3. The vertebral artery (A. vertebralis) arises from the brachial (or brachiocephalic) opposite the first intercostal space and passes upward and forward. On the left side it crosses the œsophagus, on the right the trachea. Emerging from the thorax it passes between the longus colli internally and the scalenus externally, under the transverse process of the seventh cervical vertebra, and continues along the neck through the series of foramina transversaria, between which it is covered by the intertransversales colli. Emerging from the foramen of the axis, it crosses the capsule of the atlanto-axial joint, and joins the retrograde branch of the occipital artery under cover of the great oblique muscle of the head. At each intervertebral foramen a spinal branch (Ramus spinalis) is given off which enters the vertebral canal and reinforces the ventral spinal artery. It also gives off series of dorsal and ventral muscular branches (Rami musculares). The dorsal branches are the larger; they supply the deep extensor muscles of the head and neck, and anastomose with the deep cervical and occipital arteries. The ventral branches supply chiefly the scalenus, longus colli, intertransversales, and rectus capitis anterior major. The artery is accompanied by the vertebral vein and a sympathetic nerve-trunk.

In some cases the last cervical transverse process has a foramen transversarium, through which the artery passes.

4. The internal thoracic artery (A. thoracica s. mammaria interna) is a large vessel which arises from the ventral side of the brachial opposite the first rib. It curves downward and backward, being at first on the inner surface of the rib, and then crosses the lower part of the first intercostal space and passes under the transversus thoracis muscle. It runs backward under cover of that muscle over the chondro-sternal joints to the eighth costal cartilage, where it divides into asternal and anterior abdominal branches. At each intercostal space two collateral branches are detached. The intercostal branches (Rami intercostales) pass upward in the intercostal spaces and anastomose with homonymous descending arteries. The lower branches detach small twigs to the transversus thoracis, pleura, and pericardium, and pass out between the costal cartilages as perforating branches (Rami perforantes) to supply the pectoral muscles and skin, anastomosing with the external thoracic artery. A very small pericardiaco-phrenic artery ascends in the mediastinum on the left side, in the caval fold of pleura on the right side; it supplies fine twigs to the pericardium and pleura and accompanies the phrenic nerve to the diaphragm. In the young subject it gives small branches (Aa. thymicæ) to the thymus gland. The asternal artery (A. musculophrenica) passes along the ninth costal cartilage and continues along the costal attachment of the transversus abdominis (Fig. 185). It gives off intercostal branches which anastomose with those descending from the thoracic aorta, and twigs to the diaphragm and transversus abdominis. The anterior abdominal artery (A. epigastrica cranialis) is the direct continuation of the internal thoracic. It passes between the ninth costal cartilage and the xiphoid cartilage, runs backward on the abdominal surface of the rectus abdominis and then becomes embedded in it (Fig. 466). It supplies the ventral wall of the abdomen and anastomoses with the posterior abdominal artery.

5. The external thoracic artery (A. thoracica externa) is given off from the ventral aspect of the brachial, usually at the inner surface or anterior border of the first rib. It turns around the first rib below or behind the brachial vein (when given off within the thorax) and passes backward under the deep pectoral muscle; it is continued as a small vessel in the panniculus carnosus, where it accompanies the external thoracic (“spur”) vein. It sends branches to the pectoral muscles and the axillary lymph glands.

This artery varies in origin and size. Not rarely it arises from the internal thoracic or from the brachial outside of the thorax. In other cases it arises by a common trunk with the inferior cervical. It may be very small or even absent, in which case the perforating branches of the internal thoracic compensate.

6. The inferior cervical artery (Truncus omo-cervicalis) arises usually from the dorsal surface of the brachial opposite the first rib or where that vessel winds around the rib. It is directed downward and a little forward across the external surface of the jugular vein and the deep face of the scalenus among the lymph glands at the thoracic inlet, and divides into ascending and descending branches. The ascending branch (A. cervicalis ascendens) passes upward and forward along the external surface of the jugular vein, then turns sharply backward and runs upward along the anterior border of the anterior deep pectoral muscle, between the omo-hyoideus and mastoido-humeralis and in relation to the prescapular lymph glands; it gives branches to these muscles and the prepectoral and prescapular lymph glands. The descending branch (A. transversa scapulæ) passes downward and outward across the surface of the anterior deep pectoral and then runs in the groove between that muscle and the mastoido-humeralis in company with the cephalic vein. It supplies branches to these muscles and the skin of the breast.

