 Section 40 of Gray's Anatomy Part 3 This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. Recording by Eric Hale. Anatomy of the Human Body. Part 3 by Henry Gray. The veins of the lower extremity, abdomen, and pelvis. Part 1. The veins of the abdomen and pelvis. The veins of the lower extremity are subdivided, like those of the upper, into two sets, superficial and deep. The superficial veins are placed beneath the integument between the two layers of superficial fascia. The deep veins accompany the arteries. Both sets of veins are provided with valves, which are more numerous in the deep than in the superficial set. The valves are also more numerous in the veins of the lower than in those of the upper limb. The superficial veins of the lower extremity. The superficial veins of the lower extremity are the great and small subvenous veins and their tributaries. On the dorsum of the foot, the dorsal digital veins receive, in the clefts between the toes, the intercapitular veins from the plantar cutaneous venous arch, and join to form short, common digital veins, which unite across the distal ends of the metatarsal bones in a dorsal venous arch. Proximal to this arch is an irregular venous network, which receives tributaries from the deep veins and is joined to the sides of the foot by a medial and allateral marginal vein formed mainly by the union of branches from the superficial parts of the sole of the foot. On the sole of the foot, the superficial veins form a plantar cutaneous venous arch, which extends across the roots of the toes and opens at the sides of the foot into the medial and lateral marginal veins. Proximal to this arch is a plantar cutaneous venous network, which is especially dense in the fat beneath the heel. This network communicates with the cutaneous venous arch and with the deep veins, but is chiefly drained into the medial and lateral marginal veins. The great saphenous vein, the longest vein in the body, begins in the medial marginal vein of the dorsum of the foot and ends in the femoral vein about 3 centimeters below the inguinal ligament. It ascends in front of the tibium alleolus and along the medial side of the leg in relation with the saphenous nerve. It runs upward behind the medial condyles of the tibia and femur and along the medial side of the thigh and passing through the fossa ovalis ends in the femoral vein. Tributaries. At the ankle, it receives branches from the sole of the foot through the medial marginal vein. In the leg, it anastomoses freely with the small saphenous vein, communicates with the anterior and posterior tibial veins, and receives many cutaneous veins. In the thigh, it communicates with the femoral vein and receives numerous tributaries. Those from the medial and posterior parts of the thigh frequently unite to form a large accessory saphenous vein, which joins the main vein at a variable level. Near the fossa ovalis, it is joined by the superficial epigastric, superficial iliac circumflex, and superficial external pudendal veins. A vein named the thoracoepigastric runs along the lateral aspect of the trunk between the superficial epigastric vein below and the lateral thoracic vein above, and establishes an important communication between the femoral and axillary veins. The valves in the great saphenous vein vary from 10 to 20 in number. They are more numerous in the leg than in the thigh. The small saphenous vein begins behind the lateral malleolus as a continuation of the lateral marginal vein. It first ascends along the lateral margin of the tendocalcaneus and then crosses it to reach the middle of the back of the leg. Running directly upward, it perforates the deep fascia in the lower part of the popliteal fossa and ends in the popliteal vein between the heads of the gastrocnemius. It communicates with the deep veins on the dorsum of the foot and receives numerous large tributaries from the back of the leg. Before it pierces the deep fascia, it gives off a branch which runs upward and forward to join the great saphenous vein. The small saphenous vein possesses from 9 to 12 valves, one of which is always found near its termination in the popliteal vein. In the lower third of the leg, the small saphenous vein is in close relation with the serial nerve. In the upper two thirds, with the medial serial cutaneous nerve. The deep veins of the lower extremity. The deep veins of the lower extremity accompany the arteries and their branches. They possess numerous valves. The plantar digital veins arise from plexuses on the plantar surfaces of the digits. And, after sending intercompitular veins to join the dorsal digital veins, unite to form four metatarsal veins. These run backward in the metatarsal spaces, communicate by means of perforating veins with the veins on the dorsum of the foot, and unite to form the deep plantar venous arch, which lies alongside the plantar arterial arch. From the deep plantar venous arch, the medial and lateral plantar veins run backward, close to the corresponding arteries. And, after communicating with the great and small saphenous veins, unite behind the medial malleolus to form the posterior tibial veins. The posterior tibial veins accompany the posterior tibial artery, and are joined by the perineal veins. The anterior tibial veins are the upward continuation of the venacometantis of the dorsalis pedis artery. They leave the front of the leg by passing between the tibia and fibula over the interosseous membrane, and unite with the posterior tibial to form the popliteal vein. The popliteal vein is formed by the junction of the anterior and posterior tibial veins at the lower border of the popliteus. It ascends through the popliteal fossa to the aperture and the adductor magnus, where it becomes the femoral vein. In the lower part of its course, it is placed medial to the artery. Between the heads of the gastrocnemius, it is superficial to that vessel, but above the knee joint, it is close to its lateral side. It receives tributaries corresponding to the branches of the popliteal artery, and it also receives the small saphenous vein. The valves in the popliteal vein are usually four in number. The femoral vein accompanies the femoral artery through the upper two-thirds of the thigh. In the lower part of its course, it lies lateral to the artery. Higher up, it is behind it, and at the inguinal ligament, it lies on its medial side and on the same plane. It receives numerous muscular tributaries, and about four centimeters below the inguinal ligament is joined by the v-profunda femoris. Near its termination, it is joined by the great saphenous vein. The valves in the femoral vein are three in number. The deep femoral vein receives tributaries corresponding to the perforating branches of the profunda artery, and, through these, establishes communications with the popliteal vein below and the inferior gluteal vein above. It also receives the medial and lateral femoral circumflex veins. The external iliac vein, the upward continuation of the femoral vein, begins behind the inguinal ligament, and, passing upward along the brim of the lesser pelvis, ends opposite the sacroiliac articulation. By uniting with the hypogastric vein to form the common iliac vein. On the right side, it lies at first medial to the artery, but, as it passes upward, gradually inclines behind it. On the left side, it lies altogether on the medial side of the artery. It frequently contains one, sometimes two, valves, tributaries. The external iliac vein receives the inferior epigastric. Deep iliac circumflex and pubic veins. The inferior epigastric vein is formed by the union of the venaecomatantis of the inferior epigastric artery, which communicate above with the superior epigastric vein. It joins the external iliac about 1.25 centimeters above the inguinal ligament. The deep iliac circumflex vein is formed by the union of the venaecomatantis of the deep iliac circumflex artery, and joins the external iliac vein about 2 centimeters above the inguinal ligament. The pubic vein communicates with the obturator vein in the obturator foramen, and ascends on the back of the pubis to the external iliac vein. The hypogastric vein begins near the upper part of the greater sciatic foramen. Passes upward behind and slightly medial to the hypogastric artery, and, at the brim of the pelvis, joins with the external iliac to form the common iliac vein. Tributaries. With the exception of the fetal umbilical vein, which passes upward and backward from the umbilicus to the liver, and the ilial lumbar vein, which usually joins the common iliac vein, their tributaries of the hypogastric vein correspond with the branches of the hypogastric artery. It receives A. the gluteal internal pudendal and obturator veins, which have their origins outside the pelvis, B. the lateral sacral veins, which lie in front of the sacrum, and C. the middle hemorrhoidal, vesicle, uterine, and vaginal veins, which originate in venous plexuses connected with the pelvis viscera. The superior gluteal veins are venaecomatantis of the superior gluteal artery. They receive tributaries from the buttock corresponding with the branches of the artery, and enter the pelvis to the greater sciatic foramen, above the piriformis, and frequently unite before ending in the hypogastric vein. The inferior gluteal veins, or venaecomatantis of the inferior gluteal artery, begin on the upper part of the back of the thigh, where they anastomose with the medial femoral circumflex and first perforating veins. They enter the pelvis to the lower part of the greater sciatic foramen, and join to form a single stem which opens into the lower part of the hypogastric vein. The internal pudendal veins are the venaecomatantis of the internal pudendal artery. They begin in the deep veins of the penis, which issue from the corpus cavernosum penis, accompany the internal pudendal artery, and unite to form a single vessel, which ends in the hypogastric vein. They receive the veins from the urethral bulb, and the perineal and inferior hemorrhoidal veins. Deep dorsal vein of the penis communicates with the internal pudendal veins, but ends mainly in the pudendal plexus. The obturator vein begins at the upper portion of the adductor region of the thigh, and enters the pelvis through the upper part of the obturator foramen. It runs backward and upward on the lateral wall of the pelvis below the obturator artery, and then passes between the ureter and the hypogastric artery to end in the hypogastric vein. The lateral sacral veins accompany the lateral sacral arteries on the anterior surface of the sacrum, and end in the hypogastric vein. The middle hemorrhoidal vein takes origin in the hemorrhoidal plexus, and receives tributaries from the bladder, prostate, and seminal vesicle. It runs lateralward on the pelvic surface of the levator ani to end in the hypogastric vein. End of Section 40 Recording by Eric Hale Section 41 of Grey's Anatomy Part 3 This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. Recording by Eric Hale Anatomy of the Human Body Part 3 by Henry Gray The veins of the lower extremity, abdomen, and pelvis. Part 2 The hemorrhoidal plexus surrounds the rectum and communicates in front with the vesicle plexus in the male and the