Talk:Paper - Note on the basement membranes of the tubules of the kidney (1901)

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NOTE ON THE BASEMENT MEMBRANES OF THE TUBULES OF THE KIDNEY

Mall FP. Note on the basement membranes of the tubules of the kidney. (1901) Johns Hopkins Hospital Bulletin 12:

By Frankin P. Mall. Professor of Analomy, Johns Hopkins Universily.


In au earlier jmMication upon reticulated t).«sues in general tlie statement wns made that the whole framework of tlie kidney, including the lja.sement membranes, from the capsule to the pelvis, is formed by one mass of anastomosing fibrils, and that the sliarp borders of the librils mark the outlines


of the tubules to form the basement membranes which in ordinary sections i!]ipear to be homogeneous.' This statement was based upon observations made by digesting frozen


' Mall, Abhandl. dcr math.-phys. classe dcr Kiiiiigl. Siicli. (iesehell. der wisscusch., Bd. Ill, and Johns Iloiikius Hospital Reports, vol. 1.

sections of the kidney, digested in pancreatin, stained with acid fuchsin and differentiated with picric acid. By this method all of the cells and other structnres of the kidney are destroyed, leaving only the white fibres and reticulated fibrils which are stained intensely red. This observation has been confirmed by Eiihle," who used a method similar to the one I employed. Eiihle digested small blocks of kidney (after hardening in alcohol) with pancreatin until all the cells were dissolved, then made sections in paraffin, which were stained irpon the slide. By this method the topography of the reticulum is retained much better than is the case in specimens made by the freezing method.



Fig. 1. — Longitudinal section of the fr.imewoik encircling a kidney tubule digested in pancreatin, stained witli acid fuchsin, and differentiated with picric acid. Enlarged 'SiS times.

The work of Eiihle, which is very accurate and extensive, shows quite conclusively that the fibrils obtained by his method, as well as by the freezing method, are identical with those which form the interstitial tissue as seen in ordinary sections.

The observations given above have been confirmed by Disse,' who states, however, that the basement membranes of the kidney which have been isolated by means of strong acids always appear to be homogeneous. This he explains by as.suming that pancreatic digestion resolves the membrane into fibrils by dissolving the cement substance between them. The strong acids, however, dissolve the interstitial connective


tissue but do not affect those fibrils which are stuck together by the cement substance to form basement membranes.

Von Ebner' is of the opinion that the iibrillar a])pearance of the basement membranes of the kidney is due to fine folds in it owing to the method of preparation. He further states that the fibrils of connective tissue between the tubules stain with acid fuchsin while the membranes do not. There is some truth in this statement, for in sections of the kidney which have been macerated and slightly tinged the stained fibres shine through the homogeneous membrane, often making it ajipcar folded. Yet with some care the true nature of these makings is easily determined.


-lUihle, His's. Archiv, iS'.l".

3 Disse, Sitzungsbericlite dcr Gescliellsch. zur Beforderung der gesanimten Naturwisseuschaftcn zu Marburg, November, 1898.



Fig. :.'.— Transverse section of the rcticulura encircling a kidney tubule prepared as Fig. 1.

Keceiilly, while studying sections of the fresh kidney liy m{>ans of various methods, I obtained specimens which ]n-oved that tlie ol)servations of Eiihle, Disse and myself are correct, so far as they go, but that our conclusions regarding the basement membranes are not correct. The baskets, which I reproduce in Figs. 1 and 2, do exist, are easily obtained by means of pancreatic digestion, but do not form the basement membranes. An additional membrane, the basement membrane, lies within this tube and is totally destroyed by means of pancreatic digestion. The most instructive specimens I obtained were made by macerating frozen sections of the rabbit's kidney in a cold saturated solution of bicarbonate of soda for a number of days, after which most of the cells have been converted into a slimy mass. Shaking the section vigorously in water soon cleared the framework, wliicli was next spread upon a slide and examined. In case most of the cell remnants had been removed the section was dried upon the slide, stained with acid fuchsin, differentiated with picric


■• Von Ebner, Kolliker's Handbuch der Gewebelehre, Bd. 3, S. 374-375.


April-May-JuxNU, IIJOI.J


JOHNS HOPKINS HOSPITAL liULLETIN.


135


acid and numiite'd in halsani. Suceossful sections prepared in this way sliow the basement membranes partly filled with the remnants of epithelial cells, the interstitial reticidatcd connective tissue and the blood-vessels. A portion of such a specimen is shown in Fig. 3.

After specimens of the basement membranes and the rcticuhim are obtained through maceration in bicarbonate of soda, as described aliove, they may be treated with various reagents to test their projierties. Dilute solutions of IICl and KOI I cause the reticulum to swell and become transparent, whili' the basement mendjrane and the elastic filjrils accompanying the arteries remain unchanged. But it is shown by the Weigert's elastic tissue stain that the mem])ranes are not elastic, for they do not take on the stain wliile the elastic tissue fibres do. Furthermore, Mallory's connective tissue stain,° stains the reticulum but not the membranes. As far as I have tested the basement membranes they give reactions


^ Mallory, Journal of Exitcriniental Mi'tliciiiu, vol.


much like the membranes of elastic fibres, but whether they arc identical with them I have been unable to determine.



Fig. 3. Lon</;itu(linal section of a kidney tubule with the surrouudinK

reticulum from a specimen macerated in bicarbonate of soda for a week, shaken, dried upon the slide, stained with acid fuchsiu and dill'erentiated with picric acid. The basement membrane partly tilled with broken epithelial cells and surrounded with reticulum are shown. The drawingis semidiaijrammatic.


A COMPARATIVE STUDY OF THE DEVELOPMENT OF THE GENERATIVE TRACT

IN TERMITES/

By H. McK. Kxower, Ph.D., Inslrnclor in Anaioniij. Johns Hopkins Univcrsiiij.