THE COMMON CAROTID ARTERY

These two vessels (Arteriæ carotides communes) arise from the brachiocephalic artery by a common trunk. This stem, the truncus bicaroticus or cephalic artery, is detached from the inner face of the brachiocephalic opposite the first rib and passes forward in the median plane beneath the trachea. It is related ventrally to the prepectoral lymph glands, the terminal parts of the jugular veins, and the anterior vena cava, and laterally to the vagus and recurrent nerves. It is commonly two or three inches (ca. 5 to 7 cm.) in length, but it may vary between one and eight inches (ca. 2.5 to 20 cm.).

The right common carotid artery passes obliquely from the ventral face of the trachea to its right side. In this position it runs upward and forward and divides at the crico-pharyngeus muscle and under the submaxillary gland into external carotid, internal carotid, and occipital arteries. It is inclosed in a fibrous sheath, and is accompanied dorsally by the vagus and sympathetic nerves, ventrally by the recurrent nerve. At the last two cervical vertebræ it is in contact superficially with the jugular vein, but further forward the omo-hyoideus muscle intervenes between the artery and vein. Near its termination the artery becomes more deeply placed and is related externally to the submaxillary and parotid glands, internally to the œsophagus. In some cases it is in contact ventrally with the thyroid gland, especially when the latter is larger than usual.

The left common carotid artery differs from the right one in that it is related deeply to the œsophagus, which separates it from the trachea in the greater part of its course.

The collateral branches of the common carotids are in the main small. They comprise:

1. Muscular branches (Rami musculares) of variable size, which go to the ventral muscles of the neck and the skin.

2. Œsophageal and tracheal branches (Rami œsophagei et tracheales). Small twigs go to the cervical lymph glands also.

3. The parotid artery. This comes off near the termination and enters the ventral part of the parotid gland. It also supplies the subparotid lymph glands, and sometimes sends a branch to the submaxillary gland. It is inconstant.

4. The thyro-laryngeal artery (A. thyreoidea cranialis). This, the largest collateral branch of the carotid, arises from the latter two or three inches before it divides. It curves over the anterior end of the thyroid gland, into which it sends several branches. It gives off a laryngeal branch (A. laryngea), which sends twigs to the external muscles of the larynx and the constrictors of the pharynx, passes between the cricoid and thyroid cartilages, and supplies the internal muscles and the mucous membrane of the larynx. A small pharyngeal branch (A. pharyngea ascendens) runs upward and forward to the crico-pharyngeus, and supplies twigs to the posterior part of the pharynx and the origin of the œsophagus. Small innominate twigs are given off to the trachea, the œsophagus, and the sterno-thyro-hyoideus and omo-hyoideus muscles.

In some cases the thyroid and laryngeal arteries arise from the carotid separately or by a short common stem. A laryngeal branch is often detached from the carotid in front of the thyro-laryngeal and enters the larynx with the superior laryngeal nerve. The pharyngeal branch frequently comes directly from the carotid.

5. The accessory thyroid artery (A. thyreoidea caudalis) is an inconstant vessel which arises from the carotid at a variable distance behind the thyro-laryngeal—sometimes from the latter or from the parotid artery. It sends branches into the posterior part of the thyroid gland and detaches small tracheal and muscular twigs. In some cases it is distributed chiefly or entirely to the adjacent muscles.