uteral vaginal plexus in the female. It consists of two parts, an internal in the submucosa and an external outside the muscular coat. The internal plexus presents a series of dilated pouches which are arranged in a circle around the tube immediately above the anal orifice and are connected by transverse branches. The lower part of the external plexus is drained by the inferior hemorrhoidal veins into the internal pudendal vein. The middle part by the middle hemorrhoidal vein which joins the hypogastric vein and the upper part by the superior hemorrhoidal vein which forms the commencement of the inferior mesenteric vein, a tributary of the portal vein. A free communication between the portal and systemic venous systems is established through the hemorrhoidal plexus. The veins of the hemorrhoidal plexus are contained in very loose connective tissue so that they get less support from surrounding structures than most other veins and are less capable of resisting increased blood pressure. The pudendal plexus lies behind the arcuate public ligament and the lower part of the symphysis pubis and in front of the bladder and prostate. Its chief tributary is the deep dorsal vein of the penis but it also receives branches from the front of the bladder and prostate. It communicates with the vesicle plexus and with the internal pudendal vein and drains into the vesicle and hypogastric veins. The prostatic veins form a well-marked prostatic plexus which lies partly in the fascial sheath of the prostate and partly between the sheath and the prostatic capsule. It communicates with the pudendal and vesicle plexuses. The vesicle plexus envelopes the lower part of the bladder and the base of the prostate communicates with the pudendal and prostatic plexuses. It is drained by means of several vesicle veins into the hypogastric veins. The dorsal veins of the penis are two in number, a superficial and a deep. The superficial vein drains the pre-puse and skin of the penis and running backward in the subcutaneous tissue inclines to the right or left and opens into the corresponding superficial external pudendal vein, a tributary of the great subvenous vein. The deep vein lies beneath the deep fascia of the penis. It receives the blood from the glans penis and corpora cavernosa penis and courses backward in the middle line between the dorsal arteries. Near the root of the penis, it passes between the two parts of the suspensory ligament and then through an aperture between the arcuate pubic ligament and the transverse ligament of the pelvis and divides into two branches which enter the pudendal plexus. The deep vein also communicates below the symphysis pubis with the internal pudendal vein. The uterine plexuses lie along the sides and superior angles of the uterus between the two layers of the broad ligament and communicate with the ovarian and vaginal plexuses. They are drained by a pair of uterine veins on either side. These arise from the lower part of the plexuses opposite the external orifice of the uterus. And open into the corresponding hypogastric vein. The vaginal plexuses are placed at the sides of the vagina. They communicate with the uterine, vesicle and hemorrhoidal plexuses and are drained by the vaginal veins. One on either side into the hypogastric veins. The common iliac veins are formed by the union of the external iliac and hypogastric veins in front of the sacroiliac articulation. Passing obliquely upward toward the right side, they end upon the fifth lumbar vertebra by uniting with each other at an acute angle to form the inferior vena cava. The right common iliac is shorter than the left, nearly vertical in its direction and ascends behind and then lateral to its corresponding artery. The left common iliac, longer than the right and more oblique in its course, is at first situated on the medial side of the corresponding artery and then behind the right common iliac. Each common iliac receives the ilial lumbar and sometimes the lateral sacral veins. The left receives, in addition, the middle sacral vein. No valves are found in these veins. The middle sacral veins accompany the corresponding artery along the front of the sacrum and join to form a single vein which ends in the left common iliac vein, sometimes in the angle of junction of the two iliac veins. Peculiarities, the left common iliac vein, instead of joining with the right in its usual position, occasionally ascends on the left side of the aorta as high as the kidney, where, after receiving the left renal vein, it crosses over the aorta and then joins with the right vein to form the vena cava. In these cases, the two common iliacs are connected by a small communicating branch at the spot where they are usually united. The inferior vena cava returns to the heart the blood from the parts below the diaphragm. It is formed by the junction of the two common iliac veins on the right side of the fifth lumbar vertebra. It ascends along the front of the vertebral column on the right side of the aorta and, having reached the liver, is continued in a groove on its posterior surface. It then perforates the diaphragm between the median and right portions of its central tendon. It subsequently inclines forward and medial word 0.5 centimeters and, piercing the fibrous pericardium, passes behind the serous pericardium to open into the lower and back part of the right atrium. In front of its atrial orifice is a semi-lunar valve termed the valve of the inferior vena cava. This is rudimentary in the adult, but is of large size and exercises an important function in the fetus. Relations The abdominal portion of the inferior vena cava is in relation in front from below upward with the right common iliac artery, the mesentary, the right internal spermatic artery, the inferior part of the duodenum, the pancreas, the common bile duct, the portal vein, and the posterior surface of the liver. The last partly overlaps and occasionally completely surrounds it. Behind, with the vertebral column, the right psoas major, the right crus of the diaphragm, the right inferior phrenic, suprarenal, renal and lumbar arteries, right sympathetic trunk and right celiac ganglion, and the medial part of the right suprarenal gland. On the right side with the right kidney and ureter, on the left side with the aorta right crus of the diaphragm and the caudate lobe of the liver. The thoracic portion is only about 2.5 cm in length and is situated partly inside and partly outside the pericardial sac. The extra pericardial part is separated from the right pleura and lung by a fibrous band named the right phrenicopericardiac ligament. This ligament, often feebly marked, is attached below to the margin of the vena cable opening in the diaphragm and above to the pericardium in front of and behind the root of the right lung. The intrapericardiac part is very short and is covered anterior laterally by the cirrus layer of the pericardium. Peculiarities in position This vessel is sometimes placed on the left side of the aorta as high as the left renal vein and after receiving this vein crosses over to its usual position on the right side or it may be placed altogether on the left side of the aorta and in such a case the abdominal and thoracic viscera together with the great vessels are all transposed. Point of termination Occasionally, the inferior vena cava joins which is then of large size. In such cases, the superior vena cava receives the whole of the blood from the body before transmitting it to the right atrium except the blood from the hepatic veins which passes directly into the right atrium. Tributaries The inferior vena cava receives the following veins lumbar renal inferior phrenic super renal hepatic The lumbar veins, for a number on each side collect the blood by dorsal tributaries from the muscles and entanglement of the loins and by abdominal tributaries from the walls of the abdomen where they communicate with the epigastric veins. At the vertebral column they receive veins from the vertebral plexuses and then pass forward around the sides of the bodies of the vertebrae beneath the psoas major and end in the back part of the inferior cava. The left lumbar veins are longer than the right and pass behind the aorta. The lumbar veins are connected together by a longitudinal vein which passes in front of the transverse process of the lumbar vertebrae and is called the ascending lumbar. It forms the most frequent origin of the corresponding azygos or hemi-azygos vein and serves to connect the common iliac, ilial lumbar and azygos or hemi-azygos veins of its own side of the body. The spermatic veins emerge from the back of the testes and receive tributaries from the epididymis. They unite and form a convoluted plexus called the Pampiniform plexus which constitutes the greater mass of the spermatic cord. The vessels composing this plexus are very numerous and ascend along the cord in front of the ductus deference. Below the subcutaneous inguinal ring they unite to form three or four veins which pass along the inguinal canal and entering the abdomen through the abdominal inguinal ring coalesce to form two veins which ascend on the psoas major behind the peritoneum lying one on either side of the internal spermatic artery. These unite to form a single vein which opens on the right side into the inferior vena cava at an acute angle on the left side into the left renal vein at a right angle. The spermatic veins are provided with valves. The left spermatic vein passes behind the iliac colon and is thus exposed to pressure from the contents of that part of the bowel. The ovarian veins correspond with the spermatic in the male. They form a plexus in the broad ligament near the ovary and uterine tube and communicate with the uterine plexus. They end in the same way as the spermatic veins in the male. Valves are occasionally found in these veins. Like the uterine veins they become much enlarged during pregnancy. The renal veins are of large size and placed in front of the renal arteries. The left is longer than the right and passes in front of the aorta just below the origin of the superior mesenteric artery. It receives the left spermatic and left inferior phrenic veins and, generally, the left supra renal vein. It opens into the inferior vena cava at a slightly higher level than the right. The supra renal veins are two in number. The right ends in the inferior vena cava. The left, in the left renal or left inferior phrenic vein the inferior phrenic veins follow the course of the inferior phrenic arteries. The right ends in the inferior vena cava. The left is often represented by two branches one of which ends in the left renal or supra renal vein while the other passes in front of the esophageal hiatus in the diaphragm and opens into the inferior vena cava. The hepatic veins commence in the substance of the liver and the terminations of the portal vein and hepatic artery and are arranged in two groups, upper and lower. The upper group usually consists of three large veins which converge toward the posterior surface of the liver and open into the inferior vena cava while that vessel is situated in the groove on the back part of the liver. The veins of the lower group vary in number and are of small size. They