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glands, one or two in number, lie on the medial side of the basilic vein, a short distance proximal to the medial epicondyle of the humerus. They receive lymph from both aspects and from the ulnar border of the forearm, and their efferents pass to the deep glands of the arm.
(2) Lymphoglandulæ Cubitales Profundæ.-Occasionally small glands are found in association with the arteries of the forearm, but in most cases the lymph from the deeper parts of the hand and forearm, below the region of the elbow, passes to the deep cubital glands or to the brachial or axillary glands.
FIG. 806.-DISSECTION OF AXILLA AND ANTERIOR PART OF THORACIC WALL, SHOWING LYMPH GLANDS
The deep cubital lymph glands lie anterior to the elbow in the neighbourhood of the terminal part of the brachial artery. They receive many of the deep lymph vessels of the forearm and their efferents pass to the brachial and axillary glands.
Brachial lymph glands, irregular in number and size, are found along the course. of the brachial artery. Their afferents are derived from the forearm, from the deep cubital and superficial cubital glands, from adjacent parts, and from the elbowjoint. Their efferents end in lateral group of axillary glands.
In addition to the glands which lie along the course of the brachial artery other deep glands are occasionally met with in the arm. (1) One in the sulcus
between the brachioradialis and the brachialis; (2) another in the radial sulcus. When they are present both of these glands receive lymph from the ligaments of the elbow-joint as well as from other adjacent soft parts.
Lymphoglandulæ Axillares1The axillary lymph glands lie in the region of the axilla, where they form several groups, some of which are practically constant, whilst others are very variable.
(a) The lateral or brachial group of axillary lymph glands, 1-7, lies in relation with the lateral boundary of the axillary space along the line of the great axillary vessels. The glands receive the lymph from the greater part of the upper extremity. Their efferents anastomose with the lymph vessels of the central glands; some terminate in the inferior deep cervical glands and others pass to the subclavian lymph trunk (Fig. 806).
(b) The posterior or subscapular lymph glands lie in relation with the posterior wall of the axilla, along the line of the subscapular vessels. Their afferents are the vessels of the lateral and posterior walls of the body, above the level of the umbilicus, and lymph vessels from the lower and posterior part of the neck. Their efferents join the lateral, the central, and the infraclavicular axillary glands (Fig. 806).
(c) The anterior or pectoral group of axillary lymph glands, 2-4, lies along the line of the lateral thoracic artery, in the angle between the lower border of the pectoralis major and the serratus anterior. The glands extend from the third to the sixth intercostal space, sometimes in a single and sometimes in a double row. Occasionally one or two outlying members of this group, called the paramammary glands, are found on the superficial surface of the pectoralis major. The afferents of the
1 The B.N.A. axillary lymph glands are the lateral glands of the axilla, but, as the other groups mentioned also lie in the axillary region, the general term " axillary" is used here to include all the groups.
FIG. 807.-SUPERFICIAL LYMPH VESSELS OF THE TRUNK, AND THE LYMPH GLANDS AND VESSELS-SUPERFICIAL AND DEEP-OF THE LIMBS (diagrammatic). All superficial lymph vessels are printed black; the deep lymph vessels throughout are coloured red. Afferent vessels are represented by continuous lines; efferent and interglandular vessels by dotted lines.
A.A. Anterior axillary glands. E.A. Lateral axillary glands.
A.C. Superficial cubital glands.
Superficial subinguinal glands.
P.A. Posterior axillary glands.
anterior glands are derived from the anterior wall of the body above the umbilicus from the lateral two-thirds of the mamma. Their efferents pass to the central, lateral, and infra-clavicular axillary glands (Fig. 806).
(d) The central axillary lymph glands, 2-6, lie in the central part of the axilla, and frequently along the line of the intercosto-brachial nerve. They receive afferents from the anterior, the subscapular, and the lateral glands. Their efferents pass to the infra-clavicular glands (Fig. 806).
