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

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

  The human heart is divided by septa into right and left halves, and each half is further divided into two cavities, an upper termed the atrium and a lower the ventricle. The heart therefore consists of four chambers, two, the right atrium and right ventricle, forming the right half, and two, the left atrium and left ventricle the left half. The right half of the heart contains venous or impure blood; the left, arterial or pure blood. The atria are receiving chambers, and the ventricles distributing ones. From the cavity of the left ventricle the pure blood is carried into a large artery, the aorta, through the numerous branches of which it is distributed to all parts of the body, with the exception of the lungs. In its passage through the capillaries of the body the blood gives up to the tissues the materials necessary for their growth and nourishment, and at the same time receives from the tissues the waste products resulting from their metabolism. In doing so it is changed from arterial into venous blood, which is collected by the veins and through them returned to the right atrium of the heart. From this cavity the impure blood passes into the right ventricle, and is thence conveyed through the pulmonary arteries to the lungs. In the capillaries of the lungs it again becomes arterialized, and is then carried to the left atrium by the pulmonary veins. From the left atrium it passes into the left ventricle, from which the cycle once more begins.

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

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

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

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

  The inner coat (tunica intima) can be separated from the middle by a little maceration, or it may be stripped off in small pieces; but, on account of its friability, it cannot be separated as a complete membrane. It is a fine, transparent, colorless structure which is highly elastic, and, after death, is commonly corrugated into longitudinal wrinkles. The inner coat consists of: (1) A layer of pavement endothelium, the cells of which are polygonal, oval, or fusiform, and have very distinct round or oval nuclei. This endothelium is brought into view most distinctly by staining with nitrate of silver. (2) A subendothelial layer, consisting of delicate connective tissue with branched cells lying in the interspaces of the tissue; in arteries of less than 2 mm. in diameter the subendothelial layer consists of a single stratum of stellate cells, and the connective tissue is only largely developed in vessels of a considerable size. (3) An elastic or fenestrated layer, which consists of a membrane containing a net-work of elastic fibers, having principally a longitudinal direction, and in which, under the microscope, small elongated apertures or perforations may be seen, giving it a fenestrated appearance. It was therefore called by Henle the fenestrated membrane. This membrane forms the chief thickness of the inner coat, and can be separated into several layers, some of which present the appearance of a net-work of longitudinal elastic fibers, and others a more membranous character, marked by pale lines having a longitudinal direction. In minute arteries the fenestrated membrane is a very thin layer; but in the larger arteries, and especially in the aorta, it has a very considerable thickness.

  The middle coat (tunica media) is distinguished from the inner by its color and by the transverse arrangement of its fibers. In the smaller arteries it consists principally of plain muscle fibers in fine bundles, arranged in lamellae and disposed circularly around the vessel. These lamellae vary in number according to the size of the vessel; the smallest arteries having only a single layer and those slightly larger three or four layers. It is to this coat that the thickness of the wall of the artery is mainly due. In the larger arteries, as the iliac, femoral, and carotid, elastic fibers unite to form lamellae which alternate with the layers of muscular fibers; these lamellae are united to one another by elastic fibers which pass between the muscular bundles, and are connected with the fenestrated membrane of the inner coat. In the largest arteries, as the aorta and innominate, the amount of elastic tissue is very considerable; in these vessels a few bundles of white connective tissue also have been found in the middle coat. The muscle fiber cells are about 50μ in length and contain well-marked, rod-shaped nuclei, which are often slightly curved.

  The external coat (tunica adventitia) consists mainly of fine and closely felted bundles of white connective tissue, but also contains elastic fibers in all but the smallest arteries. The elastic tissue is much more abundant next the tunica media, and it is sometimes described as forming here, between the adventitia and media, a special layer, the tunica elastica externa of Henle. This layer is most marked in arteries of medium size. In the largest vessels the external coat is relatively thin; but in small arteries it is of greater proportionate thickness. In the smaller arteries it consists of a single layer of white connective tissue and elastic fibers; while in the smallest arteries, just above the capillaries, the elastic fibers are wanting, and the connective tissue of which the coat is composed becomes more nearly homogeneous the nearer it approaches the capillaries, and is gradually reduced to a thin membranous envelope, which finally disappears.

  Some arteries have extremely thin walls in proportion to their size; this is especially the case in those situated in the cavity of the cranium and vertebral canal, the difference depending on the thinness of the external and middle coats.

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

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

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

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

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

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

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

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

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

  In many situations a delicate sheath or envelope of branched nucleated connective tissue cells is found around the simple capillary tube, particularly in the larger ones; and in other places, especially in the glands, the capillaries are invested with retiform connective tissue.

Sinusoids.—In certain organs, viz., the heart, the liver, the suprarenal and parathyroid glands, the glomus caroticum and glomus coccygeum, the smallest bloodvessels present various differences from true capillaries. They are wider, with an irregular lumen, and have no connective tissue covering, their endothelial cells being in direct contact with the cells of the organ. Moreover, they are either arterial or venous and not intermediate as are the true capillaries. These vessels have been called sinusoids by Minot. They are formed by columns of cells or trabeculae pushing their way into a large bloodvessel or blood space and carrying its endothelium before them; at the same time the wall of the vessel or space grows out between the cell columns.