come from the right and caudate lobes. The hepatic veins run singly and are in direct contact with the hepatic tissue. This is the epistitute of valves. End of section 41 Recording by Eric Hale Section 42 of Gray's Anatomy Part 3 This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer please visit LibriVox.org Anatomy of the Human Body Part 3 by Henry Gray The Portal System of Veins The Portal System includes all the veins which drain the blood from the abdominal part of the digestive tube with the exception of the lower part of the rectum and from the spleen, pancreas, and gallbladder. From these viscera the blood is conveyed to the liver by the portal vein. In the liver this vein ramifies like an artery and ends in capillary like vessels term sinusoids from which the blood is conveyed to the inferior vena cava by the hepatic veins. From this it will be seen that the blood of the portal system passes through two sets of minute vessels, namely A. the capillaries of the digestive tube spleen, pancreas, and gallbladder and B. the sinusoids of the liver. In the adult the portal vein and its tributaries are destitute of valves. In the fetus and for a short time after birth valves can be demonstrated in the tributaries of the portal vein. As a rule they soon atrophy and disappear but in some subjects they persist in a degenerate form. The portal vein, vena porti is about 8 cm in length and is formed at the level of the 2nd lumbar vertebra by the junction of the superior mesenteric and leonal veins. The union of these veins taking place in front of the inferior vena cava and behind the neck of the pancreas. It passes upward behind the superior part of duodenum and then ascends in the right border of the lesser omentum to the right extremity of the portahepatus where it divides into a right and a left branch which accompany the corresponding branches of the hepatic artery into the substance of the liver. In the lesser omentum it is placed behind and between the common bile duct and the hepatic artery the former lying to the right of the latter. It is surrounded by the hepatic plexus of nerves and is accompanied by numerous lymphatic vessels and some lymph glands. The right branch of the portal vein enters the right lobe of the liver but before doing so generally receives the portal vein. The left branch longer but of smaller caliber than the right crosses the left sagittal fossa gives branches to the caudate lobe and then enters the left lobe of the liver. As it crosses the left sagittal fossa it is joined in front by a fibrous cord, the ligamentum terus, obliterated umbilical vein and is united to the inferior vena cava by a second fibrous cord, the ligamentum venosum obliterated ductus venosis. Tributaries The tributaries of the portal vein are lienol, superior mesenteric, coronary, pyloric, cystic and paraumbilical. The lienol vein v. lianalis spleenic vein commences by 5 or 6 large branches which return the blood from the spleen. These unite to form a single vessel which passes from left to right, grooving the upper and back part of the pancreas below the lineal artery and ends behind the neck of the pancreas by hiding at a right angle with the superior mesenteric to form the portal vein. The lienol vein is of large size but is not torturous like the artery. Tributaries The lineal vein receives the short gastric veins, the left gastroepoploic vein, the pancreatic veins and the inferior mesenteric veins. The short gastric veins, VV gastric brevis, 4 or 5 in number, drain the fundus and left part of the greater curvature of the stomach and pass between the two layers of the gastro- lienol ligament to end in the lienol vein or in one of its large tributaries. The left gastroepoploic vein, V gastroepoploica sinistra receives branches from the anterior superior and posterior inferior surfaces of the stomach and from the greater omentum. It runs from right to left along the greater curvature of the stomach and ends in the commencement of the lienol vein. The pancreatic veins, VV pancreatic ca consists of several small vessels which drain the body and tail of the pancreas and open into the trunk of the lienol vein. The inferior mesenteric vein, V mesenterica inferior returns blood from the rectum and the sigmoid and descending parts of the colon. It begins in the rectum as the superior hemorrhoidal vein which has its origin in the hemorrhoidal plexus and through this plexus communicates with the middle and inferior hemorrhoidal veins. The superior hemorrhoidal vein leaves the lesser pelvis and crosses the left common iliac vessels with the superior hemorrhoidal artery and is continued upward as the inferior mesenteric vein. This vein lies to the left of its artery and ascends behind the peritoneum and in front of the left sorus major. It then passes behind the body of the pancreas and opens into the lienol vein. Sometimes it ends in the angle of union of the lienol and super mesenteric veins. Tributaries. The inferior mesenteric vein receives the sigmoid veins from the sigmoid colon and iliac colon and the left colic vein from the descending colon and the left colic flexure. The superior mesenteric vein, V mesenterica superior returns the blood from the small intestine from the cecum and from the ascending and transverse portions of the colon. It begins in the right iliac fossa by the union of the veins which drain the terminal part of the ilium the cecum and the vermaform process and ascends between the two layers of the mesenteri on the right side of the superior mesenteric artery. In its upward course it passes in front of the right ureter the inferior vena cava the inferior part of the duodenum and the lower portion of the head of the pancreas. Behind the neck of the pancreas it unites with the lienol vein to form the portal vein. Tributaries. Besides the tributaries which correspond with the branches of the superior mesenteric artery namely the intestinal, iliocolic, right colic, and middle colic veins the superior mesenteric vein is joined by the right gastroepiploic and pancreatic duodenal veins. The right gastroepiploic vein, V gastroepiploica dextra receives branches from the greater omentum and from the lower parts of the anterior superior and posterior inferior surfaces of the stomach. It runs from left to right along the greater curvature of the stomach between the two layers of the greater omentum. The pancreatic duodenal veins VV pancreatico duodenalis accompany their corresponding arteries. The lower of the two frequently joins the right gastroepiploic vein. The coronary vein, V coronaria ventriculi gastric vein derives tributaries from both surfaces of the stomach. It runs from right to left along the lesser curvature of the stomach between the two layers of the lesser omentum to the esophageal opening of the stomach where it receives some esophageal veins. It then turns backward and passes from left to right behind the omental bursa and ends in the portal vein. The pyloric vein is of small size and runs from left to right along the pyloric portion of the lesser curvature of the stomach between the two layers of the lesser omentum to end in the portal vein. The cystic vein, V cystica drains the blood from the gallbladder and accompanying the cystic duct usually ends in the right branch of the portal vein. Parumbilical veins, VV parumbilica calis. In the course of the ligamentum terus of the liver and of the middle umbilical ligament, small veins, parumbilical are found which establish an anastomosis between the veins of the anterior abdominal wall and the portal hypogastric and iliac veins. The best marked of these small veins is one which commences at the umbilicus and runs backward and upward in or on the surface of the ligamentum terus between the layers of the falcoform ligament to end in the left portal vein. Collateral venous circulation to relieve portal obstruction in the liver may be affected by communications between A. the gastric veins and the esophageal veins which often project as a varicose bunch into the stomach, emptying themselves into the hemiasigus vein. B. the veins of the colon in the duodenum and the left renal vein. C. the accessory portal system of sapi, branches of which pass in the round and falcoform ligaments, particularly the latter, to unite with the epigastric and internal mammary veins and through the diaphragmatic veins with the azigos. A single large vein, shown to be a parumbilical vein, may pass from the highless of the liver by the round ligament of the umbilicus, producing there a bunch of prominent varicose veins known as the capute medusae. D. the veins of Rezius which connect the intestinal veins with the inferior vena cava and its retroperitoneal branches. E. the inferior mesenteric veins and the hemorrhoidal veins that open into the hypogastrics. F. very rarely the ductus venosis remains patent, affording a direct connection between the portal vein and the inferior vena cava. End of section 42 Section 43 of Grey's Anatomy Part 3 This is LibriVox recording or LibriVox recordings are in the public domain. For more information or to volunteer please visit LibriVox.org Recording by Shuley from Wallacham. Anatomy of the Human Body Part 3 by Henry Gray The Lymphatic System Introduction The Lymphatic System consists one of complex capillary networks which collect the lymph in the various organs and tissues two of an elaborate system of collecting vessels which conduct the lymph from the capillaries to the large veins of the neck at the junction of the internal jugular and subclavian veins where the lymph is poured into the bloodstream and three lymph glands on nodes which are interspaced in the pathways of the collecting vessels filtering the lymph as it passes through them and contributing lymphocytes to it. The lymphatic capillaries and collecting vessels are lined throughout by continuous layer of endothelial cells forming thus a closed system. The lymphatic vessels of the small intestine receive the special designation of lacteals or chylophorous vessels They differ in no respect to lymphatic vessels generally accepting that during the process of digestion they contain a milk-wide fluid the chyle the development of the lymphatic vessels The lymphatic system begins as a series of sacs at the point of junction of certain of the embryonic veins These lymph sacs are developed by the confluence of numerous venous capillaries which at first lose their connections to the lymphatic system but subsequently on the formation of the sacs regains them The lymphatic system is therefore developmentally an offshoot of the venous system and the lining walls of its vessels are always anothelial In a human embryo the lymph sacs from which the lymphatic vessels are derived are 6 and number 2 paired the jugular and the posterior lymph sacs the anilial and the cisterna chyle In lower mammals an additional pair subclavian is present but in the human embryo these are merely extensions of the jugular sacs The position of the sacs is as follows 1. Jugular sac the first to appear at the junction of the subclavian vein with a primitive jugular 2. Posterior sac at the junction of the ilioc vein 3. Retroperitoneal and the root of the mesentery near the suprarenal glands 4. Cisterna chyle