule, does not reach quite as high a level in the neck. The posterior border of the Sternocleidomastoideus corresponds pretty closely to the lateral border of the Scalenus anterior, so that the third portion of the artery, the part most accessible for operation, lies immediately lateral to the posterior border of the Sternocleidomastoideus.

 

Collateral Circulation.—After ligature of the third part of the subclavian artery, the collateral circulation is established mainly by three sets of vessels, thus described in a dissection:

  1. A posterior set, consisting of the transverse scapular and the descending ramus of the transverse cervical branches of the subclavian, anastomosing with the subscapular from the axillary.

  2. A medial set, produced by the connection of the internal mammary on the one hand, with the highest intercostal and lateral thoracic arteries, and the branches from the subscapular on the other.

  3. A middle or axillary set, consisting of a number of small vessels derived from branches of the subclavian, above, and, passing through the axilla, terminating either in the main trunk, or some of the branches of the axillary below. This last set presented most conspicuously the peculiar character of newly formed or, rather, dilated arteries, being excessively tortuous, and forming a complete plexus.

  The chief agent in the restoration of the axillary artery below the tumor was the subscapular artery, which communicated most freely with the internal mammary, transverse scapular and descending ramus of the transverse cervical branches of the subclavian, from all of which it received so great an influx of blood as to dilate it to three times its natural size. 101

  When a ligature is applied to the first part of the subclavian artery, the collateral circulation is carried on by: (1) the anastomosis between the superior and inferior thyroids; (2) the anastomosis of the two vertebrals; (3) the anastomosis of the internal mammary with the inferior epigastric and the aortic intercostals; (4) the costocervical anastomosing with the aortic intercostals; (5) the profunda cervicis anastomosing with the descending branch of the occipital; (6) the scapular branches of the thyrocervical trunk anastomosing with the branches of the axillary, and (7) the thoracic branches of the axillary anastomosing with the aortic intercostals.

 

Branches.—The branches of the subclavian artery are:

Vertebral.

Internal mammary.

Thyrocervical.

Costocervical.

 

  On the left side all four branches generally arise from the first portion of the vessel; but on the right side the costocervical trunk usually springs from the second portion of the vessel. On both sides of the neck, the first three branches arise close together at the medial border of the Scalenus anterior; in the majority of cases, a free interval of from 1.25 to 2.5 cm. exists between the commencement of the artery and the origin of the nearest branch.

  1. The vertebral artery (a. vertebralis) , is the first branch of the subclavian, and arises from the upper and back part of the first portion of the vessel. It is surrounded by a plexus of nerve fibers derived from the inferior cervical ganglion of the sympathetic trunk, and ascends through the foramina in the transverse processes of the upper six cervical vertebrae it then winds behind the superior articular process of the atlas and, entering the skull through the foramen magnum, unites, at the lower border of the pons, with the vessel of the opposite side to form the basilar artery.

 

     Relations.—The vertebral artery may be divided into four parts: The first part runs upward and backward between the Longus colli and the Scalenus anterior. In front of it are the internal jugular and vertebral veins, and it is crossed by the inferior thyroid artery; the left vertebral is crossed by the thoracic duct also. Behind it are the transverse process of the seventh cervical vertebra, the sympathetic trunk and its inferior cervical ganglion. The second part runs upward through the foramina in the transverse processes of the upper six cervical vertebræ, and is surrounded by branches from the inferior cervical sympathetic ganglion and by a plexus of veins which unite to form the vertebral vein at the lower part of the neck. It is situated in front of the trunks of the cervical nerves, and pursues an almost vertical course as far as the transverse process of the atlas, above which it runs upward and lateralward to the foramen in the transverse process of the atlas. The third part issues from the latter foramen on the medial side of the Rectus capitis lateralis, and curves backward behind the superior articular process of the atlas, the anterior ramus of the first cervical nerve being on its medial side; it then lies in the groove on the upper surface of the posterior arch of the atlas, and enters the vertebral canal by passing beneath the posterior atlantoöccipital membrane. This part of the artery is covered by the Semispinalis capitis and is contained in the suboccipital triangle—a triangular space bounded by the Rectus capitis posterior major, the Obliquus superior, and the Obliquus inferior. The first cervical or suboccipital nerve lies between the artery and the posterior arch of the atlas. The fourth part pierces the dura mater and inclines medialward to the front of the medulla oblongata; it is placed between the hypoglossal nerve and the anterior root of the first cervical nerve and beneath the first digitation of the ligamentum denticulatum. At the lower border of the pons it unites with the vessel of the opposite side to form the basilar artery.