Development of the Arterial System

Bloodvessels first make their appearance in several scattered vascular areas which are developed simultaneously between the entoderm and the mesoderm of the yolk-sac, i. e., outside the body of the embryo. Here a new type of cell, the angioblast or vasoformative cell, is differentiated from the mesoderm. These cells as they divide form small, dense syncytial masses which soon join with similar masses by means of fine processes to form plexuses. These plexuses increase both by division and growth of its cells and by the addition of new angioblasts which differentiate from the mesoderm. Within these solid plexuses and also within the isolated masses of angioblasts vacuoles appear through liquefaction of the central part of the syncytium into plasma. The lumen of the bloodvessels thus formed is probably intracellular. The flattened cells at the periphery form the endothelium. The nucleated red blood corpuscles develop either from small masses of the original angioblast left attached to the inner wall of the lumen or directly from the flat endothelial cells. In either case the syncytial mass thus formed projects from and is attached to the wall of the vessel. Such a mass is known as a blood island and hemoglobin gradually accumulates within it. Later the cells on the surface round up, giving the mass a mulberry-like appearance. Then the red blood cells break loose and are carried away in the plasma. Such free blood cells continue to divide. The term blood island was originally used for the syncytial masses of angioblasts found in the area vasculosa, but it is probably best to limit the term to the masses within the lumen from which the red blood cells arise as Sabin 88 has done. Blood islands have been seen in the area vasculosa in the omphalomesenteric vein and arteries, and in the dorsal aorta.

  The differentiation of angïoblasts from the mesoderm occurs not only in the area vasculosa but within the embryo and probably most of the larger bloodvessels are developed in situ in this manner. This process of the differentiation of angioblasts from the mesoderm probably ceases in different regions of the embryo at different periods and after its cessation new vessels are formed by sprouts from vessels already laid down in the form of capillary plexuses.

  The first rudiment of the heart appears as a pair of tubular vessels which are developed in the splanchnopleure of the pericardial area. These are named the primitive aortae, and a direct continuity is soon established between them and the vessels of the yolk-sac. Each receives anteriorly a vein—the vitelline vein—from the yolk-sac, and is prolonged backward on the lateral aspect of the notochord under the name of the dorsal aorta. The dorsal aortae give branches to the yolk-sac, and are continued backward through the body-stalk as the umbilical arteries to the villi of the chorion.

  Eternod describes the circulation in an embryo which he estimated to be about thirteen days old. The rudiment of the heart is situated immediately below the fore-gut and consists of a short stem. It gives off two vessels, the primitive aortae, which run backward, one on either side of the notochord, and then pass into the body-stalk along which they are carried to the chorion. From the chorionic villi the blood is returned by a pair of umbilical veins which unite in the body-stalk to form a single vessel and subsequently encircle the mouth of the yolk-sac and open into the heart. At the junction of the yolk-sac and body-stalk each vein is joined by a branch from the vascular plexus of the yolk-sac. From his observations it seems that, in the human embryo, the chorionic circulation is established before that on the yolk-sac.

Further Development of the Arteries.—Recent observations show that practically none of the main vessels of the adult arise as such in the embryo. In the site of each vessel a capillary network forms, and by the enlargement of definite paths in this the larger arteries and veins are developed. The branches of the main arteries are not always simple modifications of the vessels of the capillary network, but may arise as new outgrowths from the enlarged stem.

  It has been seen (page 506) that each primitive aorta consists of a ventral and a dorsal part which are continuous through the first aortic arch. The dorsal aortae at first run backward separately on either side of the notochord, but about the third week they fuse from about the level of the fourth thoracic to that of the fourth lumbar segment to form a single trunk, the descending aorta. The first aortic arches run through the mandibular arches, and behind them five additional pairs are developed within the visceral arches; so that, in all, six pairs of aortic arches are formed. The first and second arches pass between the ventral and dorsal aortae, while the others arise at first by a common trunk from the truncus arteriosus, but end separately in the dorsal aortae. As the neck elongates, the ventral aortae are drawn out, and the third and fourth arches arise directly from these vessels.

  In fishes these arches persist and give off branches to the gills, in which the blood is oxygenated. In mammals some of them remain as permanent structures while others disappear or become obliterated

The Anterior Ventral Aortae.—These persist on both sides. The right forms (a) the innominate artery, (b) the right common and external carotid arteries. The left gives rise to (a) the short portion of the aortic arch, which reaches from the origin of the innominate artery to that of the left common carotid artery; (b) the left common and external carotid arteries.