opposite the third and fourth lumbar vertebrae From the lymph sacs the lymphatic vessels bud out along fixed lines corresponding more or less closely to the cause of the embryonic flott vessels Both in the body wall and in the wall of the intestine the deeper plexuses are the first to be developed By continued growth of these the vessels in the superficial layers are gradually formed The thoracic duct is probably formed from anisomosing outgrows from the jugular sac and cisterna chyle At its connection with the cisterna chyle it is at first double but the two vessels soon join All the lymph sacs except the cisterna chyle are at a later stage divided up by slender connective tissue bridges and transformed into groups of lymph glands The lower portion of the cisterna chyle is similarly converted but its upper portion remains as the adult cisterna Lymphatic capillaries The complex capillary plexuses which consist of a single layer of thin, flat and atelial cells lie in the connective tissue spaces in the various regions of the body to which they are distributed and are bathed by the intercellular tissue fluids Two views are at present held as to the mode in which the lymph is formed One being by the physical processes of filtration, life fusion and osmosis and the other that in addition to these physical processes the endothelial cells have an active secretary function The coloreal liquid lymph consists of a single composition as a blood plasma It contains many lymphocytes and frequently red blood capitals Granules and bacteria are also taken up by the lymph from the connective tissue spaces partly by the action of lymphocytes which pass into the lymph between the endothelial cells and partly by the direct passage of the granules through the endothelial cells The lymphatic capillary plexuses vary greatly in form The enosomotors are usually in numeras, blind ends or cooler sucks are especially common in the intestinal villi the dermal papulae and the filiform papulae of the tongue The plexuses are often in two layers a superficial and a deep the superficial being of smaller caliber than the deep The caliber however varies greatly in a given plexus from 1mm to 1mm The capillaries are without valves Dissepiation The skin Lymphatic capillaries are abundant in the dermas where they form superficial and deep plexuses the form is sending blind ends into the derma papulae The plexuses are especially rich over the palmar surface of the hands and fingers and over the plantar surface of the feet and toes The epidermis is without capillaries The conjunctiva has an especially rich plexus The subcutonase tissue is without capillaries The tendons of striated muscle and muscle sheets are richly supplied In muscle however their existence is still disputed The periosteum of bone is richly supplied They have been described the havesian canals They are absent in cartilage and probably in bone marrow The joint capsules are richly supplied with lymphatic capillaries They do not however open into the joint cavities Beneath them is a celium lining of the pleural, peritoneal and pericardial cavities are rich plexuses They do not open into these cavities The elementary canal is supplied with rich plexuses Beneath the epithelium often as a superficial plexus and the mucosa and a deeper submucosal plexus Kildesug's extend into the filiform papulae of the tongue and the villi of the small intestine Those portions of the elementary canal covered by peritoneum have in addition a subsuric lymphatic capillary plexus beneath them as a thelium The delivery glands are supplied with lymphatic capillaries The liver has a rich subsuric plexus in the capsule and also extensive plexuses which accompany the hepatic artery and portal vein The lymphatic capillaries have not been followed into the liver lobules The limb from the liver forms a large part of that which flows through the thoracic duct The gallbladder and bile ducts have a plexus and the former a subsuric plexus The spleen has a rich subsuric set and a capsular set of lymphatic capillaries Their presence in the parenchyma is uncertain The nasal cavity has extensive capillary plexuses in the mucosa and submucosa The trachea and bronchi have plexuses in the mucosa and submucosa that the smaller bronchi have only a single layer The capillaries do not extend to the air cells The plexuses around the smaller bronchi connect with a rich subsuric plexus of the lungs in places where the veins reach the surface Lymphatics have been described in the thyroid gland and in the thymus The adrenal has a superficial plexus divided into two layers One in the luster tissue above the gland and the other beneath the capsule Capillaries have also been described within the parenchyma The kidney is supplied with a coarse subsuric plexus and a deeper plexus of finer capillaries in the capsule Lymphatics have been described within the substance of the kidney surrounding the tubules The urinary bladder has rich plexus of lymphatic capillaries just beneath the epithelial lining also a subsuric set which anisomoses with the form through the muscle layer The submucous plexus is continuous with the submucous plexus of the urethra The prostate has a rich lymphatic plexus surrounding the gland and a wide meshed subcapsular plexus The testes has a rich superficial plexus beneath the tunica albinia The presence of deep lymphatics is disputed The uterus is provided with a subsuric plexus and the subcapsular plexus are uncertain Subapithelial plexuses are found in the vagina The ovary has a rich superficial plexus and a deep interstitial plexus The heart has a rich subsuric plexus beneath the apicardium Lymphatic capillaries have also been described beneath the anacardium and throughout the muscle Lymphatic capillaries are probably absent in the central nervous system The eyeball, except the conjunctiva the orbit the internal ear the striated muscle the spleen pulp and kidney parenchyoma They are entirely absent in cartilage In many places further investigation is needed Lymphatic vessels The lymphatic vessels are exceedingly delicate and their codes are so transparent that a fluid they contain are easily seen through them They are interrupted at intervals by constrictions which gives them a knotted or beaded appearance These constrictions correspond to the situations of valves in their interior Lymphatic vessels have been found in nearly every texture and organ of the body which contains blood vessels Such non-vescular structures as cartilage the nails, cuticle and hair have none With these exceptions it is probable that eventually all parts will be found to be permeated by these vessels Structure of lymphatic vessels The larger lymphatic vessels are each composed of three codes The internal code is a thin, transparent slightly elastic and consists of a layer of elongated anethelial cells with a wavy margins by which the contiguous cells have tailed into one another The cells are supported on an elastic membrane The middle code is composed of smooth, muscular and fine elastic fibres disposed in a transverse direction The external code consists of connective tissue and is mixed with a smooth muscular fibres longitudinally or obliquely disposed It forms a protective covering to the other codes to connect the vessel with the neighbouring structures In the smaller vessels there are no muscular or elastic fibres and the wall consists only of a connective tissue code lined by anethelium The thoracic duct has a more complex structure than the other lymphatic vessels It presents a distinct subanethelium layer of branched corpuscles similar to Z found in the arteries In the middle code there is in addition to the muscular and elastic fibres a layer of connective tissue with its fibres arranged longitudinally The lymphatic vessels are supplied by nutrient vessels which are distributed to their aorta and middle codes and here also have been traced many non-modulated nerves in the form of a fine plexus of fibres The valves of the lymphatic vessels are formed of thin layers of fibros tissue covered on both surfaces by anethelium which presents the same arrangement as on the valves of veins In form the valves of semiluna they are retouched by their convex edges to the wall of the vessel The concave edges being free and directed along the cores of the contained current Usually two such valves of equal size are found opposite to one another but occasionally exceptions occur especially at or near the anisomosis of lymphatic vessels Thus one valve may be of small size and the other increase in proportion In the lymphatic vessels the valves are placed at much shorter intervals than in the veins They are most numerous near the lymph glands and are found more frequently in the lymphatic vessels of the neck The lower extremity the lower extremity the wall of the lymphatic vessel immediately above the point of attachment of each segment of a valve is expanded into a pouch or sinus which gives to these vessels when distended the not at all beaded appearance already referred to Valves are wanting in the vessels composing the plexiform network in which the lymphatic vessels enter and leave the interior The efferent lymphatic vessel also emerges from the gland at this spot while the efferent vessels pass through them on their way to the blood Each generally presents on one side a slight depression through which the blood vessels enter and leave the interior The efferent lymphatic vessel also emerges from the gland while the efferent vessels enter the organ at different parts of the periphery On section a lymph gland displays two different structures an external of lighter color the cortical and an internal darker the medullary The cortical structure does not form a complete investment but is deficient at the high list where the medullary portion reaches the surface of the gland so that the efferent vessel is derived directly from the medullary structures while the efferent vessels empties themselves into the cortical substance Structure of lymph glands A lymph gland consists of one, a pharynx embolobe or capsule from which a framework of processes trabeculae, proceeds inward and perfectly dividing the gland into open spaces freely communicating with each other Two, a quantity of lymphatic tissue occupying these spaces without completely filling them Three, a free supply of blood vessels which are supported in the trabeculae and four, the efferent and efferent vessels communicating through the lymph paths in the substance of the gland The nerves passing into the hyalis are few in number and are chiefly distributed to the blood vessels supplying the gland The capsule is composed of connective tissue with some plain muscle fibers and from its internal surface are given off a number of membranous processes or trabeculae consisting in man of connective tissue with a smaller mixture of plain muscle fibers but in many of the lower animals composed almost entirely of involuntary muscle They pass inward radiating toward the center of the gland for a certain distance that is to say for about one third or one fourth of the space between the circumference and the center of the gland In some animals they are sufficiently well marked to divide the peripheral or cortical