(e) The subpectoral group of axillary lymph glands, 3-14, is formed by several small glands which lie posterior to the pectoralis minor and anterior or medial to the axillary artery. They receive lymph from the glands situated at a lower level and from the lateral wall of the thorax. Their efferents pass to the infra-clavicular glands.
(f) The infra-clavicular group of axillary lymph glands, 1-11, lies in the region between the upper border of the pectoralis minor and the clavicle, along the medial side of the axillary artery. The glands receive efferents from the arm, from the other groups of axillary glands, and directly from the mamma and the pectoral muscles, along the line of the pectoral branches of the thoraco-acromial artery, and from the inter-pectoral glands. Their efferents pass to the inferior deep cervical glands and to the subclavian lymph trunk (Fig. 806).
(9) A delto-pectoral lymph gland is occasionally found in the groove between the deltoid and the pectoralis major muscles. It receives afferents from the superficial parts of the arm and the shoulder, and gives efferents to the subclavian trunk and to the infra-clavicular glands.
(h) Small inter-pectoral lymph glands are sometimes found between the great and small pectoral muscles. They are connected with the lymph vessels which pass from the posterior part of the mamma to the infra-clavicular glands (Fig. 806).
THE LYMPH VESSELS OF THE SUPERIOR EXTREMITY.
The lymph vessels of the superior extremity, like the glands, form two groups-(1) superficial, and (2) deep.
(1) The superficial lymph vessels lie in the skin and the subcutaneous tissues. They commence in cutaneous plexuses, which are finest and most dense on the volar aspects of the fingers and hand. The efferents from the volar digital plexus of each finger pass to the dorsum of the digit. There they unite to form dorsal digital vessels, 2-4, which run to the dorsum of the hand where they unite together to form new vessels.
FIG. 808.-SUPERFICIAL LYMPHATICS OF THE DIGITS AND OF THE DORSAL ASPECT OF THE HAND.
The efferents from the volar plexus of the hand run proximally, distally, and to the lateral and medial margins of the hand. The lateral efferents, as they turn round the lateral border of the hand, join the efferents of the thumb. The medial efferents turn round the medial border of the hand, and join the efferents of the little finger. The afferents which run proximally are few and variable; when they are present they lie along the line of the superficial median vein of the forearm. The efferents which run distally pass to the interdigital clefts where they turn dorsally and join the vessels on the dorsum of the hand (Figs. 807, 808).
As the superficial lymphatics pass towards the elbow they tend to form two main streams(1) a lateral stream which accompanies the cephalic vein, and (2) a medial stream which accompanies the basilic vein. The lymph vessels which commence on the dorsum of the hand and forearm converge to one or other of the two main groups of vessels. In the region of
the elbow the vessels of the two streams anastomose together and some pass through the fase a and join the deep cubital glands.
As they pass from the forearm to the arm, the majority of the lymph vessels conver towards the medial side. Some join the superficial cubital glands, but others pass those gland and accompany their efferents, along the basilic vein, to the axilla where they join the later. group of axillary glands. There is, however, a varying number of lymph vessels, from the lateral stream of the forearm, which accompany the cephalic vein in the arm. Some of these terminate in the delto-pectoral gland, if it is present, but, whether it is present or not, some pass directly to the infra-clavicular glands.
The superficial lymph vessels of the arm terminate, for the most part, in the lateral grou of axillary glands.
The deep lymph vessels of the upper extremity accompany the deeper blood-vessels. Some of the lymph vessels of the hand and forearm end in the deep glands, which are occasionally present in the forearm, but the majority either end in the deep cubital glands, or they pass directly to the lateral group of axillary glands.
The Lymph Vessels of the Mamma.-As the mamma is a modified skin gland, and as it is embedded in the superficial fascia, the lymph vessels which issue from it pass first into the superficial fascia and thence into the deep fascia. Having traverse! the deep fascia, more or less obliquely, they either end in lymph glands or enter and traverse other layers of the body wall.
