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Lymphoglandulæ Subaorticæ.-The subaortic lymph glands (1-3) lie on the anterior aspect of the fifth lumbar vertebra. Their afferents are from the sacral glands, the hypogastric glands, and the external iliac glands. Their efferents go to the aortic glands (Fig. 817).

Lymphoglandulæ Hypogastricæ.-The hypogastric lymph glands form right and left groups, which are associated with the corresponding hypogastric vessels. As a rule they lie near the origins of the main branches of the hypogastric artery, or in the angles between the branches, and they, therefore, are separable into a number of groups.

The Gluteal Lymph Glands lie in relation to the superior gluteal artery and receive afferents from the gluteal region. Their efferents pass to the common iliac glands.

The Pubo-gluteal Lymph Glands (1-2) lie in relation to the origins of the inferior gluteal and internal pudendal arteries. They receive afferents from the thigh and perineum and their efferents end in the common iliac glands.

The Middle Hæmorrhoidal Gland lies more medially than the other glands of the group, close to the lateral wall of the rectum at the point where the middle hæmorrhoidal artery breaks up into its terminal branches. It receives afferents from the rectum and gives efferents to the other hypogastric and to the external iliac glands.

The Inter-iliac Glands lie in the angle between the external iliac and the hypogastric arteries, and cannot be clearly disassociated from the medial external iliac glands. They receive afferents from the lower parts of the pelvic portions of the genito-urinary organs. Their efferents pass to the common iliac glands.

The Obturator Gland lies at the inner end of the obturator canal, above the obturator vessels. It receives afferents from the upper and medial parts of the thigh and its efferents join the inter-iliac and common iliac glands.

Lymphoglandulæ Iliacæ. The iliac lymph glands are separable into a lower group, associated with the external iliac artery, lymphoglandulæ iliacæ externæ, and an upper group, the lymphoglandulæ iliacæ communes.

The External Iliac Glands.—According to Poirier and Cuneo, the external iliac lymph glands form three chains, lateral, intermediate, and medial, which lie, respectively, at the lateral side, anterior to, and at the medial side of the external iliac vessels. The three lowest members of the group, that is the lowest member of each chain, lie in close relation to the abdominal aperture of the femoral ring, and are frequently spoken of as supra-femoral glands. They receive afferents from the superficial subinguinal and the deep subinguinal glands, from the urethra and the deeper parts of the penis, and from the portions of the abdominal wall supplied by the deep circumflex iliac and inferior epigastric arteries. Their efferents end in the upper glands of the external iliac group.

The higher members of the external iliac lymph glands receive afferents from the membranous part of the urethra, the prostate, the bladder, the vagina, and the neck of the uterus. They are connected by anastomoses with the hypogastric glands, particularly the middle hæmorrhoidal gland, and their efferents pass to the common iliac glands.

The Common Iliac Lymph Glands.-The glands of the common iliac group are sometimes separated into a lateral and intermediate and a medial series. The lateral and intermediate groups are quite distinct, the former lying along the lateral margin of the artery and the latter posterior to it, but the medial group is not clearly defined from the sub-aortic group already mentioned. Indeed the sub-aortic group may be looked upon as constituted by the medial common iliac glands of opposite sides.

The common iliac glands receive afferents from the external iliac and the hypogastric glands, and consequently from practically the whole of the pelvic contents, except the ovaries of the female.

THE LYMPH VESSELS OF THE PELVIC VISCERA.

The Lymph Vessels of the Urethra of the Male.-It has been pointed out that the lymph vessels of the greater part of the penile portion of the urethra are said to pass to the deep subinguinal glands. The lymph vessels of the bulbar and membranous parts of the

urethra have not yet been satisfactorily demonstrated, but it is stated that they pass to the hypogastric glands, to the medial supra-femoral gland of the external iliac group, and to the higher glands of the external iliac group. The lymph vessels of the prostatic part of the urethra unite with the other lymph vessels of the prostate.

The Lymph Vessels of the Prostate pass to the anterior and lateral vesical glands, to the external iliac glands, to the hypogastric glands, and to the sacral and hæmorrhoidal glands. They anastomose with the lymph vessels of the bladder and the deferent duct.

The Lymph Vessels of the Urethra of the Female have terminations corresponding with those of the vessels of the membranous and prostatic portions of the urethra of the male.

The Lymph Vessels of the Seminal Vesicle, on each side, pass to the medial glands of the external iliac group.

The Lymph Vessels of the Ductus Deferens, on each side, anastomose with those of the seminal vesicle, and they pass to the hypogastric and external iliac glands.