portion of the gland into a number of compartments so called follicles but in man this arrangement is not obvious The larger trabeculae springing from the capsule break up into finer bands and these interlaced to form a meshwork in the central or medially portion of the gland and these spaces formed by the interlacing trabeculae is contained the proper gland substance or lymphoid tissue The gland pulp does not however completely fill the spaces but leaves between its outer margin and the enclosing trabeculae a channel or space of uniform throughout This is termed the lymph path or lymph sinus Running across it are a number of finer trabeculae of retiform connective tissue the fibres of which are for the most part covered by ramifying cells On account of the peculiar arrangement of the framework of the organ the gland pulp in the cortical portion is exposed in the form of nodules and in the medullary part of rounded cords It consists of ordinary lymphoid tissue being made up of a delicate network of retiform tissue which is continuous with that in the lymph paths but marked off from it by closer reticulation It is probable moreover but a reticulate tissue of the gland pulp and the lymph paths is continuous with that of the trabeculae and ultimately with that of the capsule of the gland In it smashes in the nodules and cords of lymphoid tissue are closely packed lymph caposals The gland pulp is traversed by dense plexus of capillary blood vessels The nodules of follicles in the cortical portion of the gland frequently show in this centre areas where carachinatic figures indicate a division of the lymph caposals These areas are termed germ centres The cells composing them have more abundant than the peripheral cells The afferent vessels as stated above enter at all parts of the periphery of the gland and after branching and forming a dense plexus in the substance of the capsule open it to the lymph sinuses of the cortical part In doing this they lose all their codes except their endothelial lining which is continuous with a layer of similar cells lining the lymph paths In like manner the afferent vessel commences from the lymph sinuses of the medullary portion The stream of lymph carry to the gland by the afferent vessels This passes through the plexus in the capsule to the lymph paths of the cortical portion where it is exposed to the action of the gland pulp Flowing through these it enters the paths of sinuses of the medullary portion and finally emerges from the hilus by means of the afferent vessel The stream of lymph in its passage through the lymph sinuses is much retarded by the presence of the reticulum hence morphological elements eyes are normal or morbid are easily arrested and deposited in the sinuses Many lymph corpuscles pass with the afferent lymphstream to join the general bloodstream The arteries of the gland enter at the hilus and either go at once to the gland pulp to break up into a capillary plexus or else run along the travecule partly to supply them and partly running across the lymph paths to assist in forming the capillary plexus of the gland pulp This plexus traverses the lymph fluid's issue but does not enter into the lymph sinuses From it the veins commence and emerge from the organ at the same place as that at which the arteries enter The lymphatic vessels are arranged into a superficial and a deep set On the surface of the body the superficial lymphatic vessels are placed immediately beneath the integument accompanying the superficial veins they join the deep lymphatic vessels in certain situations by perforating the deep fascia In the interior of the body they lie in the submacus aureola tissue throughout the whole length of the digestive, respiratory and genetic urinary tracts and in the subsuric tissue of the thoracic and abdominal walls Plexiform networks of minute lymphatic vessels are found interspersed among the proper elements and blood vessels of the several tissues The vessels composing the network as well as the masses between them are much larger than those of the capillary plexus From these networks small vessels emerge which pass either to a neighbouring gland or to join some larger lymphatic trunk The deep lymphatic vessels fewer in number but larger than the superficial accompany the deep blood vessels Their mode of origin is probably similar to that of the superficial vessels The lymphatic vessels of any part or organ exceed the veins in number but in size they are much smaller Their anaestomosis also especially those of the large trunks are more frequent and are affected by vessels equal in diameter and those which they connect the continuous trunks retaining the same diameter Hammer lymph nodes or glands and hammer nodes which are so abundant in some mammals are probably not present in man Lymph Lymph found only in the close lymphatic vessels is a transparent, colourless or slightly yellow watery fluid of specific gravity about 1.015 It closely resembles the blood plasma but is more dilute When it is examined under the microscope leukocytes of the lymphocyte clars are found floating in the transparent fluid They are always increased in number after the passage of the through lymphoid tissue as in lymph glands Lymph should be distinguished from tissue fluid which is found outside the lymphatic vessels in the tissue spaces Section 43 Section 44 of Grey's Anatomy Part 3 This is a LibriVox recording All LibriVox recordings are in the public domain For more information or to volunteer please visit LibriVox.org Anatomy of the Human Body Part 3 by Henry Grey The Thoracic Duct The Thoracic Duct The Thoracic Duct Ductus thoracicus conveys the greater part of the lymph and chile into the blood It is the common trunk of all the lymphatic vessels of the body accepting those on the right side of the head neck and thorax and right upper extremity the right lung, right side of the heart and the convex surface of the liver In the adult it varies in length from 38 to 45 cm and extends from the second lumbar vertebra to the root of the neck It begins in the abdomen by a triangular dilatation the cisterna chile which is situated on the front of the body of the second lumbar vertebra to the right side of and behind the aorta by the side of the right crust of the diaphragm It enters the thorax through the aortic hiatus of the diaphragm and ascends through the posterior medial cavity between the aorta and azygos vein Behind it in this region are the vertebral column the right intercostal arteries and the hemiazygos veins as they cross to open into the azygos vein In front of it are the diaphragm isophagus and pericardium the last being separated from it by a recess of the right pleural cavity Opposite the fifth thoracic vertebra it inclines toward the left side enters the superior mediastinal cavity and ascends behind the aortic arch and the thoracic part of the left subclavian artery and between the left side of the isophagus and the left pleura to the upper orifice of the thorax Passing into the neck it forms an arch which rises about 3 or 4 centimeters above the clavicle and crosses anterior to the subclavian artery the vertebral artery and vein and the thyroservical trunk or its branches It also passes in front of the phrenic nerve and the medial border of the scalenus anterior but is separated from these two structures by the pre-vertebral fascia In front of it are the left common carotid artery, vagus nerve and internal jugular vein It ends by opening into the angle of junction between the left subclavian vein with the left internal jugular vein The thoracic duct at its commencement is about equal in diameter to a goose quill but it diminishes considerably in calibre in the middle of the thorax and is again dilated just before its termination It is generally flexuous and constricted at intervals so as to present a varicose appearance Not infrequently it divides in the middle of its course with vessels of unequal size which soon reunite or into several branches which form a plexiform interlacement It occasionally divides at its upper part into two branches right and left The left ending in the usual manner while the right opens into the right subclavian vein in connection with the right lymphatic duct The thoracic duct has several valves At its termination it is provided with a pair the free borders of which are turned toward the vein so as to prevent the passage of venous blood into the duct The cisterna chylee receptaculum chylee receives the two lumbar lymphatic trunks right and left and the intestinal lymphatic trunk The lumbar trunks are formed by the union of the efferent vessels from the lateral aortic lymph glands They receive the lymph from the lower limbs from the walls and viscera of the pelvis from the kidneys and supra renal glands and the deep lymphatics of the greater part of the abdominal wall The intestinal trunk receives the lymph from the stomach and intestine from the pancreas and spleen and from the lower and front part of the liver Tributaries Opening into the commencement of the thoracic duct on either side is a descending trunk from the posterior intercostal lymph glands of the lower six or seven intercostal spaces In the thorax the duct is joined on either side by a trunk which drains the upper lumbar lymph glands and pierces the crust of the diaphragm It also receives the efferents from the posterior mediastinal lymph glands and from the posterior intercostal lymph glands of the upper six left spaces In the neck it is joined by the left jugular and left subclavian trunks and sometimes by the left bronchomediastinal trunk The last named, however usually opens independently into the junction of the left subclavian and internal jugular veins The right lymphatic duct Ductis lymphaticus texter about 1.25 cm in length courses along the medial border of the scaliness and heria at the root of the neck and ends in the right subclavian vein at its angle of junction with the right internal jugular vein Its orifice is guarded by two semilunar valves which prevents the passage of venous blood into the duct Tributaries The right lymphatic duct receives the lymph from the right side of the head and neck through the right jugular trunk From the right upper extremity through the right subclavian trunk From the right side of the thorax Right lung Right side of the heart and part of the convex surface of the liver through the right bronchomediastinal trunk These three collecting trunks frequently open separately in the angle of union of the two veins End of Section 44 Section 45 of Grey's Anatomy Part 3 This is a LibriVox recording All LibriVox recordings are in the public domain For more information or to volunteer please visit LibriVox.org Anatomy of the Human Body Part 3 by Henry Gray The lymphatics of the head, face and neck The lymph glands of the head The lymph glands of the head are arranged in the following groups Oxypital, posterior auricular anterior auricular parotid, facial deep facial lingual retrofaryngeal The occipital glands Lympho-Glandulae occipitalis 1-3 in number are placed on the back of the head close to the margin of the trapezius and resting on the insertion of the semi-spinalis capitis Their afferent vessels drain the occipital region of the scalp while