Tiie facts here prescnled furnish a mure accurate guide in estimating the status of individuals in the communit} Hum has been hitherto available. Xew light is thrown on hypotheses as to the possible inlluence of workers and soldiers in the transmission of hereditary characters in these communities. These studies will also be seen to bear on jiroblems of the comparative morphology of the sexual organs of insects. Six species of two genera (Calotermcs and Termes) were investigated.

The efferent passages and accessory glands of Termites are simple, as in Thysanura. In Termes flavipes they arise first in larvs just hatched, in which the mesodermic duct from ovary or testis ends blindly against the ectoderm of the hypodermis. In the female three separate and segmental, unpaired invaginations of the ectoderm appear, one behind another on the ventral mid-line. The pouch of the anterior segment comes into contact with the mesodermic oviducts, that of the next segment later becomes the receptaculum seminis, while the posterior invagination bifurcates at its inner end and eventually forms the colleterial glands. In larva? preceding those evidently destined to become workers and soldiers, and in adult workers and soldiers, this disconnected segmental condition persists (Fig. 1). In other word.s, the workers and soldiers exhibit a peculiar arrested,


' A preliminary abstract presented to the American Morphological Society, December, lUOO.


larval stage in the dcvelopmcul u£ the sexual ap|iaraUis. In older larvaB of sexual individuals the three, segmental, independent rudiments telescope together and unite to form a vaginal canal with colleterial glands, reccptaculum seminis, and mesodermic oviducts opening into it. In the male there



Ov.il.j-ct.

Rectft. 5e«>. c:<.U.slo«A.


Fio. 1. — Modilied camera sketch of ventral aspect of tip of abdomen of Termes flavipes, adult worker or soldier. Female.

is a single median ectoderinic invagination into which the j)aired, mesodermic vesicuhe semiuales, and vasa deferentia, eventually open (Fig. 2). In adult workers and soldiers of this sex an arrested larval type is exhibited in the sexual apparatus.

Modifications of this history occur in i)tlier siiecies, affecting workers and soldiers especially.


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JOHNS HOPKINS HOSPITAL BULLETIN.


[Nog. 131-123-123.


In a species of Eutermes from Jamaica the most extreme inodiflcation is found. Not even rudiments of the cctodermic passage and accessory glands a])pear in Avorlscrs or soldiers (Nasuti) of this species. The origin of the ectodermic apparatus of sexual individuals of this species is, however, essentially that of the corresponding structures of flavipes.



SfiUicU.


Fig. 3. — Similar sketch of adult worker or soldier. Male.

The condition of the mesodermic sexual gonads, male and female, is very simjjle in a Jamaican species of Calotermes, a primitive genus of the group. In advanced larvae and in soldiers the ovary is a series of egg-tubes opening into the


oviducts, while the testis is composed of the same number of tulmles or follicles arranged serially on the vas deferens.

In T. flavipes and in the Jamaican Eutennes the youngest larvffi exhibit a condition similar to that in Calotermes, which arrangement, it will be observed, Ijears a suggestive resemblance to the type found in Thysanura.

In the Jamaican Eutermes the workers and soldiers exhibit an extreme arrest of the development of the gonads, which do not proceed beyond the stage found in the youngest larva just hatched.

The adult workers and soldiers of a Japanese species of Termes. unlike T. flavipes, possess gonads not greatly modified from the serial type which seems to be primitive.

In T. flavipes the gonads of older larvre and of adult workers and soldiers in both sexes lose this priinitive type: the tubules of the testicle, for instance, becoming twisted into a globular mass in which the original serial order is obscured.

The gonads of larvae of sexual individuals, in all species studied, change from the condition at hatching to a type in which the simpler original arrangement is much obscured.

Additional facts with suitable discussions will be published shortly, fully illustrated.


A COMPOSITE STUDY OF THE AXILLARY ARTERY IN MAN.

By J. M. HiTZEOT.

{From the Anaiotnli'al Lahorotory of the Johns Hopkins University.)


At the suggestion of Dr. Mall the following records were made from dissections in the Anatomical Laboratory of the Johns Hopkins University during 1898-99 and 1899-1900. Charts' were furnished the students with the request that they draw the axillary artery with its branches, etc., as found in their subjects, giving as nearly as possible the origin and distribution of each branch and maintaining the relation to the pectoralis minor and the various bony structures of the axillary region. The charts were merely outlines of the skeleton upon which each student sketched his dissection. When this sketch was finished it was added to or changed Ijy the writer, so that the sketch might, as nearly as jiossible, represent the artery as it existed in each dissection. Parallel with these drawings a set of not€s was kept in which the constant and the unusual branches of the artery were carefully noted. During the year 1898-99, considerable difficulty was experienced with the terms short thoracic, acromio-thoracic, etc., the student in his eagerness to apply these terms to the different branches often overlooking the more important feature, i. e., the distribution of the branch. To obviate this to some extent the charts of this year were compiled and the composite picture thus obtained was drawn and furnished as a guide for the future. The terms before mentioned were kept but special stress was laid upon the origin and distribu


1 Bardeen, Outline Record Charts used in the Anatomical Laboratory of the Johns Hopkins University, Johns Hopkins Press, Baltimore, 1900.


tion of the artery. The results thus obtained were uniformly more satisfactory than those of the previous year.

The charts used in the following tabulations are less than a third of the total number made. The remainder, because of errors in drawing, broken arteries in dissecting, and discrepancies between the notes of the writer and the sketches, were omitted. These omitted charts, in so far as they were of any value, gave jiractically the same results as were obtained from the tabulation of the coiTcct and more complete charts. In making the tabulations the arbitrary divisions given by the various anatomists were used.

Part I, that portion of the artery extending fi(nn the lower border of the first rib to the ujiper border of the ]iectoralis minor.

Part II, that portion of the artery which is beneath the pectoralis minor.

Part III, that portion of the artery which extends from the lower border of the pectoralis minor to the lower border of the tendons of the teres major and latissimus dorsi.