The occipital artery (A. occipitalis) is the second in size of the terminals of the carotid. It arises usually just in front of the internal carotid, but in some cases with that artery by a common trunk of variable length. It pursues a somewhat flexuous course to the fossa atlantis, where it divides into anterior and posterior branches. It is related superficially to the submaxillary gland and the mastoido-humeralis, and deeply to the guttural pouch and the rectus capitis anterior major.^[158] The internal carotid artery, the inferior cerebral vein, and the accessory, vagus, and sympathetic nerves cross its deep face. It gives twigs to the submaxillary gland, the anterior straight muscles, the guttural pouch and the adjacent lymph glands, and two named collateral branches. The condyloid or prevertebral artery (A. condyloidea) is a small vessel which passes upward and forward on the guttural pouch, and divides into muscular and meningeal branches. The latter enter the cranium through the foramen lacerum and hypoglossal foramen and are distributed to the dura mater. This artery is very variable in its origin. The posterior meningeal or mastoid artery (A. meningea caudalis) is a much larger vessel which runs upward and forward between the small oblique muscle and the paramastoid process, passes through the mastoid foramen into the parieto-temporal canal, enters the cranial cavity, and is distributed to the dura mater.

The posterior or retrograde branch (Ramus descendens) of the occipital passes up through the foramen transversarium of the atlas and joins the vertebral artery. It gives branches to the great oblique muscle of the head, which covers it.

The anterior or occipital branch (Ramus occipitalis) passes through the alar (antero-external) foramen of the atlas and supplies the muscles and skin of the poll, anastomosing with the deep cervical artery and its fellow of the opposite side. In the alar furrow it gives off the cerebrospinal artery, which enters the spinal canal through the intervertebral (antero-internal) foramen of the atlas, perforates the dura mater, and divides into cerebral and spinal branches. The cerebral branch unites with that of the opposite side to form the basilar artery, and the spinal branch similarly forms by union with its fellow the middle spinal artery.

The basilar artery (A. basilaris cerebri) passes forward in the median groove on the ventral surface of the medulla and pons and divides into the two posterior cerebral arteries. The collateral branches of the basilar are:

1. Medullary branches (Rami medullares), ten or twelve in number, distributed to the medulla oblongata.

2. Posterior cerebellar arteries (Aa. cerebelli caudales) which pass outward around the medulla behind the pons to the cerebellum, to which they are distributed after giving twigs to the medulla and pons.

3. The small auditory artery (A. auditiva interna) accompanies the eighth nerve to the internal ear. It often arises from the posterior cerebellar.

4. Anterior cerebellar arteries (Aa. cerebelli nasales). These are very variable in number and origin. There are often two or three on either side and they frequently arise from the posterior cerebrals. They pass outward in front of the pons and supply the anterior part of the cerebellum.

The posterior cerebral arteries (Aa. communicantes caudales) diverge at an acute angle and join the posterior communicating branches of the internal carotid arteries on the inferior surface of the cerebral peduncles. They are connected by a transverse branch and by a network of fine twigs which form often a rete mirabile.

THE INTERNAL CAROTID ARTERY (Figs. 434, 436, 437)

This artery (A. carotis interna) is somewhat smaller than the occipital. It usually arises just behind that artery, crosses its deep face, and runs upward and forward on the guttural pouch to the foramen lacerum. It is closely related to the vagus nerve and the superior cervical ganglion of the sympathetic nerve, fibers from which accompany it. It is crossed externally by the ninth and twelfth cranial nerves and the pharyngeal branch of the vagus. It passes through the inferior petrosal sinus and enters the cavernous sinus, within which it forms an S-shaped curve. It is connected with the opposite artery by a transverse branch (A. intercarotica), which lies behind the pituitary body in the intercavernous sinus. A branch (A. caroticobasilaris) sometimes connects it with the basilar artery. It then perforates the dura mater, gives off the posterior communicating branch, and passes forward and divides at the side of the optic chiasma into anterior and middle cerebral arteries.

The posterior communicating artery (A. communicans posterior) turns backward and joins the posterior cerebral. It gives off the deep cerebral artery (A. cerebri profunda) which winds around the cerebral peduncle and is distributed chiefly to the mid-brain. A smaller collateral branch is the anterior choroid artery (A. chorioidea nasalis) which passes along the optic tract and is distributed in the choroid plexus of the lateral ventricle.