their efferents pass to the superior deep cervical glands The posterior auricular glands Lympho-Glandulae auricularies mastoid glands usually two in number are situated on the mastoid insertion of the sternocleidomastoidius beneath the auricularis posterior Their afferent vessels drain the posterior part of the temporal parietal region the upper part of the cranial surface of the auricular or pinna and the back of the external acoustic meadas Their efferents pass to the superior deep cervical glands The anterior auricular glands Lympho-Glandulae auricularies anterioris superficial parotid or pre-auricular glands From one to three in number lie immediately in front of the tragus Their afferents drain the lateral surface of the auricular and the skin of the adjacent part of the temporal region Their efferents pass to the superior deep cervical glands The parotid glands Lympho-Glandulae parotidiae form two groups in relation with the parotid salivary gland These are a group embedded in the substance of the gland and a group of sub-parotid glands lying on the lateral wall of the pharynx Occasionally, small glands are found in the subcutaneous tissue over the parotid gland Their afferent vessels drain the root of the nose, the eyelids, the frontal temporal region, the external acoustic meadas and the tympanic cavity also the posterior parts of the palate and the floor of the nasal cavity The efferents of these glands pass to the superior deep cervical glands The afferents of the sub-parotid gland strain the nasal part of the pharynx and the posterior parts of the nasal cavities Their efferents pass to the superior deep cervical glands The facial glands comprise three groups A. Infraorbital or Maxillary scattered over the Infraorbital region from the groove between the nose and cheek to the zygomatic arch B. Buxinator One or more placed on the Buxinator opposite the angle of the mouth C. Supermandibular on the outer surface of the mandible in front of the masseter and in contact with the external maxillary artery and anterior facial vein Their efferent vessels drain the eyelids the conjunctiva and the skin and mucous membrane of the nose and cheek Their efferents pass to the sub-maxillary glands The deep facial glands lympho-glangeli, fasciallis, profunda internal maxillary glands are placed beneath the ramus of the mandible on the outer surface of the pterogoidius externus in relation to the internal maxillary artery Their efferent vessels drain the temporal and infratemporal foci and the nasal part of the pharynx Their efferents pass to the superior deep cervical glands The lingual glands lympho-glangeli, lingualis are two or three small nodules lying on the hyoglossus and under the genioglossus They form merely glandular substations in the course of the lymphatic vessels of the tongue The retrofaryngeal glands from one to three in number lie in the buccal pharyngeal fascia behind the upper part of the pharynx and in front of the arch of the atlas being separated however from the latter by the longest capitis Their efferents drain the nasal cavities the nasal part of the pharynx and the auditory tubes Their efferents pass to the superior deep cervical glands The lymphatic vessels of the scalp are divisible into A. those of the frontal region which terminate in the anterior auricular and parotid glands B. those of the temporal parietal region which end in the parotid and posterior auricular glands and C. those of the occipital region which terminate partly in the occipital glands and partly in a trunk which runs down along the posterior border of the sternocleidomastodius to end in the inferior deep cervical glands The lymphatic vessels of the auricular and external acoustic meiasis are also divisible into three groups A. an anterior from the lateral surface of the auricular and anterior wall of the meiasis to the anterior auricular glands B. a posterior from the margin of the auricular the upper part of its cranial surface the internal surface and posterior wall of the meiasis to the posterior auricular and superficial deep cervical glands C. an inferior from the floor of the meiasis and from the lobule of the auricular to the superficial and superior deep cervical glands The lymphatic vessels of the face are more numerous than those of the scalp Those from the eyelids and conjunctiva terminate partly in the submaxillary but mainly in the parotid glands The vessels from the posterior part of the cheek also pass to the parotid glands while those from the anterior portion of the cheek the side of the nose, the upper lip and the lateral portions of the lower lip and in the submaxillary glands The deeper vessels from the temporal and infratemporal fossey pass to the deep facial and superior deep cervical glands The deeper vessels of the cheek and lips end like the superficial in the submaxillary glands Both superficial and deep vessels of the central part of the lower lip run to the submental glands Lymphatic vessels of the nasal cavities Those from the anterior parts of the nasal cavities communicate with the vessels of the integument of the nose and end in the submaxillary glands Those from the posterior two-thirds of the nasal cavities and from the accessory aer sinuses pass partly to the retrofaryngeal and partly to the superior deep cervical glands Lymphatic vessels of the mouth The vessels of the gums pass to the submaxillary glands Those of the hard palate are continuous in front with those of the upper gum but pass backward to pierce the constrictor faringes superior and end in the superior deep cervical and subparotid glands Those of the soft palate pass backward and lateralward and end partly in the retrofaryngeal and subparotid and partly in the superior deep cervical glands The vessels of the anterior part of the floor of the mouth pass either directly to the inferior glands of the superior deep cervical group or indirectly through the submental glands From the rest of the floor of the mouth the vessels pass to the submaxillary and superior deep cervical glands The lymphatic vessels of the palatine tonsil usually three to five in number pierce the buccofaryngeal fascia and constrictor faringes superior and pass between the stylohyoidius and internal jugular vein to the uppermost of the superior deep cervical glands They end in a gland which lies at the side of the posterior belly of the digastricus on the internal jugular vein Occasionally one or two additional vessels run to small glands on the lateral side of the vein under cover of the sternocleidomastoidius The lymphatic vessels of the tongue are drained chiefly into the deep cervical glands lying between the posterior belly of the digastricus and the superior belly of the omohyoidius One gland situated at the bifurcation of the common carotid artery is so intimately associated with these vessels that it is known as the principal gland of the tongue The lymphatic vessels of the tongue may be divided into four groups One apical from the tip of the tongue to the suprahyoid glands and principal gland of the tongue Two lateral from the margin of the tongue Some of these pierce the mylohyoidius to end in the submaxillary glands Others pass down on the hyoglossus to the superior deep cervical glands Three basal from the region of the valate papillae to the superior deep cervical glands And four median a few of which perforate the mylohyoidius to reach the submaxillary glands While the majority turn around the posterior border of the muscle to enter the superior deep cervical glands The lymph glands of the neck The lymph glands of the neck include the following groups Submaxillary Submental Superficial Cervical Anterior Cervical Deep Cervical The submaxillary glands 3-6 in number are placed beneath the body of the mandible in the submaxillary triangle and rest on the superficial surface of the submaxillary salivary gland One gland the middle gland of star on the external maxillary artery as it turns over the mandible is the most constant of the series Small lymph glands are sometimes found on the deep surface of the submaxillary salivary glands The afferents of the submaxillary glands drain the medial pepibril commissure the cheek, the side of the nose the upper lip the lateral part of the lower lip the gums and the anterior part of the margin of the tongue afferent vessels from the facial and submental glands also enter the submaxillary glands Their afferent vessels pass to the superior deep cervical glands The submental or suprahyoid glands are situated between the anterior bellies of the digastric eye Their afferents drain the central portions of the lower lip and floor of the mouth and the apex of the tongue Their afferents pass partly to the submaxillary glands and partly to a gland of the deep cervical group situated on the internal jugular vein at the level of the cricoid cartilage The superficial cervical glands lympho-glanduli, cervicalis, superficialis lie in close relationship with the external jugular vein as it emerges from the parotid gland and, therefore, superficial to the sternocleidomastoidius Their afferents drain the lower parts of the auricular and parotid region while their afferents pass around the anterior margin of the sternocleidomastoidius to join the superior deep cervical glands The anterior cervical glands form an irregular and inconstant group on the front of the larynx and trachea They may be divided into A. A superficial set placed on the anterior jugular vein B. A deeper set which is further subdivided into pre-laryngeal on the middle cricothyroid ligament and pre-tracheal on the front of the trachea This deeper set drains the lower part of the larynx, the thyroid gland and the upper part of the trachea Its efferents pass to the lowest of the superior deep cervical glands The deep cervical glands lympho-glanduli, cervicalis, profundi are numerous and of large size They form a chain along the carotid sheath lying by the side of the pharynx, esophagus and trachea and extending from the base of the skull to the root of the neck They are usually described in two groups One, the superior deep cervical glands lying under the sternocleidomastoidius in close relation with the accessory nerve and the internal jugular vein Some of the glands lying in front of and others behind the vessel Two, the inferior deep cervical glands extending beyond the posterior margin of the sternocleidomastoidius into the supraclavicular triangle where they are closely related to the brachial plexus and subclavian vein A few minute peritracheal glands are situated alongside the recurrent nerves on the lateral aspects of the trachea and esophagus The superior deep cervical glands drain the occipital portion of the cervical gland They also drain the occipital portion of the scalp, the auricula, the back of the neck, a considerable part of the tongue, the larynx, thyroid gland, trachea, nasal part of the pharynx, nasal cavities, palate and esophagus They also receive the efferent vessels from all the other glands of the head and neck except those from the inferior deep cervical glands The inferior deep cervical glands drain the back of the scalp and neck, the superficial pectoral region, part of the arm and, occasionally, part of the superior surface of the