 

Branches.—The branches of the vertebral artery may be divided into two sets: those given off in the neck, and those within the cranium.

Cervical Branches.

Cranial Branches.

Spinal.

Meningeal.

Muscular.

Posterior Spinal.

Anterior Spinal.

Posterior Inferior Cerebellar.

Medullary.

 

  Spinal Branches (rami spinales) enter the vertebral canal through the intervertebral foramina, and each divides into two branches. Of these, one passes along the roots of the nerves to supply the medulla spinalis and its membranes, anastomosing with the other arteries of the medulla spinalis; the other divides into an ascending and a descending branch, which unite with similar branches from the arteries above and below, so that two lateral anastomotic chains are formed on the posterior surfaces of the bodies of the vertebræ, near the attachment of the pedicles. From these anastomotic chains branches are supplied to the periosteum and the bodies of the vertebræ, and others form communications with similar branches from the opposite side; from these communications small twigs arise which join similar branches above and below, to form a central anastomotic chain on the posterior surface of the bodies of the vertebræ.

  Muscular Branches are given off to the deep muscles of the neck, where the vertebral artery curves around the articular process of the atlas. They anastomose with the occipital, and with the ascending and deep cervical arteries.

  The Meningeal Branch (ramus meningeus; posterior meningeal branch) springs from the vertebral opposite the foramen magnum, ramifies between the bone and dura mater in the cerebellar fossa, and supplies the falx cerebelli. It is frequently represented by one or two small branches.

  The Posterior Spinal Artery (a. spinalis posterior; dorsal spinal artery) arises from the vertebral, at the side of the medulla oblongata; passing backward, it descends on this structure, lying in front of the posterior roots of the spinal nerves, and is reinforced by a succession of small branches, which enter the vertebral canal through the intervertebral foramina; by means of these it is continued to the lower part of the medulla spinalis, and to the cauda equina. Branches from the posterior spinal arteries form a free anastomosis around the posterior roots of the spinal nerves, and communicate, by means of very tortuous transverse branches, with the vessels of the opposite side. Close to its origin each gives off an ascending branch, which ends at the side of the fourth ventricle.

  The Anterior Spinal Artery (a. spinalis anterior; ventral spinal artery) is a small branch, which arises near the termination of the vertebral, and, descending in front of the medulla oblongata, unites with its fellow of the opposite side at the level of the foramen magnum. One of these vessels is usually larger than the other, but occasionally they are about equal in size. The single trunk, thus formed, descends on the front of the medulla spinalis, and is reinforced by a succession of small branches which enter the vertebral canal through the intervertebral foramina; these branches are derived from the vertebral and the ascending cervical of the inferior thyroid in the neck; from the intercostals in the thorax; and from the lumbar, iliolumbar, and lateral sacral arteries in the abdomen and pelvis. They unite, by means of ascending and descending branches, to form a single anterior median artery, which extend as far as the lower part of the medulla spinalis, and is continued as a slender twig on the filum terminale. This vessel is placed in the pia mater along the anterior median fissure; it supplies that membrane, and the substance of the medulla spinalis, and sends off branches at its lower part to be distributed to the cauda equina.

  The Posterior Inferior Cerebellar Artery (a. cerebelli inferior posterior) , the largest branch of the vertebral, winds backward around the upper part of the medulla oblongata, passing between the origins of the vagus and accessory nerves, over the inferior peduncle to the under surface of the cerebellum, where it divides into two branches. The medial branch is continued backward to the notch between the two hemispheres of the cerebellum; while the lateral supplies the under surface of the cerebellum, as far as its lateral border, where it anastomoses with the anterior inferior cerebellar and the superior cerebellar branches of the basilar artery. Branches from this artery supply the choroid plexus of the fourth ventricle.

  The Medullary Arteries (bulbar arteries) are several minute vessels which spring from the vertebral and its branches and are distributed to the medulla oblongata.

  The Basilar Artery (a. basilaris) , so named from its position at the base of the skull, is a single trunk formed by the junction of the two vertebral arteries: it extends from the lower to the upper border of the pons, lying in its median groove, under cover of the arachnoid. It ends by dividing into the two posterior cerebral arteries.

  Its branches, on either side, are the following:

Pontine.

Anterior Inferior Cerebellar.

Internal Auditory.

Superior Cerebellar.

Posterior Cerebral.

 

  The pontine branches (rami ad pontem; transverse branches) are a number of small vessels which come off at right angles from either side of the basilar artery and supply the pons and adjacent parts of the brain.

