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(4) Lymphoglandulæ Mediastinales Posteriores.-The posterior mediastinal lymph glands, 8-12, lie along the descending part of the thoracic aorta and the thoracic part of the oesophagus. They receive afferents from the diaphragm, the
FIG. 810.-THE GLANDS IN RELATION TO THE TRACHEA AND THE
pericardium, the œsophagus, and other immediately adjacent tissues. Some of their efferents join the thoracic duct, others the broncho-mediastinal trunk, and some pass to the bronchial glands.
(5) Lymphoglandulæ Bronchiales.-Under the term bronchial lymph glands are included all the lymph glands which are closely associated with the walls of the intrathoracic part of the trachea and with the main bronchi and their intrapulmonary branches. The glands are extremely numerous, and they are conveniently classified, by Bartels, into four groups (1) tracheo-bronchial right and left; (2) the glands of the bifurcation, also called intertracheo-bronchial; (3) bronchopulmonary; (4) pulmonary. At birth and for some years afterwards they are pink in colour, but later they become blackened by the deposit of carbonaceous particles derived from the atmosphere.
(1) The Tracheo-Bronchial Lymph Glands are those which are situated in the lateral angle between the trachea and the bronchus, on each side. On the right side they vary in number from 5 to 9, on the left from 3 to 6. Those on the left are in close relation with the left recurrent nerve. afferents are derived from the other groups of bronchial glands and from the adjacent parts of the trachea and bronchi. They are connected with the anterior and posterior mediastinal glands. Their efferents pass to the broncho-mediastinal trunk and also to the inferior deep cervical glands. They are associated, also, by interglandular vessels, with the paratracheal glands.
(2) The Lymph Glands of the Bifurcation (intertracheo-bronchial) lie below the trachea, in the angle between the two main bronchi. They are situated between the roots of the great vessels anteriorly and the oesophagus and the aorta posteriorly. Their afferents are derived from the broncho-pulmonary glands and from adjacent parts; their efferents terminate in the tracheo-bronchial glands. They are connected with the posterior mediastinal glands.
(3) The Broncho-Pulmonary Lymph Glands. Each group of broncho-pulmonary glands, right and left, lies in the hilum of the corresponding lung, in the angles between the branches of the bronchial tube. The glands vary considerably in number, and they receive afferents, either directly or through the pulmonary glands, from the lung substance. They also receive afferents from the pleura; and their efferents pass to the tracheo-bronchial glands and to the glands of the bifurcation.
(4) The Pulmonary Lymph Glands lie in the lung substance and usually in the angles between two bronchial tubes. Their afferents are derived from the lung substance, and their efferents pass to the broncho-pulmonary glands.
THE LYMPH VESSELS OF THE THORAX.
The lymph vessels of the thorax form two main groups-(a) the vessels of the thoracic wall, and (b) the vessels of the contents of the thorax.
(a) The Lymph Vessels of the Thoracic Wall are the intercostal lymph vessels and the lymph vessels of the diaphragm.
(1) The Intercostal Lymph Vessels receive lymph from the ribs and from the content of the intercostal spaces, and they terminate in the intercostal and sternal glands. Communications are said to exist between the intercostal vessels and the glands of the axilla.
(2) The Lymph Vessels of the Diaphragm.-The lymph vessels from the anterior part of the diaphragm pass to the lower sternal and anterior mediastinal glands, and those from the posterior part to the posterior mediastinal glands.
(b) The Lymph Vessels of the Contents of the Thorax are:
(1) The Lymph Vessels of the Heart, which follow the courses of the coronary arteries, and pass to the anterior mediastinal glands.
(2) The Lymph Vessels of the Pericardium, which terminate in adjacent glands.
(3) The Lymph Vessels of the Thymus, some of which pass to the anterior mediastinal glands, some to the tracheo-bronchial glands, others to the medial inferior deep cervical glands.
(4) The Lymph Vessels of the Thoracic Part of the Esophagus, which are separable into upper and lower groups. The upper pass to the bronchial, the posterior mediastinal, and the lower deep cervical glands. The lower group end in the glands situated at the cardiac end of the stomach. The two groups anastomose together.
(5) The Lymph Vessels of the Pleura. The vessels from the apical parts of the parietal portion of the pleura pass to the adjacent lymph trunks or their tributaries. The vessels from the posterior part of the parietal pleura join the intercostal glands, and those from the anterior part end in the sternal glands.
The Lymph Vessels of the Lungs and the Visceral Pleura pass to the broncho-pulmonary glands.
