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Lymphoglandulæ Cervicales Profundæ Superiores et Inferiores.-The deep cervical lymph glands lie in the anterior and posterior triangles of the neck and under cover of the sterno-mastoid muscle. They form a more or less continuous sheet of gland nodules and inter-communicating lymph vessels; but the glands are divided into two main groups, the (a) superior, and (b) inferior, and each group is separable into (1) medial, and (2) lateral components.
(a) The Superior Deep Cervical Lymph Glands.-(1) The medial group of upper deep cervical lymph glands lies on the superficial surface of the internal jugular vein and in the carotid triangle of the neck. One of the largest, which is closely associated with the tongue, lips, gums, cheeks, and the outer part of the nose, is
FIG. 801.-LYMPH GLANDS OF THE HEAD AND NECK AS SEEN AFTER THE REMOVAL OF THE STERNOMASTOID MUSCLE. The anterior and posterior auricular and the occipital glands are inserted in accordance with descriptions. The other glands were present in one or other or in both the bodies from which the figure was made. Compare Fig. 799.
frequently situated in the region of the union of the common facial vein with the internal jugular vein. The lowest gland of the group lies on the lateral surface of the internal jugular vein immediately above the omo-hyoid muscle; it receives a communication from the submental glands. The highest members of the group may be under cover of the postero-medial surface of the parotid gland, in association with the posterior belly of the digastric muscle. (2) The members of the lateral group of superior deep cervical lymph glands lie under cover of the posterior part of the upper portion of the sterno-mastoid, and in the upper part of the posterior triangle of the neck. They are embedded in the fat-laden fascia which covers the roots of the cervical plexus and the upper part of the brachial plexus,
and the levator scapula and the scalene muscles, and several of them are in close relation with the accessory nerve (Fig. 801).
The superior deep cervical glands are connected by afferent vessels with the various groups of glands which lie in the regions of the pharynx, the face, and the upper part of the neck. They receive lymph, therefore, from the nose, the mouth, the tongue, the upper parts of the pharynx and larynx, the tonsil, the upper part of the thyreoid gland, the submaxillary, sublingual, and parotid salivary glands, and from the interior of the cranium. Their efferents pass either to the inferior deep cervical glands or to the jugular lymph trunk. In some cases the medial and lateral members of the superior group are connected with the corresponding members of the lower group only, but in other cases the medial or lateral members of the superior group may be connected with both the medial and the lateral members of the inferior glands.
The inferior deep cervical lymph glands (Figs. 800, 801), which are also termed the supra-clavicular glands, are situated below the level of the omo-hyoid muscle. (1) The members of the medial group lie in relation with the lower part of the internal jugular vein, opposite the interval between the sternal and the clavicular heads of the sterno-mastoid. They receive afferents from the members of the upper medial group and from the pretracheal and the paratracheal glands and from the upper part of the thorax. Their efferents unite with some of the efferents of the upper medial group and pass with them to the jugular lymph trunk.
(2) The members of the lateral group of inferior deep cervical glands lie in the subclavian triangle, in the fatty tissue superficial to the lower part of the brachial plexus and the third part of the subclavian artery. They receive lymph from the lower parts of the neck, from the upper part of the thorax, and from the upper lateral glands. They receive lymph also from the deep parts of the mammary gland, and they are in communication with the axillary glands. Their efferents join the jugular lymphatic trunk.
THE LYMPH VESSELS OF THE HEAD AND NECK.
The lymph vessels of the head and neck may be separated into two groups, intracranial and extracranial.
Intracranial Lymph Vessels and Lymph Spaces. The cerebro-spinal fluid which fills the ventricles of the brain, the central canal of the spinal medulla, and the subarachnoid and subdural spaces, differs in chemical constitution from true lymph; nevertheless it plays the part of lymph, to some extent, and there can be little doubt that some of it eventually passes into lymph vessels; therefore it may be considered as a modified form of lymph. The fluid is secreted by the chorioid plexuses of the cerebral ventricles, and it passes through the medial and lateral foramina of the fourth ventricle into the cerebello - medullary subarachnoid cistern. Part of the fluid transudes through the arachnoideal granulations into the superior sagittal and other cerebral blood sinuses; and part, probably, passes by osmosis into the subdural space and thence into the meningeal lymphatics, by which it is conveyed to the exterior of the
Cerebral Lymph Channels.-It appears probable that the so-called peri-vascular and pericellular lymph spaces which have so frequently been described in the central nervous system are merely artifacts produced by unsatisfactory methods of preparation. Nevertheless, the fluid which pervades the cerebral substance must have some exit, and it is not unlikely that it passes, with the lymphocytes, through cleft-like intercommunicating spaces in the adventitial coats of the blood vessels, similar to those demonstrated by Bruce in the case of the spinal medulla, and so reaches the pia-mater and subarachnoid space; that is, it runs along the walls of the arteries, enters the meningeal lymphatics, and passes through them to the exterior of the cranium and where it enters the extracranial lymph vessels. The above statements are based upon Bruce's researches and the fact that the lymph vessels of the nose, the ear, and the deep lymph vessels of the neck have been injected from the subdural space.