The anterior cerebral artery (A. cerebri anterior) unites with the corresponding branch of the opposite artery above the optic chiasma. From this junction proceeds the artery of the corpus callosum (A. corporis callosi), which turns around the genu of the corpus callosum, enters the great longitudinal fissure, divides into two branches, and is distributed to the inner aspect of the cerebral hemispheres. A small anterior meningeal branch (A. meningea nasalis) of the anterior cerebral is distributed to the anterior part of the dura, and assists in forming a network in the ethmoidal fossa (Rete ethmoidale), anastomosing with the ethmoidal branch of the ophthalmic artery.

The middle cerebral artery (A. cerebri media) passes outward in the lateral fissure (of Sylvius) and divides into branches on the outer surface of the hemisphere.

The arterial circle of Willis (Circulus arteriosus) (Fig. 434) is formed at the interpeduncular space of the base of the brain by the union of the anterior cerebral arteries in front, by the diverging posterior cerebral arteries behind, and is completed laterally by the junction of the latter with the posterior communicating arteries and by the internal carotid. It is irregularly polygonal in outline.

The cerebral arteries are very variable in arrangement, and the foregoing account is a brief statement of the more usual disposition of the larger vessels. The internal carotid artery often arises with the occipital by a common trunk of variable length.

THE EXTERNAL CAROTID ARTERY (Figs. 436, 437)

This artery (A. carotis externa) by its size and direction constitutes the continuation of the common carotid. It passes forward on the lateral wall of the pharynx at the lower border of the guttural pouch, covered by the submaxillary gland and the stylo-maxillaris, digastricus, and stylo-hyoideus muscles. It then emerges between the stylo-hyoideus and the great cornu of the hyoid bone, passes upward on the latter parallel with the posterior border of the lower jaw, and terminates about two inches (ca. 5 cm.) below the temporo-maxillary articulation by dividing into superficial temporal and internal maxillary branches. It is crossed deeply near its origin by the superior laryngeal and pharyngeal branches of the vagus nerve. Just before its emergence its superficial face is crossed by the hypoglossal nerve, and the glosso-pharyngeal nerve passes over its inner surface at the ventral border of the great cornu. The chief collateral branches are the masseteric, external maxillary, and posterior auricular. It also furnishes variable branches to the submaxillary and parotid glands, the guttural pouch, and the pharyngeal lymph glands, as well as twigs to some adjacent muscles.

1. The inferior masseteric or maxillo-muscular artery (A. masseterica inferior) is given off from the external carotid at its emergence from beneath the stylo-hyoideus. It passes downward and slightly forward under cover of the parotid gland and over the tendon of insertion of the sterno-cephalicus to the posterior border of the mandible and appears on the masseter muscle, into which it plunges after a short course on its surface. It gives branches also to the internal pterygoid and stylo-maxillaris muscles and the parotid gland.

2. The external maxillary, facial, or submaxillary artery (A. maxillaris externa)^[159] arises from the external carotid on the inner surface of the posterior belly of the digastricus (Fig. 436). It runs downward and forward on the lateral wall of the pharynx across the deep face of the stylo-hyoideus toward the great cornu of the hyoid bone, accompanied by the glosso-pharyngeal nerve in front and the hypoglossal nerve behind. After giving off the lingual artery at the posterior border of the great cornu, it inclines more ventrally on the inner surface of the internal pterygoid muscle, crosses over the hyo-glossus muscle, the hypoglossal nerve, the submaxillary duct, and the intermediate tendon of the digastricus, and turns forward in the submaxillary space. Here it lies on the lower part of the internal pterygoid muscle, and is related internally to the submaxillary lymph glands, above to the anterior belly of the digastricus, and below to the homonymous vein. At the anterior border of the masseter it turns around the lower border of the jaw and runs upward on the face in front of that muscle.^[160] At the turn the artery is in front, the vein in the middle, and the parotid duct posterior. The artery and vein pass upward along the anterior border of the masseter, under cover of the facial panniculus and the zygomaticus, and are crossed superficially by branches of the facial nerve and deeply by the parotid duct. The artery terminates over the levator labii superioris proprius by dividing into the dorsal nasal and the angular artery of the eye. The chief branches of the external maxillary are as follows:

(1) The pharyngeal artery (A. palatina ascendens) arises usually behind the stylo-pharyngeus, passes between that muscle and the great cornu, and runs forward on the lateral wall of the pharynx under the elastic pharyngeal fascia. It is distributed to the soft palate, pharynx, and tonsil.