During the first tabulation separate tables were made for the right and left sides to determine whether the origin and distribution differed on the two sides. As the only dift'erence found was in the presence or absence of the long thoracic artery this distinction was dropped, the relative dift'erence consisting in the more constant presence of the long thoracic artery on the left side.


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JOHNS HOPKINS HOSPITAL BULLETIN.


137


The charts themselves conveniently fall into different types, that i.-;. the artery in a certain number of instances gives oif its lij'anches from the same divisions of tlie arterial trunk and these brandies are distributed to tlie same regions. The ti' charts here taimlated fall into 7 types, type I being present in 20 cases; type II in 9 casjs; type III in 7 cases; type IV in 4 cases; type V in 3 cases; and tyi>es VI, VII each in 2 cases.

Type I (Fig. 1 and Table I).

This type, the most constant found in the laboratory during the two years the dissections were observed, differs from the text-book descriptions by the absence of the long thoracic artery. The area ordinarily supplied by this artery, accord


FiG. 1. — Type I of the axillary artery. Present 30 times in 47 cases.

.1, Ramus acromialis ; a, Ramus ascendens; AC, A. circumflexa humeri anterior; b, M. biceps; C, R. clavicularis ; eb, M. coraco-brachialis; D, M. deltoideus; <l, Ramus anastomotieus; DH, A. eireumflexa, scapukr, (dorsal scapular); LB, il. latissimus dorsi; P, R. pectoralis; PC, A. circumtlexa humeri posterioris; PM, M. pectoralis major; pm, M. pectoralis minor; .S', A. subscapularis ; s, M. subscapularis; SM, M. Serratus anterior (magnns); .S'P, A. profunda bracliii, (superior profunda); T\ A. thoracalis suprema ; T-, A. thoraco-acromialis ; T ■', A. thoracalis lateralis; TM, M. teres major; 1, 2, 3, 4, 5, 1st, 3d, 3d, 4th and .5th intercostal spaces.

ing to te.vt-books, being supplied by liranches from the acromio-thoracic and subscapular arteries. The branches in this type can be conveniently arranged in the following schema: I

( 1. Superior thoracic.


Part 1.


Part II.


Part III.


Acromio-thoracic.


No branches. 1. Subscapular.


(■ 1. Thoracic branch.

I 3. Acromio-hnmeral branch. l_ 3. Clavicular.


C 1. Dorsal scapular.

I 3. Muscular branches.

] 3. Anterior.

[ 4. Posterior.


., , . . . „ ( Ascending branch.

3. Anterior circumflex. .; , . ",. ( Anastomotic.


o. Posterior circumflex. 4. Muscular branches.


( Muscular. \ Anastomotic.

iCoraeo-brachialis. Biceps.


The superior thoracic (A. thoracalis suprema) rises just below subclavius muscle and crosses the first inters]iace, ending in it and in the second interspace. The origin of the artery is remarkalily constant in this type (19 times in 20 cases), it supjilies the muscles in the first and second interspaces.

The acromio-thoracic (A. thoraco-acromialis) rises from Part I. about midway between the clavicle and upper border of the pectoralis minor, runs almost directly anteriorly and divides into the (1) thoracic branch, (2) the acromio-humeral and (3) clavicular branch.

This artery is the most constant in this type, being present in ail 20 cases. The thoracic branch turns downward beneatli the pectoralis minor, giving off branch to the pectoralis major and minor, and to the second and third intercostal spaces and the overlying skin. The acromio-humeral branch runs upward and outward across the costo-coracoid membrane over the coracoid process of the scapula and gives a branch to the acromion and accompanying the cejihalic vein between the deltoid and pectoralis major breaks into branches, supplying these two muscles and the snrnuinding fascia and skin. The clavicular branch is a small branch which turns upward to sujiply the subclavius muscle.

Tlie subscapular artery arises from the axillary trunk at the lower border of the subscapularis muscle and takes a downward and inward course through the axilla. Near its origin it gives off a branch to the subscapular muscle and a large branch, the dorsal scajiular, which passes through the triangular space formed iiy the subsca]iularis, teres major and long head of the triceps, to the dorsum of the scapula, sup]ilying the muscles of that region. A small branch to the teres major muscle then comes from the subscapular trunk as it crosses that miscle, and before it splits into the thoracic iir anterior branch and its posterior or muscular branch. The thoracic branch crosses the base of the axilla from the back to the front and supplies the serratus magnus, the fourth and fifth interspaces, and the adjacent skin. The posterior branch continues the downward and backward course of the subscapular trunk tn end in the serratus magnus, and the latissimus dorsi, giving off numerous branches to these muscles.

Two small muscle branches are given oft' to the coracobrachialis and biceps.

From the anterior portion of the axillai'y trunk a small artery, the anterior circumflex, rises, passes beneath the coraco-brachialis aJid biceps and sends a branch to the joint by way of the bicipital groove and a branch around the arm to anastomose with the posterior circumflex artery. In its course it gives otf brandies to the overlying muscles. At aiiout the same level and from the posterior portion of the axillary artery the posterior circumflex takes its origin, passes downward and backward through the space bounded by the teres minor, long head of the triceps, teres major and the humerus, winds around the neck of the humerus, supplying the deltoid, the joint, the triceps, and the adjacent skin


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JOHNS HOPKINS HOSPITAL BULLETIN.


[No.s. 121-123-123.


iml anastomoses with the anturior circumflex artery and bufierior profunda artery.

Type II (Fig. 3 and Table II).

Tlie braiulics in type II are conveniently arranged according to the following plan:


C Superior tlioracic.


Parti.


] Acromio-tluiracic.

L

Part II. j Long tboracic.


!1. Thoracic braucli. 2. Acromio-lnimeral 1 o. Clavicular braucli.


branch.


Part III.


Subscapular.


C 1. Dorsal scapular. I 2. Muscular branches.