The Superficial Lymph Vessels of the Head.-(1) The superficial lymphatics from the frontal and anterior temporal regions of the head accompany the branches of the superficial temporal artery and terminate in anterior auricular glands, from which efferents pass to the parotid, the superficial cervical, and to the medial glands of the superior deep cervical group.
(2) The lymphatics of the posterior temporal and parietal region run to the posterior auricular glands. It is stated that they sometimes communicate directly with the lateral glands of the superior deep cervical group.
(3) The lymphatics from the occipital part of the scalp pass along the branches of the occipital artery and terminate in the occipital glands, which transmit the lymph to the lateral superior deep cervical glands.
The Superficial Lymph Vessels of the Neck.-The majority of the lymph vessels from the skin and the subcutaneous tissues of the upper part of the neck pass to the inferior deep cervica glands, but some end in the occipital glands and others in the superior deep cervical glands.
The superficial lymph channels of the lower part of the neck terminate in the axillary glandThe Lymph Vessels of the Eyelids and the Conjunctiva. The lymph vessels which drain the region of the eyelids and the conjunctiva form two groups, a medial and a lateral (a) The medial vessels pass from the superficial and deeper parts of the medial portions of the superior and inferior eyelids and, following the course of the angular and the external maxillary arteries, they pass to the submaxillary lymph glands. The more superficial vessels lie anterior, and the deeper vessels posterior to the orbicularis oculi. Both groups may be connected with infra-orbital and the anterior buccinator glands. (b) The lymph vessels from the lateral parts of the eyelids pass posteriorly, along the line of the transverse facial artery. They end in the anterior auricular and the parotid lymph glands. In some cases they become connected also with the buccinator and superficial cervical glands.
Lymph Vessels of the Eyeball.-It is doubtful if any true lymph vessels exist in the eyeball. Lymph spaces have been described in association with the coats of the eyeball, and Ïymph vessels are stated to exist in the chorioid coat, but their existence is uncertain. The sinus venosus sclera (Schlemm), formerly looked upon as a lymph channel, is probably a venous canal. If lymph vessels are absent then the fluids in the tissues and spaces of the eye must pass into
FIG. 802.-LYMPH VESSELS OF THE TONGUE.
the capillaries of the veins, unless channels exist in the adventitia of the vessels similar to those described by Bruce in the spinal medulla.
The Lymph Vessels of the Ear. The lymph vessels from the upper and lateral parts of the auricle end in the anterior auricular glands. Those from the lower part of the auricle go to the upper superficial cervical glands. The lymph channels from the medial surface of the auricle end in the posterior auricular glands, but in a few cases they establish direct communication with the superior deep cervical glands.
The lymph vessels of the external acoustic meatus end in the anterior and posterior auricular glands.
The lymph vessels of the middle ear pass in two directions. Those from the more laterally situated parts of the walls of the cavity join the vessels of the external acoustic meatus and terminate in the posterior auricular glands. The lymph vessels which drain the more medial parts of the middle ear and the auditory tube terminate in the lateral retro-pharyngeal glands
It is doubtful if any lymph vessels exist in the internal ear. It is possible that the perilymph drains into the subarachnoid space of the posterior fossa of the skull along the line of the ductus endolymphaticus and that the endolymph reaches the subarachnoid space along the fibres of the acoustic nerve.
The Lymph Vessels of the Nose. The lymph vessels from the external part of the nose form two groups, superior and inferior. The superior group accompany the vessels from the lateral parts of the eyelids and end in the anterior auricular glands. The inferior group accompanies the angular and the external maxillary arteries, and the majority of the vessels end
in the submaxillary glands, but in some cases one or more vessels of this group pass to the upper superficial cervical glands.
The Lymph Vessels of the Nasal Muco-periosteum. The vessels from the anterior part of the nasal muco-periosteum accompany the vessels of the lower portion of the external part of the nose and end in the submaxillary glands. Those from the posterior part of the muco-periosteum end partly in the medial superior deep cervical glands, and partly in the lateral retro-pharyngeal glands.
There is little definite knowledge regarding the lymph vessels of the accessory sinuses of the nose, but it is probable that they follow the lines of the bloodvessels which supply the mucoperiosteum of the cavities.
The Lymph Vessels of the Lips. The vessels from the skin of the medial part of the lower lip pass to the submental glands and, occasionally, direct to the superior deep cervical glands. The vessels from the deeper parts of the lower lip unite with those from the upper lip and end in the submaxillary glands, but some of the superficial vessels of the upper lip may end in the superficial cervical glands.
Lymph vessels of dorsum and sides)
of anterior twothirds of tongue
The Lymph Vessels of the Cheeks. The majority of the superficial and deep lymph vessels of the cheeks pass to the submaxillary glands, but in some cases they communicate directly with the superficial or with the superior deep cervical glands. They may communicate also with the buccinator glands.
The Lymph Vessels of the Gums.-The vessels from the outer part of the anterior portion
of the mandibular gum pass to the submental glands. Those from the posterior part, together with the vessels from the outer part of the gum of the maxilla, terminate in the submaxillary glands. The vessels of the gum of the maxilla may also communicate with the buccinator glands.