(2) The lingual artery (A. lingualis) is a large branch which diverges from the parent trunk at an acute angle, runs along the ventral border of the great cornu of the hyoid bone, and dips under the hyo-glossus muscle. It then passes across the kerato-hyoideus, turns inward under the intercornual joint of the hyoid bone, and runs forward in the tongue between the hyo-glossus and genio-glossus. This part (A. profunda linguæ) is flexuous and is accompanied by branches of the hypoglossal and lingual nerves. It is the chief artery of the tongue, and anastomoses with the opposite artery and the sublingual.

(3) The sublingual artery (A. sublingualis) is a smaller vessel which arises at the anterior extremity of the submaxillary gland (Fig. 436). It passes forward on the anterior belly of the digastricus between the ramus of the mandible and the mylo-hyoideus, perforates the latter, runs along the lower border of the sublingual gland, and ramifies in the mucous membrane of the anterior part of the floor of the mouth. It detaches branches to the muscles and skin in the submaxillary space, the submaxillary lymph glands, and the sublingual gland. It also gives off the small submental artery, which runs forward superficially toward the lower lip, supplying twigs to the skin and the mylo-hyoideus.

In some cases the sublingual artery arises from the lingual and the submental from the external maxillary. Sometimes the sublingual remains on the external face of the mylo-hyoideus—thus resembling the submental of man—and the sublingual gland is supplied by a special branch of the lingual.

Not uncommonly a considerable branch, given off in the submaxillary space, turns round the lower border of the jaw and enters the middle of the lower part of the masseter muscle. In some cases this artery is of large size and its pulsation can be felt. It is accompanied by a vein.

(4) The inferior labial artery (A. labialis inferior) arises from the facial a little before it reaches the depressor labii inferioris (Fig. 435). It passes forward, dips under the depressor muscle, and continues to the lower lip. It supplies branches to the muscles and skin in this region, to the inferior buccal glands, the mucous membrane of the cheek, and the lower lip, anastomosing with the mental artery and the corresponding vessels of the opposite side. It detaches a branch (A. anguli oris) to the angle of the mouth, which anastomoses with the superior labial.

(5) The superior labial artery (A. labialis superior) arises from the facial in front of the facial crest (Fig. 435). It passes forward under the dilatator naris lateralis and levator nasolabialis to the upper lip, gives twigs to the upper part of the cheek and the lateral nasal region, and ramifies in the upper lip, anastomosing with the opposite artery and the palato-labial.

(6) The lateral nasal artery (A. lateralis nasi) arises usually a little above the preceding one, and runs forward parallel with it and under the levator nasolabialis to the nostril (Fig. 435). It supplies branches to the lateral nasal region and the nostril.

The vessel is often double. It may arise from the superior labial at the point of bifurcation of the facial or with the dorsal nasal from the infraorbital artery (as in the ox). In some cases it gives off a dorsal nasal branch.

(7) The dorsal nasal artery (A. dorsalis nasi) arises on the levator labii superioris proprius and passes forward under the levator nasolabialis to the dorsum nasi (Fig. 435).

(8) The angular artery of the eye (A. angularis oculi) runs toward the internal canthus of the eye, where it anastomoses with the orbital branch (Ramus malaris) of the infraorbital artery (Fig. 435).

In addition to the preceding, unnamed branches are supplied to the submaxillary salivary gland and the submaxillary lymph glands.