liver In addition, they receive vessels from the superior deep cervical glands The efferents of the superior deep cervical glands pass partly to the inferior deep cervical glands and partly to a trunk which unites with the efferent vessel of the inferior deep cervical glands on the right side, this trunk ends in the junction of the internal jugular and subclavian veins On the left side, it joins the thoracic duct The lymphatic vessels of the skin and muscles of the neck pass to the deep cervical glands From the upper part of the pharynx the lymphatic vessels pass to the retrofaryngeal from the lower part to the deep cervical glands From the larynx, two sets of vessels arise, an upper and a lower The vessels of the upper set pierce the hyothyroid membrane and join the superior deep cervical glands Of the lower set, some pierce the conus elasticus and join the pre tracheal and pre laryngeal glands Others run between the crocoid and first tracheal ring and enter the inferior deep cervical glands The lymphatic vessels of the thyroid gland consist of two sets The upper, which accompanies the superior thyroid artery and enters the superior deep cervical glands and the lower, which runs partly to the pre tracheal glands and partly to the small paratracheal glands which accompany the recurrent nerves These latter glands receive also the lymphatic vessels from the cervical portion of the trachea End of section 45 Section 46 of Grey's Anatomy Part 3 This is a LibriVox recording All LibriVox recordings are in the public domain For more information or to volunteer please visit LibriVox.org Anatomy of the Human Body Part 3 by Henry Gray Section 46 The Lymphatics of the Upper Extremity The Length Glands of the Upper Extremity are divided into two sets superficial and deep The superficial lymph glands are few and of small size One or two super trochlear glands are placed above the medial epicondyle of the humerus medial to the bacillic vein Their afferents drain the middle ring and little fingers the medial portion of the hand and the superficial area over the ulnar side of the forearm These vessels are however in free communication with the other lymphatic vessels of the forearm Their afferents accompany the bacillic vein and join the deeper vessels One or two Deltoideopectoral glands are found beside the cephalic vein between the pectoralis major and deltoidius immediately below the clavicle They are situated in the course of the external collecting trunks of the arm The deep lymph glands are cheaply grouped in the axilla Although a few may be found in the forearm in the course of the radial ulnar and interosseous vessels and in the arm along the medial side of the brachial artery The axillary glands lymphoglangulae axillaries are of large size vary from 20 to 30 in number and may be arranged in the following groups One, a lateral group of from 4 to 6 glands lies in relation to the medial and posterior aspects of the axillary vein The afferents of these glands drain the whole arm with the exception of that portion whose vessels accompany the cephalic vein The efferent vessels pass partly to the central and subclavicular groups of axillary glands and partly to the inferior deep cervical glands Two, an anterior or pectoral group consists of 4 or 5 glands along the lower border of the pectoralis minor lateral thoracic artery Their afferents drain the skin and muscles of the anterior and lateral thoracic walls and the central and lateral parts of the NAMA Their efferents pass partly to the central and partly to the subclavicular groups of axillary glands Three, a posterior or subscapular group of 6 or 7 glands along the lower margin of the posterior wall of the axilla in the course of the subscapular artery The afferents of this group drain the skin and muscles of the lower part of the back of the neck and of the posterior thoracic wall Their efferents pass to the central group of axillary glands Four, a central or intermediate group of 3 or 4 large glands is embedded in the adipose tissue near the base of the axilla Its afferents are the efferent vessels of all the preceding groups of axillary glands Its efferents pass to the subclavicular group Five, a medial or subclavicular group of 6 to 12 glands is situated partly posterior to the upper portion of the pectoralis minor and partly above the upper border of this muscle Its only direct territorial afferents are those which accompany the cephalic vein and one which drains the upper peripheral part of the mammoth but it receives the efferents of all the other axillary glands The efferent vessels of the subclavicular group are the subclavian trunk which opens either directly into the junction of the internal jugular and subclavian veins or into the jugular lymphatic trunk On the left side it may end in the thoracic duct A few efferents from the subclavicular glands usually pass to the inferior deep cervical glands The lymphatic vessels of the upper extremity The lymphatic vessels are divided into two sets superficial and deep The superficial lymphatic vessels commence in the lymphatic plexus which everywhere pervades the skin The meshes of the plexus are much finer in the palm and on the flexor aspect of the digits than elsewhere The digital plexuses are drained by a pair of vessels which run on the sides of each digit and incline backward to reach the dorsum of the hand From the dense plexus of the palm vessels pass in different directions This upward toward the wrist downward to join the digital vessels medialward to join the vessels on the ulnar border of the hand and lateralward to those on the thumb Several vessels from the central part of the plexus unite to form a trunk which passes around the metacarpal bone of the index finger to join the vessels on the back of that digit and on the back of the thumb Running upward in front of and behind the wrist the lymphatic vessels are collected into radial median and ulnar groups which accompany respectively the cephalic, median and the cilic veins in the forearm A few of the ulnar lymphatics end in the super trochlear glands but the majority pass directly to the lateral group of axillary glands Some of the radial vessels are collected into a trunk which ascends with the cephalic vein to the deltoideopectoral glands The efferents from this group pass either to the subclavicular axillary glands or to the inferior cervical glands The deep lymphatic vessels accompany the deep blood vessels In the forearm they consist of four sets corresponding with the radial ulnar, volar and dorsal interosseous arteries They communicate at intervals with the superficial lymphatics and some of them end in the glands which are occasionally found beside the arteries In their course upward a few end in the glands which lie upon the brachial artery but most of them pass to the lateral group of axillary glands End of Section 46 Recording by Selena Arter Section 47 of Grey's Anatomy Part 3 This is a LibriVox recording All LibriVox recordings are in the public domain For more information or to volunteer, please visit LibriVox.org Anatomy of the Human Body Part 3 by Henry Gray The Lymphatics of the Lower Extremity The Lymph glands of the Lower Extremity The Lymph glands of the Lower Extremity consist of the anterior tibial gland and the popliteal and inguinal glands The anterior tibial gland lymphoglangelo tibialis anterior is small and inconstant It lies on the interosseous membrane in relation to the upper part of the anterior tibial vessels and constitutes a substation in the course of the anterior tibial lymphatic trunks The popliteal glands lymphoglangelo poplitea small in size and some 6 or 7 in number are embedded in the fat contained in the popliteal fossa One lies immediately beneath the popliteal fascia near the terminal part of the small saphenous vein and drains the region from which this vein derives its tributaries Another is placed between the popliteal artery and the posterior surface of the knee joint It receives the lymphatic vessels from the knee joint together with those which accompany the genicular arteries The others lie at the sides of the popliteal vessels and receive as efferents the trunks which accompany the anterior and posterior tibial vessels The efferents of the popliteal glands pass almost entirely alongside the femoral vessels with a deep inguinal glands but a few may accompany the great saphenous vein and end in the glands of the superficial sub-inguinal group The inguinal glands lymphoglangelo inguinales from 12 to 20 in number are situated at the upper part of the femoral triangle They may be divided into two groups by a horizontal line at the level of the termination of the great saphenous vein The lines above this line are termed the superficial inguinal glands and those below it the sub-inguinal glands The latter group consisting of a superficial and a deep set The superficial inguinal glands form a chain immediately below the inguinal ligament They receive as efferents lymphatic vessels from the entanglement of the penis, scrotum, perineum, and batak The deep sub-inguinal glands are placed on either side of the upper part of the great saphenous vein Their efferents consist chiefly of the superficial lymphatic vessels of the lower extremity but they also receive some of the vessels which drain the entanglement of the penis, scrotum, perineum, and batak The deep sub-inguinal glands lympho-glangulae sub-inguinales profundae vary from one to three in number and are placed under the fascialata on the medial side of the femoral vein When three are present the lowest is situated just below the junction of the great saphenous and femoral veins the middle in the femoral canal and the highest in the lateral part of the femoral ring The middle one is the most inconstant of the three but the highest, the gland of cloquette or rosimular is also frequently absent They receive as efferents the deep lymphatic trunks which accompany the femoral vessels The lymphatics from the glands penis-vel clitoridus and also some of the efferents from the superficial sub-inguinal glands The lymphatic vessels of the lower extremity consist of two sets superficial and deep and in their distribution correspond closely with the veins The superficial lymphatic vessels lie in the superficial fascia and are divisible into two groups a medial which follows the course of the great saphenous vein and a lateral which accompanies the small saphenous vein The vessels of the medial group are larger and more numerous than those of the lateral group and commenced on the tibial side and dorsum of the foot They ascend both in front of and behind the medial malleolus run up the leg with the great saphenous vein pass with it behind the medial condyle of the femur and accompany it to the groin where they end in the sub-inguinal group of superficial glands The vessels of the lateral group arise from the fibular side of the foot Some ascend in front of the leg and just below the knee Cross the tibia to join the lymphatics on the medial side of the thigh Others pass behind the lateral malleolus and accompanying the small saphenous vein enter the popliteal glands The deep lymphatic vessels are few in number and accompany the deep blood vessels In the leg they consist of