  The internal auditory artery (a. auditiva interna; auditory artery), a long slender branch, arises from near the middle of the artery; it accompanies the acoustic nerve through the internal acoustic meatus, and is distributed to the internal ear.

  The anterior inferior cerebellar artery (a. cerebelli inferior anterior) passes backward to be distributed to the anterior part of the under surface of the cerebellum, anastomosing with the posterior inferior cerebellar branch of the vertebral.

  The superior cerebellar artery (a. cerebelli superior) arises near the termination of the basilar. It passes lateralward, immediately below the oculomotor nerve, which separates it from the posterior cerebral artery, winds around the cerebral peduncle, close to the trochlear nerve, and, arriving at the upper surface of the cerebellum, divides into branches which ramify in the pia mater and anastomose with those of the inferior cerebellar arteries. Several branches are given to the pineal body, the anterior medullary velum, and the tela chorioidea of the third ventricle.

  The posterior cerebral artery (a. cerebri posterior) is larger than the preceding, from which it is separated near its origin by the oculomotor nerve. Passing lateralward, parallel to the superior cerebellar artery, and receiving the posterior communicating from the internal carotid, it winds around the cerebral peduncle, and reaches the tentorial surface of the occipital lobe of the cerebrum, where it breaks up into branches for the supply of the temporal and occipital lobes.

  The branches of the posterior cerebral artery are divided into two sets, ganglionic and cortical:

Ganglionic  

Posterior-medial.

     Cortical  

Anterior Temporal.

Posterior Choroidal.

Posterior Temporal.

Postero-lateral.

Calcarine.

Parietoöccipital.

 

Ganglionic.—The postero-medial ganglionic branches  are a group of small arteries which arise at the commencement of the posterior cerebral artery: these, with similar branches from the posterior communicating, pierce the posterior perforated substance, and supply the medial surfaces of the thalami and the walls of the third ventricle. The posterior choroidal branches run forward beneath the splenium of the corpus callosum, and supply the tela chorioidea of the third ventricle and the choroid plexus. The postero-lateral ganglionic branches are small arteries which arise from the posterior cerebral artery after it has turned around the cerebral peduncle; they supply a considerable portion of the thalamus.

 

Cortical.—The cortical branches are: the anterior temporal, distributed to the uncus and the anterior part of the fusiform gyrus; the posterior temporal, to the fusiform and the inferior temporal gyri; the calcarine, to the cuneus and gyrus lingualis and the back part of the convex surface of the occipital lobe; and the parietoöccipital, to the cuneus and the precuneus.

  2. The thyrocervical trunk (truncus thyreocervicalis; thyroid axis)  is a short thick trunk, which arises from the front of the first portion of the subclavian artery, close to the medial border of the Scalenus anterior, and divides almost immediately into three branches, the inferior thyroid, transverse scapular, and transverse cervical.

  The Inferior Thyroid Artery (a. thyreoidea inferior) passes upward, in front of the vertebral artery and Longus colli; then turns medialward behind the carotid sheath and its contents, and also behind the sympathetic trunk, the middle cervical ganglion resting upon the vessel. Reaching the lower border of the thyroid gland it divides into two branches, which supply the postero-inferior parts of the gland, and anastomose with the superior thyroid, and with the corresponding artery of the opposite side. The recurrent nerve passes upward generally behind, but occasionally in front, of the artery.

  The branches of the inferior thyroid are:

Inferior Laryngeal.

Esophageal.

Tracheal.

Ascending Cervical.

Muscular.

 

  The inferior laryngeal artery (a. laryngea inferior) ascends upon the trachea to the back part of the larynx under cover of the Constrictor pharyngis inferior, in company with the recurrent nerve, and supplies the muscles and mucous membrane of this part, anastomosing with the branch from the opposite side, and with the superior laryngeal branch of the superior thyroid artery.

  The tracheal branches (rami tracheales) are distributed upon the trachea, and anastomose below with the bronchial arteries.

  The esophageal branches (rami æsophagei) supply the esophagus, and anastomose with the esophageal branches of the aorta.

  The ascending cervical artery (a. cervicalis ascendens) is a small branch which arises from the inferior thyroid as that vessel is passing behind the carotid sheath; it runs up on the anterior tubercles of the transverse processes of the cervical vertebræ in the interval between the Scalenus anterior and Longus capitis. To the muscles of the neck it gives twigs which anastomose with branches of the vertebral, and it sends one or two spinal branches into the vertebral canal through the intervertebral foramina to be distributed to the medulla spinalis and its membranes, and to the bodies of the vertebræ, in the same manner as the spinal branches from the vertebral. It anastomoses with the ascending pharyngeal and occipital arteries.