1^ 3. Posterior branch.

». , ( Anterior circumtlex. Trunk. - „ , • • „

^ Posterior eircumfle.x.


This type ditl'er.'; fmni tyiie 1 only by the presence of a branch from the part II of the axillary trunk and corresponds



Fig. 3. — Type II of the axillary artery. Present '.) times in 47 cases.

with the description of the axillary artery usually given in the text-books. This branch from the second part of the artery bears the name long thoracic (A. thoracalis lateralis). It takes its origin beneath the pectoralis minor, courses downward along the lower border of this muscle, supplying it, the serratus magnus, and the third, fourth and fifth interspaces. In its course it gives off small branches to the fascia of the axilla, and terminal branches which piercing the pectoralis major terminate in the overlying skin. The other arterial branches have the same origin and distribution as described in type I, except that the intercostal areas of the thoracic branch of the acromio-thoracic artery and the thoracic branch of the subscajnilar artery are replaced wholly or in part by this branch from part II. The anterior and posterior circumflex arteries arise by a common trunk but otherwise their course and distribution correspond to the description gi-ven under type I.


Type 111 (Fig. 3 and Tai;le III).


Part I.


f Superior thorjicic

I

J

! .\cromio-th'_'racic.


Thoracic br. A croniio- humeral. Clavicular. C I. Thoracic branch. I 3. Muscular branches. I H. Posterior circumflex. "j 4. Dorsales scapulae. I r>. Anterior branch. [ G. Posterior " ( Ascending. .\nterior circumflex. I

( Anastomotic.


Part II. Subscapular


Part III


The branches from part I are similar in their origin and distribution to those described in type I. From part II a large subscajnilar artery takes its origin. It immediately gives off a l)ranch (tlioracic) which supplies the serratus magnus and crossing the axilla licmeath the pectoralis minor



Fig.


-Type III of the axillary artery. Present 7 times in 47 cases.


supplies that muscle and the second, third and fourth interspaces. Just above the lower border of the pectoralis minor a larger branch descends which gives off the posterior circumflex dorsal scapular, and muscular branches and terminates in an anterior branch to the fifth interspace and serratus and a posterior branch to latissimus dorsi and serratus. From the drawing and description the thoracic branch of this artery can be seen to correspond with the description of the " long thoracic " artery, while the lower descending branch corresponds to the description usually allotted to the subscapular artery. The artery, however, can lie Ijetter descriljed as the subscapular artery because, as is seen in type I, the subscapular artery does supply the mid-thoracic region and because the long thoracic artery is so often absent. The anterior circumflex has the same origin and distribution as that given it under type I.


Apeil-Mat-June, 1901.]


JOHNS HOPKINS HOSPITAL BULLETIN.


139


Type IV (Fig. 1 axd Table IV).

In type IV the aeromio-thoracic artery commonly fonnd in part I is foimd arising from part II of the axillary trnnk. The distribiition of the branches in this type is similar to that given nndor type I (the snperior thoracic supplying the



Fig. 4. — Type IV of tlie axillary artury. Present 4 times in 47 cases.

first interspace only), with an added lirancli to the subseapnlaris mnscle which, taking its origin from part I, turns backward and downward, passes between the trunks of the brachial plexus and ends in the subscapularis muscle.


( Superior thoracic. Part I. )

( Braneli to M. subscapularis f Tboi'aci

Part II. Aeromio-thoracic. '


i Clavicular. I Acromio-bunieral. ^ Acromial. (^ ( Muscular.

C ., , , , ( Coraco-bracliialis.

I Muscular branch. - „.

( Bleeps.

I pi. Muscular.

T, , „, ' , , , I 2. Dorsal scapular.

Part III. -; Subscapular. >,.,,,■

'^ ' 3. Anterior.

[_ 4. Posterior.

„ , ( Anterior circumllex. i Trunk. < r, , • [ (Posterior "


Type V (Fig. 5 and Table V).

From the table aud drawing it is readily seen that practically the wliole jiectoral area, the thoracic and subscapular regions, are supplied by an artery given off from part II of the axillary artery. From the table it will be noticed that this was the case twice, while in the third case two arteries with the same distribution as the above mentioned trunk have separate origins from the main trunk. In this latter case the origins of the two arteries supplying this whole area were so close together that for practical purposes they can bo called a common trunk and are incorporated as such in the drawing of tin's type. It is important, however, to re


member that type V may be represented by two branches rising close together from part II, as is seen by the drawing given for that type. In one ease the trunk had an even larger area of distribution than is shown in the drawing, the anterior and posterior circumflex regions being supplied by




3—


m


^


^^


sA



s

If


Fig. 5. — Type V of tlie axillary artery. Present "• tinics'iu 47 cases.

branches from the large trunk from part II. These two variations in type V are given because future research may show that one of these variations is more common than that found to be most frequent in my observations.


Part I.


Part II.


I Superior thoracic (small).

f c Thoracic branch.

. . ■ .1 • ! . ■ ( Clavicular.

1. Acromio-thoracic. J Acromio- \ . . ,

, , J. Acromial,

humeral. 1 ., [ ( Muscular.

2. Long thoracic.

[' Muscular.

., „ , , I Dorsal scapular.

i. subscapular. ■ . , • . ■

] Anterior branch.

[_ Posterior " Anterior circumflex.


Part III.


( Anterior ( Posterio


In the above schema I have called the branches by their adopted names, and the distribution of each branch from this trunk is similar to the distribution described under types I and II.

Type VI (Fig. G and Table VI).

This type existed but twice in the dissections observed and is remarkable for the number of branches wliicli ari.'^e from part I.


Part I.


f Superior thoracic. Aeromio-thoracic.


I Pectoral branch. Long tlioracic.


{Clavicular. Acromial. Deltoid. ( Muscular. ( Intercostal.


I


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JOHNS HOPKINS HOSPITAL BULLETIN.