3. The posterior auricular artery (A. auricularis posterior) arises at an acute angle from the external carotid just above the origin of the masseteric. It passes upward under cover of the parotid gland, to which it gives branches, and divides into several branches which supply the skin and muscles of the external ear (Fig. 435). The posterior branch passes to the posterior part of the base of the ear, where it divides into two branches; of these, one (Ramus intermedius) passes up the convex surface of the external ear to the apex, while the other (Ramus medialis) winds around to the anterior (inner) border, and forms an arch with the intermediate branch. The external branch (Ramus lateralis) passes up the posterior (external) border of the ear and forms an arch with the intermediate branch. The deep branch (A. auricularis profunda) enters the interval between the external auditory canal and mastoid process, and passes through an opening into the interior of the external ear and ramifies in the skin which lines it. It gives off the stylo-mastoid artery, which passes through the stylo-mastoid foramen into the tympanum, forms an arch around the membrana tympani, and supplies the middle ear and its muscles.

THE SUPERFICIAL TEMPORAL ARTERY

This artery (A. temporalis superficialis) is much the smaller of the two terminal branches of the external carotid. It passes upward behind the posterior border of the ramus of the mandible under cover of the parotid gland, and divides below the level of the condyle into the anterior auricular and transverse facial arteries. It is crossed superficially by the facial nerve.

The anterior auricular artery (A. auricularis anterior) passes upward behind the temporo-mandibular articulation under cover of the parotid gland, crosses the zygomatic arch, and reaches the temporalis muscle. It is crossed deeply at its origin by the superficial temporal nerve and is accompanied by a satellite vein and the auriculo-palpebral branch of the facial nerve. It is distributed to the skin and the temporal and anterior auricular muscles, and sends a branch through the conchal cartilage to the skin which lines it. Collateral twigs are detached to the parotid gland, and an anterior branch anastomoses with the supraorbital artery. A branch sometimes passes into the parieto-temporal canal and anastomoses with the posterior meningeal (mastoid) artery.

The transverse facial artery (A. transversa faciei) is larger than the preceding. It turns around the neck below the condyle of the mandible and emerges from beneath the parotid gland (Fig. 435). It then passes forward a short distance on the masseter about half an inch below the zygomatic arch and plunges into the muscle, in which it commonly divides into two chief branches. It is accompanied by a vein and a branch of the superficial temporal nerve. It supplies the masseter and the skin of this region, and anastomoses with the external maxillary and posterior deep temporal arteries.

The pulse may usually be felt in this artery as it passes below the articulation of the jaw.

THE INTERNAL MAXILLARY ARTERY (Figs. 437, 438, 439)

This artery (A. maxillaris interna) is much the larger of the two terminal branches of the external carotid. It begins at the inner side of the posterior border of the mandible about two inches (ca. 5 cm.) below the articulation of the jaw and ends in the anterior part of the pterygo-palatine fossa. On account of its complex course and the large number of branches given off it is convenient to divide it into three parts.

The first part is much the longest, forms an S-shaped curve, and is in great part in contact with the guttural pouch. It passes upward and forward on the inner surface of the mandible a distance of about an inch (ca. 2 to 3 cm.) and is related here to the vein, which is ventral. It then turns inward below the external pterygoid muscle and the inferior maxillary nerve, passes between that muscle and the tensor palati, and runs forward to enter the alar (pterygoid) foramen. This part gives off the following branches:

1. The inferior alveolar or dental artery (A. alveolaris mandibulæ s. inferior) passes downward and forward with the homonymous vein and nerve, being at first between the external and internal pterygoid muscles, then between the latter and the ramus of the mandible. It enters the mandibular foramen, passes downward and forward in the mandibular canal, and terminates at the mental foramen by dividing into mental and incisor branches. The mental branch (A. mentalis) emerges through the mental foramen and anastomoses in the lower lip with the opposite artery and the inferior labial. The incisor branch continues forward in the bone, supplies twigs to the canine and incisor teeth, and anastomoses with its fellow of the opposite side. Collateral branches are detached to the pterygoid and mylo-hyoid muscles, and within the bone to the teeth, alveolar periosteum, the gums, and the spongy substance of the mandible.

2. The pterygoid arteries, two or three in number, are distributed to the pterygoid and tensor and levator palati muscles.

3. The tympanic artery is a very small vessel which passes along the Eustachian tube to the petro-tympanic fissure (of Glaser) and enters the middle ear.