three sets posterior tibial posterior tibial and perineal which accompany the corresponding blood vessels two or three with each artery they enter the popliteal lymph glands The deep lymphatic vessels of the gluteal and ischial regions follow the course of the corresponding blood vessels Those accompanying the superior gluteal vessels end in a gland which lies on the intrapelvic portion of the superior gluteal artery near the upper border of the greater sciatic foramen Those following the inferior gluteal vessels traverse one or two small glands which lie below the piriformis muscle and end in the hypogastric glands End of Section 47 Recording by Selena Arter Section 48 of Grey's Anatomy Part 3 This is a LibriVox recording I'm in the public domain For more information or to volunteer please visit LibriVox.org Recording by Jennifer Stearns Anatomy of the Human Body Part 3 by Henry Gray Lymphatics of the abdomen and pelvis Part 1 The lymph glands of the abdomen and pelvis may be divided from the situations into a parietal lying behind the peritoneum and in close association with the larger blood vessels and B. visceral which are found in relation to the visceral arteries The parietal glands include the following groups external iliac common iliac epigastric iliac circumflex hypogastric sacral lateral aortic The external iliac glands 8-10 in number lie along the external iliac vessels They are arranged in three groups one on the lateral another on the medial and a third on the anterior aspect of the vessels The third group is, however, sometimes absent Their principal afference are derived from the inguinal and sub-inguinal glands The deep lymphatics of the abdominal wall below, the ambilicus and of the adductor region of the thigh and the lymphatics from the glans penis from the glands penis clitoridus the membranus urethra the prostate, the fundus of the bladder the cervix uteri and up a part of the vagina The common iliac glands 4-6 in number are grouped behind and on the sides of the common iliac artery 1 or 2 be in place below on the occasion of the aorta in front of the 5th lumbar vertebra They drain chiefly the hypogastric and external iliac glands and their afference past the lateral aortic glands The epigastric glands Lymphoglandylo epigastrico 3 or 4 in number are placed alongside the lower portion of the inferior epigastric vessels The iliac circumflex glands 2 to 4 in number Presituated along the course of the deep iliac-circle-flex vessels, they are sometimes absent. The hypogastric glands, lymphoglindulohibogastrico, internal iliac gland, surround the hypogastric vessels and receive the lymphatics corresponding to the distribution of the branches of the hypogastric artery. That is, they receive lymphatics from the pelvic viscera from the deeper parts of the perineum including the membranous and cavernous portions of the urethra and from the buttock and back of the thigh. An upterritor gland is sometimes seen in the upper part of the upterritor foreman. The sacral glands are placed in the concavity of the sacrum in relation to the middle and lateral sacral arteries. They receive lymphatics from the rectum and posterior wall of the pelvis. The efferents of the hypogastric group end in the common iliac glands. The lumbar glands, lymphoglindulohibogastrico, lumbalis, are very numerous and consist of right and left lateral aortic, pre-aortic, and retroaortic groups. The right lateral aortic glands are situated partly in front of the inferior vena cava near the termination of the renal vein and partly behind it on the origin of the psoas major and on the right cruise of the diaphragm. The left lateral aortic glands form a chain on the left side of the abdominal aorta in front of the origin of the psoas major and left cruise of the diaphragm. The glands on either side receive A. The efferents of the common iliac glands. B. The lymphatics from the testes in the male and from the ovary, uterine tube and body of the uterus in the female. C. The lymphatics from the kidney and super renal gland. And D. The lymphatics draining the lateral abdominal muscles and accompanying the lumbar veins. Most of the efferent vessels of the lateral aortic glands converge to form the right and left lumbar trunks, which join the cisterna, chile, but some enter the pre and retro aortic glands. And others pierce the crua of the diaphragm to join the lower end of the thoracic duct. The pre aortic glands lie in front of the aorta and may be divided into ciliac, superior mesenteric and inferior mesenteric groups, arranged around the origins of the corresponding arteries. They receive a few vessels from the lateral aortic glands, but their principal efferents are derived from the viscera supplied by the three arteries with which they are associated. Some of the efferents pass to the retro aortic glands, but the majority unite to form the intestinal trunk, which enters the cisterna, chile. The retro aortic glands are passed below the cisterna, chile on the bodies of the third and fourth lumbar vertebrae. They receive lymphatic trunks from the lateral and pre aortic glands while their efferents end in the cisterna, chile. The lymphatic vessels of the abdomen and pelvis. The lymphatic vessels of the walls of the abdomen and pelvis may be divided into two sets, superficial and deep. The superficial vessels follow the course of the superficial blood vessels and converge to the superficial inguinal glands. Those derived from the entanglement of the front of the abdomen below the umbilicus follow the course of the superficial epigastric vessels and those on the sides of the lumbar part of the abdominal wall pass along the crest of the ilium with the superficial iliac circumflex vessels. The superficial lymphatic vessels of the gluteal region turn horizontally around the buttock and join the superficial inguinal and sub-inguinal glands. The deep vessels run alongside the principal blood vessels. Those are the parieties of the pelvis which accompany the superior and inferior gluteal and obturator vessels. Follow the course of the hypogastric artery and ultimately join the lateral aortic glands. Lymphatic vessels of the perineum and external genitals. The lymphatic vessels of the perineum of the entanglement of the penis and of the scrotum or vulva follow the course of the external pudendal vessels and end in the superficial inguinal and sub-inguinal glands. Those of the glands penis bell gluteus terminate partly in the sub-inguinal glands and partly in the external iliac glands. The visceral glands are associated with the branches of the celiac superior and inferior mesenteric arteries. Those related to the branches of the celiac artery form three sets, gastric, hepatic, and pancreaticolino. The gastric glands consist of two sets superior and inferior. The superior gastric glands, lymphoblandylo, gastrico, superioris, accompany the left gastric artery and are divisible into three groups, namely a, upper, on the stem of the artery, b, lower, accompanying the descending branches of the artery along the cardiac half of the lesser curvature of the stomach, between the two layers of the lesser omentum and c, pericardial, outline members of the gastric glands, disposed in a manner comparable to a chain of beads around the neck of the stomach. Jameson and Dobson, they receive their efferents from the stomach. Their efferents pass to the celiac group of the pre-aortic glands. The inferior gastric glands, lymphoblandylo, gastrico, inferioris, right gastric epilogue gland, 4 to 7 in number, lie between the two layers of the greater omentum along the pyloric half of the greater curvature of the stomach. The hepatic glands, lymphoblandylo, consist of the following groups a, hepatic, on the stem of the hepatic artery, and extending upward along the common bile duct, between the two layers of the lesser omentum, as far as the border hepatus. The cystic gland, a member of this group, is placed near the neck of a gallbladder, b, sub pyloric, 4 or 5 in number, in close relation to the bifurcation of the gastro dualdeno artery. In the angle between the superior and descending parts of the duodenum, an outlying member of this group is sometimes found above the duodenum on the right gastric pyloric artery. The glands of the hepatic chain receive efferents from the stomach, duodenum, liver, gallbladder, and pancreas. Their efferents join the celiac group of pre aortic glands, the pancreatic lino glands, lymphoblandylo, pancreatic linalis, splenic glands, accompany the lino-splenic artery, and are situated in relation to the posterior surface of the upper border of the pancreas. One or two members of this group are found in the gastro-lino ligament, Jameson and Dobson, in the work that was cited. Their efferents are derived from the stomach, spleen, and pancreas. Their efferents join the celiac group of the pre aortic glands. The superior mesenteric glands may be divided into three principal groups, mesenteric, iliocolic, and mesocolic. The mesenteric glands, lymphoblandylo, mesentericlo, lie between the layers of the mesenteric. They vary from 100 to 150 in number, and may be grouped into three sets, namely one lying close to the wall of a small intestine among the terminal twigs of the superior mesenteric artery, a second in relation to the loops and primary branches of the vessels, and a third along the trunk of the artery. The iliocolic glands, from 10 to 20 in number, form a chain around the iliocolic artery, but show a tendency to subdivision into two groups, one near the duodenum, and another on the lower part of the trunk of the artery. Where the vessel divides into its terminal branches, the chain is broken up into several groups, namely, a, ilial, the region in the ilial branch of the artery, b, anterior iliocolic, usually of three glands, in the iliocolic fold near the wall of the cecum, c, posterior iliocolic, mostly placed in the angle between the ilium and the colon, but partly lined behind the cecum at its junction with the ascending colon, d, a single gland between the layers of the mesenterial of the vermiform process, e, right colic, along the medial side of the ascending colon. The mesocolic glands, lymphoclangular mesocolico, are numerous and line between the layers of the transverse mesocolon in close relation to the transverse colon. They are best developed in the neighborhood of the right and left colic flexures. One or two small glands are occasionally seen along the trunk of the right colic artery, and others are found in relation to the trunk and branches of the middle colic artery. The superior mesenteric glands receive aphorins from the jejunum, ilium, cecum, vermiform process, and the ascending and transverse parts of the colon. Their aphorins pass to the preaortic glands. The inferior mesenteric glands consist of a small glands on the branches of the left colic and sigmoid arteries, b a group in the sigmoid mesocolon around the superior hermoidal artery, and c a para rectal group in contact with the muscular coat of the rectum. They drain the descending iliac and sigmoid parts of the colon and the upper part of the rectum. Their aphorins pass to the preaortic glands. End of section 48 Recording by Jennifer Stearns, Concord, New Hampshire