The Lymph Vessels of the Urinary Bladder.-Many of the lymph vessels from the anterolateral aspect of the urinary bladder pass to the corresponding anterior and lateral vesical lymph glands and, through them, become connected with the external iliac and hypogastric glands, but some apparently pass directly to the hypogastric lymph glands.

Fundus of uterus

The lymph vessels from the superior, and many from the posterior part of the bladder, on each side, end in the external iliac and hypogastric glands, but some from the posterior part pass directly to the sub-aortic glands.

The Lymph Vessels of the Ureter. Little is known of the lymph vessels of the ureter except that those of its lower extremity anastomose with the lymph vessels of the urinary bladder. It is suggested that the vessels pass to the nearest lymph glands.

Uterine tube

Lumbar lymph glands
Lymph vessels from
Ovary and upper part
of uterus

Ovary

External iliac and sub-
aortic lymph gland

Labium minus

Subinguinal lymph gland
Hypogastric lymph glands
External iliac lymph glands

[glands
Vessels to ano-rectal, sacral,, and sub-aortic lymph
Cervix uteri
Ano-rectal lymph glands

The Lymph Vessels of the Vagina. The lymph vessels of the lower part of the vagina anastomose with the lymph vessels of the labia minora and so transmit lymph to the superficial subinguinal glands. The lymph vessels of the upper parts of the vagina pass to the hypogastric glands and also, with the lymph vessels of the cervix uteri, to the external iliac glands. Some of the lymph vessels from the posterior wall of the vagina terminate in the ano-rectal glands.

The Lymph Vessels of the Uterus.-The Lymph Vessels of the Lower Part of the Uterus. The majority of the lymph vessels

from the lower part of the uterus, including the cervix, unite with the lymph vessels of the upper part of the vagina and pass to the hypogastric glands including the inter-iliac group (p. 1017). Some pass to the external iliac glands, and others from the lower and posterior part become associated with the ano-rectal, the sacral, and the sub-aortic glands.

The Lymph Vessels of the Body of the Uterus run in several directions. The most important outflow is along the upper part of the broad ligament, below the uterine tube, to the Afterwards the region of the ovary where there is an anastomosis with the ovarian lymph vessels. lymph vessels of this stream cross the brim of the pelvis minor and ascend to the lumbar lymph glands. The accessory outflows are to the external iliac glands; to the sub-aortic glands; and, along the round ligament, to the superior group of sub-inguinal glands.

The Lymph Vessels of the Uterine Tube accompany the vessels of the main outflow from the body of the uterus, and those from the ovary, and pass to the lumbar lymph glands.

The Lymph Vessels of the Ovaries. The lymph vessels of each ovary accompany the ovarian artery and some of the uterine lymph vessels, along the upper part of the broad ligament, to the brim of the pelvis minor and then upwards to the lumbar lymph glands.

The Lymph Vessels of the Testis and Epididymis. The testis and the epididymis are not normally pelvic organs in the adult, but their lymph vessels may be considered here, inasmuch as the testes correspond, morphologically, with the ovaries. The lymph vessels of each testis and its epididymis accompany the testicular arteries and ascend to the lumbar region where they terminate in the lumbar lymph glands.

The Lymph Vessels of the Rectum. The lymph vessels of the rectum and the upper part of the anal canal pass for the most part along the middle and superior hæmorrhoidal vessels

Superficial subinguinal lymph glands

Labium majus

FIG. 814.-DIAGRAM OF LYMPH VESSELS OF FEMALE GENITAL
ORGANS.

Those which accompany the branches of the middle hæmorrhoidal artery, on each side, pass to the corresponding middle hæmorrhoidal gland of the hypogastric group; whilst the lymph vessels of the rectum which accompany the branches of the superior hæmorrhoidal artery become associated with the ano-rectal, the sacral, and the inferior mesenteric lymph glands. The lymph vessels of the lower part of the anal canal go to the medial proximal subinguinal glands.

THE LYMPH GLANDS OF THE ABDOMEN.

The lymph glands of the abdomen are separated into visceral and parietal groups. The visceral groups are those more directly associated with the lymph vessels which issue from the walls of the abdominal part of the alimentary canal, although they may lie posterior to the peritoneum in relation to the posterior wall of the abdomen. The parietal glands lie in relation with the abdominal part of the aorta and the inferior vena cava and the adjacent parts of the posterior abdominal wall.

Visceral Lymph Glands of the Abdomen.

Lymphoglandulæ Gastricæ.-The gastric lymph glands are arranged in two main groups, the lymphoglandula superiores which lie in association with the arteries of the smaller curvature, and the lymphoglandulæ inferiores associated with the greater curvature. Jamieson and Dobson have separated the superior gastric glands into several subdivisions.