[Nos. 121-122-123.


Part II. No branches, f Dorsal scapular.

r „ , , I Muscular.

Subscapular -(..., ,

I ^ ' Anterior branch.

,,. J l_ Posterior "


Part


j Trunk.


f Anterior circumflex. \ Posterior "

The superior thoracic is small, giving a twig to the upper digitations of the serratus and ends in the first interspace.



Fig. 6. — Type VI of the axillary artery. Present '2 times in 47 cases.

TIlis type shows to a marked degree a variation which occurs in the origin of the acroniio-thoracic artery, i. e. a separate origin of its pectoral or tlioracie branch, while the artery designated as the acromio-thoracic is merely the acromio-hunieral division of that artery. From the table it will be noticed (line 2, table VI) that tlie thoracic branch of the acromiothoracic artery was ]n-eseut in one case. My notes on this case mention the fact tliat this branch was extremely small and that the area usually completely supplied by it receives most of its blood-supply from a branch rising from the main trunk. This pectoral branch rises from the trunk slightly above or just adjacent to the origin of the acromio-thoracic artery, courses downward and forward, supplying the pectoralis major and minor and the second, third and fourth intercostal spaces. The long thoracic artery, except for its origin, is similar to that described under type II.

The subscapular artery is the same as that of type I, and the trunk common to anterior and posterior circumflex arteries is the same as that of type II.

Type VII (Fig. 7 and Tablk VII).

Type VII occurred but twice in the records made. In this type, as in type VI, the thoracic branch of the acromiohumeral artery is very small, being represented by a small twig to the pectoralis minor, while its area of distribution is supplied by a branch from the large subscapular artery; in type VI it was supplied by a separate branch from the axillary trunk.


[■ Acromio-thoracic.


Part I.


Part II.


I




Thoracic.

Clavicular.

Acromio-humeral.


Acromial. Muscular.


Pectoral.


Subscapular.


No branches.


j Upper division, j Lower " ■{ Muscular. ! Dorsal scapular.

Anterior division. 1 Posterior '*



1 >.


F:q. 7. — Type VII of the axillary artery. Present 2 times in 47 cases.


Part III. Trunlc.


C Muscular branch.

„ , ( Anterior circumflex. ■^ Trunk.


I


( Posterior Superior profunda.


In this type the superior thdracic is absent and its area of distrilnition is supplied by the suliscapular.

The cromio-thoracic is the same as type 1; while the thoracic or pectoral branch is small. The subscapular arises well above the upper border of the pectoralis minor, turns downward beneath that muscle and supplies the whole thoracic, pectoral and subscapular regions. Part III gives off a large trunk which runs parallel to the main artery, gives off branches to the eoraco-brachialis and biceps, and a trunk wliich immediately splits to form the anterior and posterior oircumtiex arteries (distribution similar to that under type I), and then turning down, out and back passes through the musculo-spiral groove to become the superior profunda artery.

In the first part of this paper the types into which the axillary artery fell are discussed and it is my intention in this portion to discuss the individual branches with their origin, distribution and variations.

Superior Thoracic. — This artery was remarkably constant, appearing 40 times in the 47 cases here tabulated. In the 7 cases in which it was absent it was supjilied by the acromiothoracic in 4 cases. This is the condition described as normal by Testut, Sappey and Cruveilhier. In 2 cases the subscapular supplied its area (type III), and in one case a large trunk from paxt II of the axillary (type V). The artery was most frequently distributed to the first and second interspaces,


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JOHNS HOPKINS HOSPITAL BULLETIN.


141


as in type I. In 4 cases, however, the artery was distinctly longer than normal and rising high up in the axilla, turned directly downward and passed along the lateral thoracic wall, supplying the interspaces from 1 to 4 (in 2 cases the 5th also) and the serratus magnus muscle. This artery was in close relation to the posterior thoracic nerve, heing anterior to it and separated from it by an accompanying vein. As far as can he ascertained, this artery has not been described before. In one of these cases the artery was of considerable size and gave branches to the glandular contents of the axilla and sent numerous branches forward in the intercostal spaces. In some respects it corresponds to the long thoracic, hut owing to its presence in a case in which the long thoracic was present also, and its origin near that ascribed to the superior thoracic, it has been included in the description of the superior thoracic artery.

Acromio-tlwracic Artery. — This branch, the most constant of the axillary subdivisions, came from part I in 40 cases, from part II in 5 cases and in the remaining 2 cases came from the trunk common to it, the subscapular and long thoracic arteries (type V). For convenience of description the following schema of the acromio-thoracic artery will be found very useful.


Acromio-thorac


J Pectoral brai

ic. } Clavicular bi

^ Acromio-huE


Pectoral branch, branch, imeral brauch.


The pectoral branch of this artery was present 43 times in the 47 dissections. In the 4 cases in which it was absent its area of distribution was supplied by a pectoral branch from the axillary trunk in 3 cases (type VI), and in one case from the subscapular (type VII), which shows the thoracic branch present although small. This pectoral division of the acromio-thoracic trunk is very variable in size, occasionally beinglarge, in which case it supplies the pectoral muscles, the second to fifth interspaces, and the serratus magnus and latissimus dorsi. In those eases in which there is a long thoracic artery present, it is smaller than in the first instance and is limited to the pectoral muscles and the upper interspaces. Occasionally it is very 'small, being merely a muscular branch to the pectoral muscles, and its area in this case is more completely supplied by branches from the long thoracic, the subscapular or by pectoral branches from the main trunk.