  The muscular branches supply the depressors of the hyoid bone, and the Longus colli, Scalenus anterior, and Constrictor pharyngis inferior.

  The Transverse Scapular Artery (a. transversa scapulæ suprascapular artery) passes at first downward and lateralward across the Scalenus anterior and phrenic nerve, being covered by the Sternocleidomastoideus; it then crosses the subclavian artery and the brachial plexus, and runs behind and parallel with the clavicle and Subclavius, and beneath the inferior belly of the Omohyoideus, to the superior border of the scapula; it passes over the superior transverse ligament of the scapula which separates it from the suprascapular nerve, and enters the supraspinatous fossa . In this situation it lies close to the bone, and ramifies between it and the Supraspinatus, to which it supplies branches. It then descends behind the neck of the scapula, through the great scapular notch and under cover of the inferior transverse ligament, to reach the infraspinatous fossa, where it anastomoses with the scapular circumflex and the descending branch of the transverse cervical. Besides distributing branches to the Sternocleidomastoideus, Subclavius, and neighboring muscles, it gives off a suprasternal branch, which crosses over the sternal end of the clavicle to the skin of the upper part of the chest; and an acromial branch, which pierces the Trapezius and supplies the skin over the acromion, anastomosing with the thoracoacromial artery. As the artery passes over the superior transverse ligament of the scapula, it sends a branch into the subscapular fossa, where it ramifies beneath the Subscapularis, and anastomoses with the subscapular artery and with the descending branch of the transverse cervical. It also sends articular branches to the acromioclavicular and shoulder-joints, and a nutrient artery to the clavicle.

The scapular and circumflex arteries.

 

 

The Descending Aorta
The descending aorta is continuous with the aortic arch. The diaphragm divides the descending aorta into a superior thoracic aorta and an inferior abdominal aorta (Figures 21-26, 21-27, and 21-28.

The Thoracic Aorta. The thoracic aorta begins at the level of vertebra T₅ and penetrates the diaphragm at the level of vertebra T₁₂. The thoracic aorta travels within the mediastinum, on the dorsal thoracic wall, slightly to the left of the vertebral column. It supplies blood to branches servicing the tissues and organs of the mediastinum, the muscles of the chest and the diaphragm, and the thoracic spinal cord.

The branches of the thoracic aorta are anatomically grouped as either visceral branches or parietal branches. Visceral branches supply the organs of the chest: The bronchial arteries supply the nonrespiratory tissues of the lungs, the pericardial arteries supply the pericardium, the esophageal arteries supply the esophagus, and the mediastinal arteries supply the tissues of the mediastinum. The parietal branches supply the chest wall: The intercostal arteries supply the chest muscles and the vertebral column area, and the superior phrenic arteries deliver blood to the superior surface of the diaphragm, which separates the thoracic and abdominopelvic cavities. The branches of the thoracic aorta are detailed in Figure 21-26.

The Abdominal Aorta. The abdominal aorta, which begins immediately inferior to the diaphragm, is a continuation of the thoracic aorta (Figure 21-26). The abdominal aorta descends slightly to the left of the vertebral column but posterior to the peritoneal cavity. It is commonly surrounded by a cushion of adipose tissue. At the level of vertebra L₄, the abdominal aorta splits into two major arteries—the left and right common iliac arteries—that supply deep pelvic structures and the lower limbs. The region where the aorta splits is called the terminal segment of the aorta.

The abdominal aorta delivers blood to all the abdominopelvic organs and structures. The major branches to visceral organs are unpaired, and they arise on the anterior surface of the abdominal aorta and extend into the mesenteries. Branches to the body wall, the kidneys, the urinary bladder, and other structures outside the abdominopelvic cavity are paired, and they originate along the lateral surfaces of the abdominal aorta. Figure 21-26 shows the major arteries of the trunk after removal of most of the thoracic and abdominal organs. Figure 21-27 gives the distribution of those arteries to abdominopelvic organs.

The abdominal aorta gives rise to three unpaired arteries (Figures 21-26 and 21-27 ):

1. The celiac artery delivers blood to the liver, stomach, and spleen. The celiac divides into three branches:

1. The left gastric artery, which supplies the stomach and inferior portion of the esophagus.

2. The splenic artery, which supplies the spleen and arteries to the stomach (left gastroepiploic) and pancreas (pancreatic).