Lymphoglandulæ Gastricae Superiores.-(a) The Anterior Left Gastric Glands (lower coronary glands, J. and D.). The anterior left gastric glands lie between the layers of the lesser omentum along the course of the left gastric artery. They receive afferents from the greater part of the lesser curvature of the stomach and the adjacent parts of its anterior and posterior walls, and they send efferents to the posterior left gastric glands.

(b) The Right Paracardial Glands are essentially members of the anterior left gastric group which lie to the right of the cardiac orifice

Right paracardial gland
Posterior left gastric glands
Anterior left gastric glands.
Right supra-pancreatic glands
Right gastric gland

Sub-pyloric
glands

Left paracardial glands

Cut edge of greater omentum

Right gastro-epiploic glands

FIG. 815.-LYMPH VESSELS AND GLANDS OF THE STOMACH.
(After Jamieson and Dobson, modified.)

of the stomach. Their afferents are derived from the cardiac part of the stomach and their efferents go to the posterior left gastric glands.

(c) The Left Paracardial Glands lie to the left of the oesophageal orifice. They receive afferents from the adjacent parts of the cardiac portion of the stomach, and their efferents end in the posterior left gastric glands.

(d) The Posterior Paracardial Glands lie on the posterior aspect of the stomach, between the layers of the gastro-phrenic ligament. Their afferents are from the neighbouring parts of the cardia and their efferents go to the posterior left gastric E glands.

(e) The Posterior Left Gastric Glands (upper coronary, J. and D.) lie around the left gastric artery as it passes forwards through the left gastro-pancreatic fold of peritoneum. They receive afferents from the previously mentioned groups of gastric glands and direct afferents from the cardiac portion of the stomach. Their efferents pass to the middle supra-pancreatic glands of Jamieson and Dobson (coeliac glands, B.N.A.).

(f) The Right Gastric Gland (pyloric of J. and D.) is a small gland, occasionally present, which lies immediately above the pylorus or the first part of the duodenum,

in association with the right gastric artery. It receives afferents from the pylorus, and its efferents end in the sub-pyloric glands.

(g) The Right Gastro-epiploic Glands lie along the lower part of the greater curvature of the stomach, in association with the right gastro-epiploic artery. Their afferents are from the adjacent parts of the anterior and posterior surfaces of the stomach and their efferents pass to the sub-pyloric glands.

(h) The Left Supra-pancreatic Glands of Jamieson and Dobson (lymphoglandulæ pancreaticolienales, B.N.A.) lie along the course of the splenic artery and in the gastro-splenic ligament: they receive afferents from the left part of the stomach and from the spleen. Their efferents pass to the middle supra-pancreatic glands.

(i) The Right Supra-pancreatic Glands (J. and D.) lie in relation with the stem of the hepatic artery as it passes through the right gastro-pancreatic fold. They receive afferents directly from the pyloric part of the stomach and the liver, and give off efferents to the middle supra-pancreatic glands.

(j) The Sub-pyloric Glands (J. and D.). The sub-pyloric lymph glands lie at the right border of the omental bursa, in the angle between the superior and descending parts of the duodenum, between the head of the pancreas posteriorly and the peritoneum of the posterior wall of the great sac anteriorly. Their afferents are from the right gastro-epiploic glands, the right gastric gland, and from the pyloric portion of the stomach. The efferents pass to the middle supra-pancreatic glands.

(e) The Biliary Lymph Glands (J. and D.) lie along the line of the bile duct. They receive afferents from the gall-bladder and liver. One of the lower glands of the group, which lies posterior to the head of the pancreas, close to the lower end of the bile-duct, is associated, by direct afferents, with the upper part of the pylorus. Their efferents pass to the right and middle supra-pancreatic glands.

The highest member of the series is associated with the cystic artery and the gall-bladder and is called the cystic gland.

Lymphoglandulæ Hepatica (B.N.A.) The Hepatic Lymph Glands of the Basle nomenclature are a few small glands which lie in the region of the porta hepatis between the layers of the lesser omentum; they receive afferents from the liver and give efferents to the right supra-pancreatic glands (J. and D.).

Lymphoglandulæ Mesenterica (B.N.A.) The Mesenteric Lymph Glands le between the layers of the mesentery, where they form three main groups: (a) s series of juxta-intestinal glands which lie close to the walls of the small gut; (^ an intermediate series of larger glands which lie in relation with the trunks of the rami intestinales of the superior mesenteric artery; and (c) a terminal group of large glands which lie round the upper part of the stem of the superior mesenteric artery. They receive lymph from all parts of the small intestine, from the cæcum, the vermiform process, the ascending colon, the transverse colon, and the part of the descending colon. Their efferents unite to form a common intestinal trunk, which enters the cisterna chyli.