The clavicular branch is a small artery which was present 43 times in the 47 dissections. In the 4 cases in which it is absent 3 cases show no artery to this area from any of the axillary subdivisions; in one case it was supplied by a branch from the main trunk. The acroniio-humeral branch is the most constant subdivision of the acromio-thoracic, and in those cases in which the pectoral branch is absent, it, with the clavicular branch, forms the acromio-thoracic artery. In the discussion of this subject under type VI, I have suggested that this artery is merely the acromio-humeral artery and not the acromio-thoracic, since it lacks the thoracic or pectoral portion. Its distribution is also constant. In one case the humeral or descending branch was small, the anterior cir


cumflex artery in this case being large and sending off large ascending branches to the deltoid and clavicular portion of the pectoralis major. In 3 cases a branch is given off to the subscapular muscle.

The Long Thoracic. — This artery was present only 11 times as a separate branch from the a:silla.ry trunk (types II and VI) and it was with this artery that the most trouble arose in tabulating the dissections. The 11 cases here tabulated represent a large majority of the number found in all the charts received. In discussing the question of the absence or presence of a major branch from part II. it is found that in 24 cases no major branch is found, while in 23 cases there is a major trunk.

Instances in which there are no arteries from part II, tyjie I, 20; type VI, 2; type VII, 2.

Instances in which there are arteries from part II, type II, 9; type III, 7; type IV, 4; type V, 3.

The cases in which the artery, arising from part II of the axillary is the long thoracic, axe, however, less frequent, that artery being present only in the 9 cases represented by type II.

The long thoracic artery, as described by His, arises beneath the pectoralis minor, courses downward upon the serratus magnus to the fifth or sixth interspace, supplying that muscle. The external mammary branches pierce the pectoralis major and supply the skin in the mammary region. According to Testut, it arises beneath the pectoralis minor, courses obliquely downward, inward and forward along the lateral thoracic wall between the pectoralis major and the serratus magnus as far as the fifth, sixth or seventh interspace, where it terminates in anastomosis with the intercostal arteries. As it descends it gives off numerous collateral branches to the axillary glands, the subscapular muscles, the serratus magnus, pectoralis major and minor, the intercostal spaces, the mammary gland, and the antero-lateral region of the thorax. According to Quain, the long thoracic artery arises beneath the pectoralis minor, is directed downwards and inwards along tlie lower border of that muscle and is distributed to the pectoral muscle, the serratus magnus, and the breast, forming anastomosis with the intercostal arteries.

From the above descriptions it is readily seen how variable the distribution of the artery may he. My cases correspond more nearly to the description given by Quain, although in 3 of the cases the artery corresponded with tlie description given it by Testut.

The Subscapular Artery. — This artery varied consideralily in its place of origin, coming from part I in 2 cases, from part II in 8 cases, from })art III in 35 cases, and in 2 cases from the trunk common to it, the long thoracic and acromiothoracic from part II. The common distribution of this artery is that given it under type I. It may, however, vary considerably, as is seen from the description given it in type III. In four cases the artery was small, being practically only the dorsal scapular artery. In these cases its remaining areas were supplied by the long thoracic in 3 cases, and by a large thoracic branch from tlic acromio-thoracic in one case.


142


JOHNS HOPKINS HOSPITAL BULLETIN.


[Nos. 121-122-123.


(Sec table tj^pe I). The anterior and posterior circumflex areas are also supplied hy this artery, the former in 2 cases and tlie latter in 9 cases. In one case it also gave rise to tlie sujierior profunda artery. The cases in which the suliscapular included arteries usually arising from 'the axillary or brachial trunks can be classified as follows:

Subscapular -j- posterior circumflex and superior profunda.

Subscapular + posterior circumflex,

Subscapular -(- anterior circumflex.

Subscapular -|- anterior and posterior circumflex.

The Anterior Circumflex. — The* origin of this artery w'as relatively constant, conung from part III as a se])arate branch ill 22 cases and from a trunk common to it and the posterior circumflex in 21 cases. In the remaining 4 cases it took its origin from the subscajnilar in 2 cases, from a trunk common to it, the posterior circumflex and superior profunda in 1 case, and from the large trunk common to all the arteries in 1 case. Its distribution, as that given it under type I, was constant except in that case in which it was given off from the subscapular and supplied the area usually supplied by the humeral branch of the acromio-thoracic artery, that branch being small in this particular case. The cases in which the anterior circumflex is united with arteries ordinarily arising from the main artery may be grouped as follows:


.\nterior ami posterior circumflex, Subscapular ami anterior circumflex,

" " " aud posterior circumflex,


.'1 cases. 1 case. ] "


4. Truuk.


.5. Truul<.


( Auterior circumflex, "j

.j Posterior circumflex. V

( Superior profunda J

C Acromio-tlioracic. "1

I Long thoracic. [

I Subscapular. J I Anterior circumflex. |

(^ Posterior " J


The Posterior Circumflex. — This artery was ]ierhaps the most variable in origin of the axillary subdivisions being, however, constant in its distribution (see type I).

The places of origin are as follows:


1. From axillary artery.

„ ™ , f Anterior circumflex.

2. Truuk. < n i ■

\ Posterior "

3. Subscapular.


13 cases. 21 " !) "


I Posterior circumflex. \ Superior profunda. [" Acromio-tlioracic. I Long thoracic. i Subscapular. j Anterior circ-uinliex. [ Posterior " Brachial artery.


4. Truuk.


.5. Trunk.


J


The 3 trunks recorded in the table have been described elsewhere in this paper and are sufRciently clear from the table itself. The remaining muscular, cutaneous and intercostal branches are infrequent and may or may not occur. When present they are large or small as the case necessitates. The branch labelled " axillary fascia " is that which is usually described as the alar thoracic artery. It was present 8 times, its area being supplied by the larger subdivisions of the main arteries in their courses through the axilla.

The Posterior Scapular. — This artery arose from tlie axillary artery in 5 cases. The artery in its course turns backward, passes either between the trunks of the brachial jilexus or passes over them, courses along the superior margin of the scapula and then turns downward to pass parallel to the vertebral margin of the scapula. In its course it gives branches to the subscapularis, levator anguli scapuUv, trapezius, rhomboid major and rhomboid minor, supraspinatus and infraspinatus.