3. The common hepatic artery, which supplies arteries to the liver (hepatic), stomach (right gastric), gallbladder (cystic), and duodenal area (gastroduodenal, right gastroepiploic, and superior pancreaticoduodenal artery).

1. The superior mesenteric artery arises about 2.5 cm inferior to the celiac artery to supply arteries to the pancreas and duodenum (pancreaticoduodenal), small intestine (intestinal), and most of the large intestine (right and middle colic and the ileocolic).

2. The inferior mesenteric artery arises about 5 cm superior to the terminal aorta and delivers blood to the terminal portions of the colon (left colic and sigmoid) and the rectum (rectal).

3. 

The abdominal aorta also gives rise to five paired arteries:

1. The inferior phrenics, which supply the inferior surface of the diaphragm.

2. The suprarenal arteries, which originate on either side of the aorta near the base of the superior mesenteric artery. Each suprarenal artery supplies one of the adrenal glands that cap the superior portion of the kidneys.

3. The short (about 7.5 cm) renal arteries, which arise along the posterolateral surface of the abdominal aorta, about 2.5 cm (1 in.) inferior to the superior mesenteric artery, and travel posterior to the peritoneal lining to reach the adrenal glands and kidneys. We shall consider the branches of the renal arteries in Chapter 26.

4. The gonadal arteries, which originate between the superior and inferior mesenteric arteries. In males, they are called testicular arteries and are long, thin arteries that supply blood to the testes and scrotum. In females, they are termed ovarian arteries and supply blood to the ovaries, uterine tubes, and uterus. The distribution of gonadal vessels (both arteries and veins) differs in males and females; we shall describe the differences in Chapter 28.

5. Small lumbar arteries, which arise on the posterior surface of the aorta and supply the vertebrae, spinal cord, and abdominal wall.

Arteries of the Pelvis and Lower Limbs
Near the level of vertebra L₄, the terminal segment of the abdominal aorta divides to form a pair of elastic arteries, the right and left common iliac arteries. These arteries carry blood to the pelvis and lower limbs (Figures 21-28 and 21-29). As these arteries travel along the inner surface of the ilium, they descend posterior to the cecum and sigmoid colon. At the level of the lumbosacral joint, each common iliac divides to form an internal iliac artery and an external iliac artery (Figure 21-27). The internal iliac arteries enter the pelvic cavity to supply the urinary bladder, the internal and external walls of the pelvis, the external genitalia, the medial side of the thigh, and, in females, the uterus and vagina. The external iliac arteries supply blood to the lower limbs, and they are much larger in diameter than the internal iliac arteries.

Arteries of the Thigh and Leg. The external iliac artery crosses the surface of the iliopsoas muscle and penetrates the abdominal wall midway between the anterior superior iliac spine and the pubic symphysis. It emerges on the anteromedial surface of the thigh as the femoral artery. Roughly 5 cm distal to the emergence of the femoral artery, the deep femoral artery branches off its lateral surface (Figure 21-28). The deep femoral artery, which gives rise to the medial and lateral circumflex arteries, supplies blood to the ventral and lateral regions of the skin and deep muscles of the thigh.

The femoral artery continues inferiorly and posterior to the femur. At the popliteal fossa, the femoral artery becomes the popliteal artery. The popliteal artery crosses the popliteal fossa before branching to form the posterior and anterior tibial arteries. The posterior tibial artery gives rise to the peroneal artery and continues inferiorly along the posterior surface of the tibia. The anterior tibial artery passes between the tibia and fibula, emerging on the anterior surface of the tibia. As it descends toward the foot, the anterior tibial provides blood to the skin and muscles of the anterior portion of the leg.

Arteries of the Foot. When it reaches the ankle, the anterior tibial artery becomes the dorsalis pedis artery. The dorsalis pedis branches repeatedly, supplying the ankle and dorsal portion of the foot (Figure 21-28 ).

As it reaches the ankle, the posterior tibial artery divides to form the medial and lateral plantar arteries, which supply blood to the plantar surface of the foot. The medial and lateral plantar arteries are connected to the dorsalis pedis artery through a pair of anastomoses. This arrangement produces a dorsal arch (arcuate arch) and a plantar arch. Small arteries branching off these arches supply the distal portions of the foot and the toes.

CONCEPT CHECK QUESTIONS

1. Blockage of which branch from the aortic arch would interfere with the blood flow to the left arm?

2. Why would compression of the common carotid arteries cause a person to lose consciousness?

3. Grace is in an automobile accident and ruptures her celiac trunk. Which organs will be affected most directly by this injury?