The Lymph Glands of the Cæcum and the Vermiform Process and the Termina part of the Ileum.-The lymph glands particularly associated with the termin part of the ileum, the cæcum and its vermiform process, according to Jamieson an: Dobson, are (1) the ileal, (2) the anterior ileo-colic, (3) the posterior ileo-col and (4) the appendicular. All these glands give off vessels which pass to tir larger ileo-colic glands which lie along the ileo-colic branch of the superi mesenteric artery.

The Ileal Glands lie in the lower part of the mesentery. They receive afferents from the lower part of the ileum and give efferents to the main ileo-colic glands.

An Appendicular Lymph Gland is sometimes met with in the mesentery of the vermiform process. When it is present it may be associated with the vessels whi pass from any part of the vermiform process. Its efferents pass to the main ile colic glands.

The Anterior Ileo-colic Glands, 1-4, lie in the anterior ileo-colic fold of peritoneum | Their afferents are derived from the anterior part of the cæcum and the root of the vermiform process, and efferents pass to the main ileo-colic glands.

The Posterior Ileo-colic Glands, more numerous than the anterior, lie in the

[graphic]

angle between the ileum and the cæcum, and in the angle between the ileum and the ascending colon. Their afferents are from the posterior part of the cæcum and the root of the vermiform process. Their efferents pass to the main ileo-colic glands.

Main mesenteric glands

The Lymph Glands of the Colon, according to Jamieson and Dobson, may be considered as forming four groups, epicolic, paracolic, intermediate, and main.

1

Middle colic artery
Common stem of ileo-colic and
right colic arteries

Epicolic glands

The Epicolic Glands are small nodules which lie in the appendices epiploicæ and in relation with the wall of the gut. The paracolic glands lie along the medial borders Paracolic glands

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Main glands
Ileo-colic artery-

of the ascending, de-
scending, and iliac parts
of the colon; along
the upper border of
the transverse colon,
and on the mesenteric
border of the pelvic
colon. The intermedi-
ate glands lie along the
branches of the colic
arteries and the main
groups are situated
around the stems from which the colic arteries arise. The lymph gathered by the
lymph plexuses in the walls of the gut passes through one or more of the groups
of glands, and that which issues from the main group, in association with the
ileo-colic and middle colic arteries, enters the main mesenteric glands which
surround the upper part of the superior mesenteric artery. It is then carried by
the efferents of those glands to the common intestinal lymphatic trunk. The
lymph from the descending, the iliac, and the pelvic parts of the colon passes to
the intermediate groups of inferior mesenteric glands and thence, for the main
part, to the lumbar glands, but some of the efferents from the upper intermediate
inferior mesenteric glands pass to the main group of superior mesenteric glands.

The lymph glands associated with the middle colic artery and its branches are the lymphoglandulæ mesocolica of the Basle nomenclature.

Lumbar glands

Inferior mesenteric
artery
Main inferior
mesenteric glands

Superior
mesenteric
artery
Mesenteric glands

FIG. 816.-DIAGRAM OF THE LYMPH GLANDS AND LYMPH VESSELS OF THE
LARGE INTESTINE. (After Jamieson and Dobson.)

The Main Glands of the Inferior Mesenteric Group receive lymph from the intermediate left colic glands and transmit it to the lumbar glands through which it passes, by the lumbar lymph trunks, to the cisterna chyli; but some of the lymph from the upper intermediate left colic glands passes to the main mesenteric glands, and so to the common intestinal lymph trunk.

The Middle Supra-pancreatic Lymph Glands of Jamieson and Dobson correspond fairly closely with the lymphoglandulæ cœliacæ of the Basle terminology. They lie at the upper border of the pancreas around the coeliac artery. Their afferents are from the right and left supra-pancreatic glands, from the posterior left gastric glands, and from the subpyloric glands. They are connected by intermediate channels with the superior mesenteric glands, and they give efferents to the common intestinal lymph trunk and also to the common lumbar trunks.

Lymphoglandulæ Lumbales, B.N.A.-The Lumbar Lymph Glands lie behind the peritoneum of the posterior wall of the abdomen, in association with the aorta, the inferior vena cava, the psoas and quadratus lumborum muscles, and the crura of the diaphragm. Those which are situated on the anterior aspect of the aorta are frequently spoken of as pre-aortic glands and those situated more laterally as para-aortic glands.

The afferents of the lumbar lymph glands are (1) the efferents of the common

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