The suprascapular artery was found arising from the axillary artery in one ease. In one case the superior profunda was given oif in the axilla. In two cases not included in these records the axillary artery divided into the i-adial and ulnar in the axilla, and in these cases the anterior and posterior circumflex arteries and the superior profunda were given off by the radial.

The conclusions to be drawn from this study are:

(1) That while the origin of the subdivisions of the axillary artery varies, the distribution is practically constant.

(2) That type I, as here described, is the ordinary form in which the axillary artery is found.

(3) That the long thoracic artery and alar thoracic arteries are most frequently absent and that their areas of distrilmtion are supplied by the adjacent branches from the main artery.


TABLE SHOWINCx THE ORIGIN AND DISTRIBUTION OF THE BRANCHES OF THE AXILLARY ARTERY

IN FORTY-SEVEN CASES.



Origin.










D


STKIBUTION





















o


a5









(d
















ft)







u























p. n

"3

o

<y




p.




^ o


S3



o

DO





o c



a

cS

to

§





4-1

o


03





BRANCH.





03

n O


CO

o


00

s

m

o


OQ

3

00

o


s

00


o

a

a

03


a -a .2§


•a i

3



o

a o


S

a

be 03

s


'i ■§

to

9


S


a

3 'o


a

o





a o

W s- OS


•3

3

3

s

p.


O

p



— 3



S3



C3 PL,


a



a


ft>


.0


c3

o


S3 u o

o


2 a

° 2 u S


> J3


n



n

3 03



o

<o


.2


o}


c


i.



sterio scapu] perior


a s.


■d

"S


tn

OS



fU


to


C-l


CO


■*


lO


!U


p^


Ph


3 GO


3 OQ


o


0) 00


^



Pm


^.


<i


O


m


<


^ ^



a;


3


Superior thoracic


40




40


26


9


4


2






1



5















Acromio-thoracic


40


5



7 1 2


24 4 6


S4

n

22


6 11 33


2

5

41


41

1 1


38 8 8


45


4.S


3 5 43



2

11

41


1

3 41














Long thoracic


a


9







7










Subscapular


2


s


35




45


23


9


2






1


V







April-Mat-Junjs, 1901.]


JOHNS HOPKINS HOSPITAL BULLETIN.


143



Origin.


Distribution.


BRANrll.




OS


aj

V

a.

to

■3

CO

a

^ (a


(ft

C8 to


It

a>

a a


&



V

1— (


a


3J U 03

Pu

CO

"3

to



'5*

a

n

S

u a p4


a

a

■3



•a •11

a a

in

is ss

fl4



QD

o3GO


CO

03 03


s.

od


a


m

^

CO

3

a

m

IlU


'to


CO

a

'to

-5


a

[O


03

m

a

u

'u

■c

(0



a

3



.2 "0

CO

CO

fl

o3 >%


CO

2 3

u

03



g

C


to


It'

03

CJ

■5



a


■Jo

.2 9


0:

-3

d

3

2


03


t-.

a

a 1;


•3


3

CU 03

to


Auterior circumflex

Posterior circumtlex

Trunk common to anterior iiuJ posterior circumliex

Trunk common to circumflex arteries luul superior profiuulii



2


32 13

31 2



1

1


3 3

2



2


3


"2

9 .5


2


•3


3 31


•^


3 1



3


13

21

2

1


33

31

1

1

•■


8


1



9'


5


2 2



2



To subseai)ularis


15 1 3 3 5 1 1

1 1 1


.5 1

o

6 ..

1 ' ..

'2 "5

3 1 4

1 lil

1 1 19 1 ' 1

.. i ..



To pectoralis major

'I'o pectoi'alis minor



I'ectoral Ijraneli

To subclavius ami clavicle

To axillary fascia

Articular

1 st and 'Jnil interspaces

riiiil iuterspace



To coraco-brachialis .... . .


.... i 1

1 . . - ■ 1 . .


301 ..





  • 1 ■ ■


20






Posterior scapular


.5

1


I


Superior profunda



3







..





TYPE I, 20 CASES.


BRANCH.


Orioin.


Distribution.


■" ?



-5 1



E=



i-i4



ta '



rj



CO



tM


^


"


rt


a!


3



si

CO


03




« 


CO



C


^


Q


REM ARK. S.


1. Superior thoracic

2. Acromio-tboracic

3. Subscapular


4. Anterior circumflex .


5. Posterior circumflex ,


8.

9. 10. 11. 12. 13. 14. l.i.


Trunk common to anterior and posterior circumflex arteries.

To M. subscapularius

To pectoralis major

To pectoralis minor

Axillary irlands and fascia

Articular

2nd and 3rd interspaces

Coraco-bracliialis

Biceps

Posterioi- scapular


19


19


20


.51 lHil9


20


20


19


20


11


19


12


10


10


( In the absent case the region -1 was supplied by the acromio


upplied by thoracic artery.


8. times from a branch common to circumflex arteries (see line 6).

8 times from branch common to circumflex arteries, 4 times from subscapular, 1 case from brachial artery (see lines 3 aud (i).


144


JOHNS HOPKINS HOSPITAL BULLETIN.


[Nos. 121-122-123.


TYPE II, 9 CASES.



Origin,


Distribution.



BRANCH.



03


Pu


V 03

P.

m

a

CO


03

P. CO

a

1— ( •a


CO

n

T3

u

CO


6

CA 1>


0)

o

03 n

a


tA

o

Ph


1-^

o

d

a

■3

P-i


s


-" ° .2

la p-i


CO

3 CO


1

9 ft

. o3

QQ

■« 03

OS _tO

1.1

" I'So

^1^


co'

3

a

a

CO


'co t •a

CO

3

a

CO

c3

a


03

g

£

CU


0)

a

3

E

v m


Ph


M

QJ

a

3 a

'0

.2

<


sa

to 03

<H

t3

a

OD

"bt, !>. 03

'm

<1


.2 a


1


CO

p.


o3

<



a


2 3

II

2-(


03 t3

3 3

"S

u P.