The Aortic Arches.—The first and second arches disappear early, but the dorsal end of the second gives origin to the stapedial artery a vessel which atrophies in man but persists in some mammals. It passes through the ring of the stapes and divides into supraorbital, infraorbital, and mandibular branches which follow the three divisions of the trigeminal nerve. The infraorbital and mandibular arise from a common stem, the terminal part of which anastomoses with the external carotid. On the obliteration of the stapedial artery this anastomosis enlarges and forms the internal maxillary artery, and the branches of the stapedial artery are now branches of this vessel. The common stem of the infraorbital and mandibular branches passes between the two roots of the auriculotemporal nerve and becomes the middle meningeal artery; the original supraorbital branch of the stapedial is represented by the orbital twigs of the middle meningeal. The third aortic arch constitutes the commencement of the internal carotid artery, and is therefore named the carotid arch. The fourth right arch forms the right subclavian as far as the origin of its internal mammary branch; while the fourth left arch constitutes the arch of the aorta between the origin of the left carotid artery and the termination of the ductus arteriosus. The fifth arch disappears on both sides. The sixth right arch disappears; the sixth left arch gives off the pulmonary arteries and forms the ductus arteriosus; this duct remains pervious during the whole of fetal life, but is obliterated a few days after birth. His showed that in the early embryo the right and left arches each gives a branch to the lungs, but that later both pulmonary arteries take origin from the left arch.

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

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

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

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

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

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

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

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

  The left branch of the pulmonary artery (ramus sinister a. pulmonalis), shorter and somewhat smaller than the right, passes horizontally in front of the descending aorta and left bronchus to the root of the left lung, where it divides into two branches, one for each lobe of the lung.

  Above, it is connected to the concavity of the aortic arch by the ligamentum arteriosum, on the left of which is the left recurrent nerve, and on the right the superficial part of the cardiac plexus. Below, it is joined to the upper left pulmonary vein by the ligament of the left vena cava.

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

The aorta is the main trunk of a series of vessels which convey the oxygenated blood to the tissues of the body for their nutrition. It commences at the upper part of the left ventricle, where it is about 3 cm. in diameter, and after ascending for a short distance, arches backward and to the left side, over the root of the left lung; it then descends within the thorax on the left side of the vertebral column, passes into the abdominal cavity through the aortic hiatus in the diaphragm, and ends, considerably diminished in size (about 1.75 cm. in diameter), opposite the lower border of the fourth lumbar vertebra, by dividing into the right and left common iliac arteries. Hence it is described in several portions, viz., the ascending aorta, the arch of the aorta, and the descending aorta, which last is again divided into the thoracic and abdominal aortae.

the Ascending Aorta (Aorta Ascendens) — The ascending aorta is about 5 cm. in length. It commences at the upper part of the base of the left ventricle, on a level with the lower border of the third costal cartilage behind the left half of the sternum; it passes obliquely upward, forward, and to the right, in the direction of the heart’s axis, as high as the upper border of the second right costal cartilage, describing a slight curve in its course, and being situated, about 6 cm. behind the posterior surface of the sternum. At its origin it presents, opposite the segments of the aortic valve, three small dilatations called the aortic sinuses. At the union of the ascending aorta with the aortic arch the caliber of the vessel is increased, owing to a bulging of its right wall. This dilatation is termed the bulb of the aorta, and on transverse section presents a somewhat oval figure. The ascending aorta is contained within the pericardium, and is enclosed in a tube of the serous pericardium, common to it and the pulmonary artery.

Relations.—The ascending aorta is covered at its commencement by the trunk of the pulmonary artery and the right auricula, and, higher up, is separated from the sternum by the pericardium, the right pleura, the anterior margin of the right lung, some loose areolar tissue, and the remains of the thymus; posteriorly, it rests upon the left atrium and right pulmonary artery. On the right side, it is in relation with the superior vena cava and right atrium, the former lying partly behind it; on the left side, with the pulmonary artery.

Branches.—The only branches of the ascending aorta are the two coronary arteries which supply the heart; they arise near the commencement of the aorta immediately above the attached margins of the semilunar valves.

The Coronary Arteries.—The Right Coronary Artery (a. coronaria [cordis] dextra) arises from the right anterior aortic sinus. It passes at first between the conus arteriosus and the right auricula and then runs in the right portion of the coronary sulcus, coursing at first from the left to right and then on the diaphragmatic surface of the heart from right to left as far as the posterior longitudinal sulcus, down which it is continued to the apex of the heart as the posterior descending branch. It gives off a large marginal branch which follows the acute margin of the heart and supplies branches to both surfaces of the right ventricle. It also gives twigs to the right atrium and to the part of the left ventricle which adjoins the posterior longitudinal sulcus.

  The Left Coronary Artery (a. coronaria [cordis] sinistra), larger than the right, arises from the left anterior aortic sinus and divides into an anterior descending and a circumflex branch. The anterior descending branch passes at first behind the pulmonary artery and then comes forward between that vessel and the left auricula to reach the anterior longitudinal sulcus, along which it descends to the incisura apicis cordis; it gives branches to both ventricles. The circumflex branch follows the left part of the coronary sulcus, running first to the left and then to the right, reaching nearly as far as the posterior longitudinal sulcus; it gives branches to the left atrium and ventricle. There is a free anastomosis between the minute branches of the two coronary arteries in the substance of the heart.

Peculiarities.—These vessels occasionally arise by a common trunk, or their number may be increased to three, the additional branch being of small size. More rarely, there are two additional branches.

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

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

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