THE LYMPH GLANDS OF THE
The lymph glands of the inferior extremity, like those of the superior, are separable into a superficial and a deep group.
The Superficial Lymph Glands lie, almost entirely, in the subinguinal region, though occasionally one or more may be situated above the level of the inguinal ligament, and therefore in the inguinal region. On this account they are separated in the B.N.A. into inguinal and subinguinal groups. Both groups lie in the superficial fascia.
Lymphoglandulæ Inguinales. The inguinal lymph glands, when they exist, are merely scattered members of the subinguinal group which lie above the level of the inguinal ligament. They receive afferents from the lower and anterior part of the abdominal wall. Their efferents terminate either in the superficial or the deep subinguinal glands.
Lymphoglandulæ Subinguinales Superficiales. -The superficial subinguinal glands (Figs. 811, 817) form two groups, a proximal and a distal, each of which is separable into medial and lateral parts; but the various members of the groups are intimately connected together by communicating vessels.
The proximal group lies along the line of the inguinal ligament. It may extend from the anterior FIG. 811.-DIAGRAM OF THE LYMPH superior spine of the ilium to the pubic tubercle. Its lateral members receive afferents from the lower and
lateral part of the abdominal wall, from the buttock, and the proximal and lateral part of the thigh.
The more medial members of the proximal group receive afferents from the anal canal, the perineum, the scrotum, the penis, and the pubic region in the male,
Lymph vessels which pass to the proximal superficial subinguinal glands
Lymph vessels which pass to distal group of superficial subinguinal glands
and from the corresponding parts, including the lower part of the vagina, in the female.
The distal group of superficial subinguinal glands lies along the line of the proximal part of the great saphenous vein-some on its lateral and some on its medial side. They receive afferents bearing lymph from the superficies of the greater part of the inferior extremity, with the exception of the lateral part of the foot, the heel, and a part of the posterior aspect of the leg.
The efferents of both proximal and distal groups of subinguinal glands pass to the deep subinguinal glands.
The Deep Lymph Glands of the inferior extremity are the popliteal and the deep subinguinal glands. Occasionally a deep gland is met with in the leg in relation with the proximal third of the anterior tibial artery.
Lymphoglandulæ Poplites.-The popliteal lymph glands (Fig. 812) lie in the popliteal fossa. One is usually situated, comparatively superficially, at the point where the small saphenous vein pierces the deep fascia and enters the fossa. It receives afferents, which accompany the small saphenous vein, from the lateral part of the foot, the heel, and the posterior part of the calf. Its efferents pass to the deeper glands.
The deeper glands lie in the fat around the popliteal vessels and are sometimes separated into inter-condylar and supra-condylar groups. Their afferents are derived from the more superficial gland and from the deeper tissues of the leg and foot. Their efferents pass to the deep subinguinal glands.
Lymphoglandulæ Subinguinales Profunda -The deep subinguinal glands (Figs. 807, 811,817, lie in the femoral trigone. They are small glands. FIG. 812.-DIAGRAM OF THE LYMPH three to seven in number, which are difficult to VESSELS OF THE POSTERIOR PART OF demonstrate. Some of them lie in the femoral canal, the most proximal being situated in or close to the femoral ring. Their afferents are the efferents of the other glands of the lower extremity, and, in addition, vessels from the deeper parts of the penis or the clitoris. Their efferents pass to the external iliac glands.
THE LOWER EXTREMITY.
THE LYMPH VESSELS OF THE INFERIOR EXTREMITY.
The arrangement of the superficial lymph vessels of the toes and the foot is very similar to that met with in the fingers and the hand. From lymph plexuses on the plantar aspect vessels pass to the dorsum of the foot and toes, where they unite into a number of vessels, the majority of which accompany the great saphenous vein and terminate in the distal superficial subinguinal glands. Some of the lymph from the lateral part of the plantar surface and from the lateral border of the foot, and the lymph from the heel enters vessels which accompany the small saphenous vein; they end either in the more superficial gland of the popliteal fossa or in the deeper glands of that region (Fig. 812).
With the exception of the lymph vessels from the lateral and posterior part of the leg, which accompany the small saphenous vein to the popliteal glands, all the superficial lymph vessels of the leg, thigh, and buttock pass to the superficial subinguinal glands; those from the leg and thigh mainly to the glands of the distal group; those of the buttock chiefly to the lateral glands of the proximal group.
The deep lymph vessels of the inferior extremity accompany the deep blood-vessels. Many of the vessels from the leg and foot end in the popliteal glands, but some pass directly to the deep subinguinal glands. The deep vessels of the more proximal parts of the inferior extremity end in the deep subinguinal glands and in the hypogastric glands.