.2 'n

o<

3 00


3

§•


CO

eg

p.

3


REMARKS.



7 9


11



7 3

1


4 3 2


3 3 9


1

9 3


5 6


7 1

"s


6 6

'2


9


8


5 9


9


9 6


3

6


6


1


4

1


1

4 4


3

1


3'


3


■■



1


1


Absent twice, supplied by \ acromio and long thoracic


Acromio-thoraeic


(see lines 3 and 3).

Pectoral branch absent twice, , area supplied by long thoracic ' (line 3) and pectoral branch (line 11).

( Large in 3 cases, supplying J the subscapular area in part





9


( (see line 4). Small in cases, being confined to dorsal and scapular region





4 3

4

1

1

3


1




principally (see text).

For remaining place of origin see lines 4 and 7.

( For remaining places of origin j see lines 4, 7 and 8.

f For other origins of circumflex \ arteries, see lines 4, 5, 6 and 8.





7. Trunk, common to anterior and

posterior circumtiex arteries .

8 Trunk




9. Branch to M. siibscapularis


3

1 2


1

1

1



1 1 Pectoral lirauch



12 Articular











1










•;





TYPE III, 7 CASES.



6

7


7


4

1

3

>


1

]

1 1


6

3 1

2


.5

4 4

3


2

3 .5


2

7


2

7


7


6

a

1


7


7


7 2


7


7


7



3

1 3


4 3


2

1


3


3


3


1


1



( Absent once, supplied by ■1 acromio-thoraeic and sub

3. Acromio-thoraeic


( scapular.


4 Anterior circumtiex



For 3 remaining cases see line 6.


5. Posterior circumflex

6. Trunk, common to anterior and

Ijosterior circumflex

7. M. subscapiilaris

8 M coraco-bracbialis



1

] 1

1 1


J From subscapular in 3 cases. } From trunk (line 6) in 3 cases.

See lines 4 and .5.





10 Articular . .




11. 1st and 3ud interspaces

12. Br to deltoid


3



13 M pectoralis minor ...












1






April-Mat-June, 1901.]


JOHNS HOPKINS HOSPITAL BULLETIN.


145













TYPE


IV,


4 CASES.












Origin


Distribution.



■ BRANCH.


3H


rt ^



V

as P.

c

oa


75


o


a m

0)

a


cS

ZJ

a;

+-> a

xa


a

o


o a

a

rXi

O

0.



a

o

XK


03

u

V3 1/1


03

3 D. si

CO

33 cfi

O -O

o 'Sii

V


03

3

a

M

a

03


o ■a

CO

3

a

m '■H


o

a

CO

2


S

CJ

o .2

to

o Ph


a

t-.

j O

V

<


w T3

a

00

CI t^

<5


to

X2

6

o o


D.


03

3 o

«1


s.

03 CJ

en

a

o

0)

o

V

-«J m

O Ph


03 T3 3 3

CH O ^

P.

_o a

3


REMARKS.


1. Superior thoracic

8. Acromio-tlioracic


3


4


4

1 1

a

3

1 1


3

1


1

4


4 3


1

4


4


4


3


4


3


1 4

3


4


4


4


3


1

1 o

"*


1 1


1 1


3


s


"


• 1


1


j Absent once, supplied by acro( mio-thoracic (see line 2).


4 Anterior circumflex




j For 3 remaining cases, see lines





( 3 and 6.


6. Circumflex trunk





See lines 3 4 and 5



3


1



3



8. M. coraeo-brachialis

9. M. biceps


j No branch from axillary, supplied ( by brachial in 1 case. Same.




2





Represented by a definite branch twice (see line 3 for 1 case)


13. Posterior scapular


1



remainder supplied by various arteries. See text


13. Superior profunda


See text

















TYPE


V


, 3 CASES.











1. Superior thoracic


2


1

1 2



3

1


1

I 2


1 2


1 2


1 3


1

3


1 1 2


1 2


1 2


1 1 2


1 3


i'

2


1 2


3


1 3


1

9


1








3. .\cromio. thoracic



3. Subscapular




See lines 2 and 3.


5. Anterior circumflex

6. Posterior circumflex

7. Trunk, common to anterior

posterior circumflex


and


















TYPE


VI


,


2 CASKS.











1. Superior thoracic "


2 3 3



3

1 1

1

"i 1 1


2 '3


1 1 2

2


2

1


2 1

1


3


1

i


1

2


3


1 1


2


2



3 2

I ■

1


3



1 1


1 1


1

1



■■


• ■






i Pectoral branchabsent in onecase -j and small iu the other. Sup( plied by pectoral branch (line 8)

I Teres major supplied by dorsalis ^ scapular, getting no branches ( from subscapular direct.

See line 7 for remaining origin.

See line 7.

See lines r^ and 6. See line 2.


3. Long: thoracic

4. Subscapular


.5. Anterior circumflex




tJ. Posterior circumflex




7. Trunk, common to anterior aud posterior circumflex




8. Pectoral branch


2



9. Articular






11. Biceps






1



See line 2 for remaining case.














TYPE


VII,


2 CASES.












1 2 3



I 1

1


1

1

1


1 1


1

1


2 1


3


1


1

1

1 1


2


2



1


2


1 3


2


2


1 1


1

1


1

1





I


i


See lines 3 and 8. ("Pectoral branch absent iu 1 case (see line 8), supplied by pec

2. Acromio-thoracic



toral branch and by sub [ scapular (see line 3).


4. Circumflex trunk


For remaining case see line 5. See line 4.


.5. Trunk






1


7. Pectoralis minor



8. Pectoral branch



j See line 3. Supplies pectoral


9. Axillary glands aud fascia


I area of acromio-thoracic Was present as a rather large artery both in this case and in that from the subscapular (see line 3).