The main outflow of lymph from the substance of the mamma is towards the areola, where a subcutaneous plexus of lymph vessels is formed. From that plexus two or more main vessels of large size pass laterally (Fig. 806), pierce the deep fascia and join the anterior group of axillary glands. There are, however, other groups of vessels by which lymph may pass from the mamma. Some vessels issue from the medial border of the gland and run along the lines of the neighbouring anterior perforating branches of the internal mammary artery to the anterior ends of the intercostal spaces; there they pass through the deeper parts of the thoracic wall and end in the sternal lymph glands. Clinical evidence (Sampson Handley) has shown that some vessels, from the lower and medial part of the gland, pass to the angle between the seventh rib and the xiphoid process, where they pierce the fibrous layers of the abdominal wall and join the lymph vessels in the extra-peritoneal fascia of the upper part of the abdomen. It is through those vessels that cancer cells not uncommonly travel from the mamma to the abdomen (Fig. 806).
Lymph vessels pass also from the deep part of the mammary gland, through the deep fascia and the pectoralis major, and then ascend, along the line of the pectoral branches of the thoraco-acromial artery, to the infra-clavicular region, where they terminate either in the inter-pectoral or the infra-clavicular glands, or in both groups It is possible that some of those vessels, after piercing the costo-coracoid membrane, may pass directly to the inferior deep cervical glands (Fig. 806).
It is stated, further, that some of the lymph vessels which issue from the mamms pierce the whole thickness of the thoracic wall and join the lymph vessels which lie in the endo-thoracic fascia, which intervenes between the ribs and the intercostal muscles externally and the pleural membrane internally.
THE LYMPH GLANDS OF THE THORAX.
The lymph glands of the thorax form 5 named groups, with subdivisions.
(1) Lymphoglandulæ Sternales. The sternal lymph glands form two groups each of which lies at the corresponding margin of the sternum along the line of the internal mammary artery. The glands are variable in number (4-18) and in size. They receive afferents from the upper part of the muscles of the abdominal wall. from the diaphragm, from the anterior part of the wall of the thorax, and from the medial portions of the mammæ. Their efferents communicate with the upper anterior mediastinal glands and with the inferior deep cervical glands, and they terminate on the right side in the right lymphatic or the right broncho-mediastinal duct and on the left in the thoracic duct. Occasionally, also, they end directly in the internal jugular or the subclavian vein.
(2) Lymphoglandulæ Intercostales.-The intercostal lymph glands are lateral and medial. The lateral glands lie in the posterior parts of the intercostal spaces, the medial are placed in front of the heads of the ribs. Their afferents are derived from the boundaries and contents of the spaces. The efferents of the glands of the upper spaces pass either to the posterior mediastinal glands or to the thoracic
duct. Those of the lower spaces, on each side, form a descending trunk which passes through the aortic opening of the diaphragm and ends in the cisterna chyli. 1 mort sin
o yoT augadgoes
(3) Lympho-oloring glandulæ Medi-zeroing. astinales An-Bad teriores.-The
anterior medias-odobond or tinal lymph glands form two groups, a lower and an upper. The lower group consists of 3 or 4 glands, and is situated, posterior to the ster-or num, in the lower part of the anterior mediastinum. It receives afferents from immediately adjacent parts and from the liver and the diaphragm. Its efferents communicate with utid? the upper ante-nd-odoma rior mediastinal
glands, and they
The upper djanor group consists of from 8 to 19 glands which lie posterior to the manubrium sterni and anterior to the thymus and the great vessels of the superior mediastinum. Their afferents are derived from the lower group of anterior medias-F tinal glands, from laido the pericardium, Afferent vessels are represented by continuous lines, and efferent and interglandular the heart, the Vessels by dotted lines. M. thymus, the thyMediastinal glands and vessels. P.A. Pre-aortic glands and vessels. reoid gland, and Tandon R.C. Cisterna chyli. from the sternal Their glands. efferents pass mainly to the broncho-mediastinal trunk, but they communicate with the medial inferior deep cervical glands and possibly also with the thoracic duct.
Right lymphatic duct,
T.D. Thoracic duct.