Lymph vessels of
Deep lymph -vessels of right side of tongue
Lymph vessels of the side
FIG. 803.-DIAGRAM OF SIDE-VIEW ORIGINS AND TERMINATIONS OF THE LYMPH VESSELS OF THE TONGUE. (After Poirier, modified.)
FIG. 804. DIAGRAM OF LYMPH VESSELS OF ANTERIOR
The Lymph Vessels of the Teeth.It is known that lymph vessels exist in connexion with the teeth of the mandible as well as with the mandible itself, but their terminations are not definitely established. It is probable that they end in the submaxillary or the superior deep cervical glands.
The lymph vessels of the teeth of the maxilla pass partly into the infra - orbital canal and so to the face, where they join the vessels from the lateral parts of the eyelids, and terminate in the anterior auricular and submaxillary glands. The remaining vessels of the maxillary teeth end in the submaxillary glands. The lymph vessels of the tongue form three groups
The Lymph Vessels of the Tongue. (1) anterior, (2) middle, (3) posterior. The anterior and middle groups communicate freely with one another and with their fellows of the opposite side, but the posterior group have little or no communication with the middle group. (1) The anterior lymph vessels drain the tip and the
The vessels from the inner part of the gum of the mandible end in the submaxillary glands; those of the inner part of the gum of the maxilla, together with the vessels of the hard and the soft palate, end in the medial superior deep cervical glands.
lower surface of the anterior free portion of the tongue. The main trunks pierce the mylohyoid muscle and end in the submental glands. (2) The middle group of lymph vessels of the tongue drain the anterior two-thirds, exclusive of the tip, and they terminate partly in the submaxillary glands and partly in the medial superior deep cervical glands. Small lingual glands are intercalated in the course of some of these vessels. (3) The posterior lymph vessels drain the portion of the tongue which lies in the anterior wall of the pharynx posterior to the papillæ vallatæ; they pass to the medial superior deep cervical glands. (4) The lymph vessels from the deeper central portions of the tongue go, mainly, to the upper deep cervical glands.
The Lymph Vessels of the Salivary Glands. The lymph vessels of the parotid gland terminate in the parotid and superior deep cervical lymph glands. The lymph vessels of the submaxillary gland terminate, according to Most, not in the submaxillary lymph glands but in the medial superior deep cervical glands. Practically nothing is known of the lymph vessels of the sublingual gland.
The Lymph Vessels of the Pharynx. From the upper part of the pharynx, and from the posterior wall and lateral borders of the middle and lower parts, the lymph stream flows to the median line posteriorly. There the larger vessels pierce the walls of the pharynx, then they turn laterally and end in the lateral retro-pharyngeal glands.
From the lower and anterior part of the pharynx, that is, from the region of the piriform recesses and the adjacent part of the larynx, the lymph vessels pass along the course of the laryngeal branch of the superior thyreoid artery, pierce the hyo-thyreoid membrane and terminate in the medial superior deep cervical glands; they may be connected also with the infra-hyoid, and with the prelaryngeal glands.
The lymph vessels of the palatine tonsil and the adjacent parts of the glosso-palatine and pharyngo-palatine arches pierce the lateral wall of the pharynx and end in a gland, or group of glands, which lies on the lateral surface of the internal jugular vein, immediately below the posterior belly of the digastric at the level of the angle of the mandible.
Lateral axillary glands
-Superficial cubital glands
Deep cubital glands and a
FIG. 805.-SCHEMA OF THE LYMPH VESSELS AND
The Lymph Vessels of the Thyreoid Gland. The lymph vessels of the thyreoid gland form a plexus common to both lobes and the isthmus, therefore the lymph can pass from the lobe of one side to the terminal glands of the opposite side. The terminal vessels end in the prelaryngeal, the pretracheal, the paratracheal, the superior and inferior deep cervical, and the upper mediastinal glands.
The Lymph Vessels of the Larynx.-The lymph plexus of the larynx is separable into upper and lower portions; they are connected together on the posterior wall of the cavity, but are separated, laterally and anteriorly, by the plica vocales which contain extremely few lymph vessels. The efferent stems of the upper part pass mainly along the laryngeal branch of the superior thyreoid artery, and they end in the superior deep cervical glands, but are frequently connected also with the infra-hyoid glands. The efferent vessels from the lower part of the larynx form two subordinate groups. Those from the anterior region pierce the median crico-thyreoid ligament and end in the prelaryngeal, the pretracheal, and the deep cervical glands. The efferents from the posterior region pierce the crico-tracheal membrane and end in the paratracheal glands (Fig. 800).
The Lymph Vessels of the Cervical Part of the Trachea and Esophagus. The terminal vessels of the cervical part of the trachea and the adjacent portion of the oesophagus and glands. From the upper part of the traches
the paratracheal and the inferior deep cervical some vessels pass to the prelaryngeal glands also.
LYMPH GLANDS OF THE SUPERIOR EXTREMITY.
The lymph glands of the superior extremity form two groups-(1) superficial, (2) deep.
(1) Lymphoglandulæ Cubitales Superficiales.-The superficial cubital lymph