THE LYMPH GLANDS OF THE ANTERIOR ABDOMINAL WALL.
Some lymph glands are regularly, and others are occasionally present in the anterior wall of the abdomen. Those fairly regularly present are:
The inferior epigastric lymph glands, 3-6, which lie along the course of the inferior epigastric artery. Their afferents are from the deep part of the umbilicus and their efferents pass to the inferior external iliac glands.
The Pubic Gland or Glands.-One or more small glands which lie anterior to the suspensory ligament of the penis or clitoris. Their afferents are vessels from the superficial parts of the penis or clitoris, and their efferents end in the proximal superficial subinguinal glands.
The occasional glands are:
(1) A superior epigastric gland which sometimes lies in the superficial fascia of the median part of the epigastric region. Its afferents are from the adjacent parts and its efferents pass to the sternal glands. It is probably very rare.
(2) Circumflex iliac glands, 2-4, which lie along the course of the deep circumflex iliac artery. (3) An umbilical gland which lies in the extra-peritoneal tissue below the umbilicus. When it is present it receives vessels from the umbilicus and its efferents go to the external iliac glands, (4) Supra-umbilical glands, 1-2, small glands which lie in the extra-peritoneal tissue above the umbilicus. Its afferents are from the region of the umbilicus. The efferents probably pass to the inferior anterior mediastinal glands.
THE LYMPH VESSELS OF THE ANTERIOR WALL OF THE ABDOMEN.
The superficial lymph vessels of the upper part of the anterior wall of the abdomen go, for the most part, to the anterior or pectoral group of axillary glands; but some pierce the wall of the lower part of the thorax and end in the sternal glands.
The superficial lymph vessels of the lower part of the anterior wall of the abdomen terminate either in the inguinal glands or in the proximal group of superficial subinguinal glands.
The deep lymph vessels of the upper part of the anterior abdominal wall accompany the superior epigastric vessels and terminate in the sternal glands; but some may be connected with the supra-umbilical glands if they are present.
The deep lymph vessels of the lower part of the anterior wall of the abdomen accompany the inferior epigastric vessels, and end in the inferior external iliac glands or the inferior epigastric glands.
THE LYMPH VESSELS OF THE EXTERNAL GENITALS.
The lymph vessels of the scrotum in the male and of the labia majora in the female pass to the proximal superficial subinguinal glands, and mostly to the medial group.
The superficial lymph vessels of the penis go to the medial glands of the proximal subinguinal
The deep lymph vessels of the penis, including those of the penile portion of the urethra, end either in the medial glands of the proximal subinguinal group or in the deep subinguinal glands.
The termination of the lymph vessels of the clitoris is similar to that of the lymph vessels of the penis.
LYMPH GLANDS OF THE PELVIS AND ABDOMEN.
The lymph glands of the pelvis are separable into visceral and parietal groups.
The Visceral Glands of the Pelvis.
Lymphoglandulæ Vesicales.-The lymph glands of the urinary bladder form an anterior and two lateral groups.
(a) The anterior lymph glands of the bladder are variable in number. They lie in the retro-pubic fat and receive afferents from the anterior and antero-lateral parts of the bladder wall. Their efferents go to the external iliac glands.
(b) The lateral lymph glands of the bladder lie along the course of the umbilical artery on each side. Their afferents are derived from the upper and lateral parts of the bladder and their efferents end in the external iliac glands.
Lymphoglandulæ Anorectales.-The ano-rectal lymph glands (2-8) lie in the lower part of the pelvis minor, in relation with the ampullary part of the rectum,
between its muscular wall and its external fibrous coat. Their afferents are derived from the muscular and mucous coats of the rectum and from the upper part of the anal canal, and their efferents pass to the superior hæmorrhoidal glands.
Lymphoglandula Parauterinæ. The para-uterine lymph glands (1-6), lie at the sides of the neck of the uterus in the bases of the broad ligaments. They receive afferents from the neck of the uterus and the efferents pass to the hypogastric glands.
Lymphoglandulæ Hæmorrhoidales Superiores.-The superior hæmorrhoidal lymph glands lie along the course of the superior hæmorrhoidal artery in the pelvic meso-colon. They receive afferents from the walls of the rectum, and from the ano-rectal glands. Their efferents go to the inferior mesenteric glands.
The Parietal Lymph Glands of the Pelvis.
Lymphoglandulæ Sacrales.-The sacral lymph glands, variable in number, lie along the anterior aspect of the sacrum, between the anterior sacral foramina. Upper hypogastric lymph glands