THE LYMPH NODES OF THE HEAD AND FACE 783 



except those from the lower deep cervical group. The lower deep cervical nodes 

 drain the back of the scalp and neck, the superficial pectoral region, part of 

 the arm (see page 786), and occasionally part of the upper surface of the liver. 

 In addition, they receive vessels from the upper group. The efferents of the upper 

 deep cervical nodes pass partly to the lower group and partly to a trunk which 

 unites with the efferent trunk of the lower deep cervical nodes arid forms the 

 jugular trunk (truncus jugttlaris). This trunk, on the right side, ends in the junc- 

 tion of the internal jugular and subclavian veins, while 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 

 nodes. From the upper part of the pharynx the lymphatic vessels pass to the 

 retropharyngeal, from the lower part to the deep cervical nodes. From the 

 larynx two sets of vessels arise, an upper and a lower. The vessels of the upper 

 set pierce the thyrohyoid membrane and join the upper deep cervical nodes. 

 Of the lower set, some pierce the cricothyroid membrane and join the pretracheal 

 and prelaryngeal nodes; others run between the cricoid and first tracheal ring 

 and enter the lower deep cervical nodes. The lymphatic vessels of the thyroid 

 body consist of two sets, an upper, which accompanies the superior thyroid artery 

 and enters the upper deep cervical nodes, and a lower, which runs partly to the 

 pretracheal and partly to the small nodes which accompany the recurrent laryn- 

 geal nerve. These latter nodes receive also the lymphatic vessels from the cervical 

 portion of the trachea. 



Applied Anatomy. The cervical nodes are very frequently the seat of tuberculous dis- 

 ease. This condition is most usually set up by some lesion in those parts from which they receive 

 their lymph. It is very desirable, therefore, for the surgeon, in dealing with these cases, to possess 

 a knowledge of the relation of the respective groups of glands to the periphery, while in order to 

 eradicate them by operation a long and difficult dissection may be required. Sir Frederick 

 Treves prepared a table to show to what group lymph from each region is sent. The table is 

 practically as follows: 



Scalp Posterior part = suboccipital and mastoid nodes. Frontal and parietal portions = 

 parotid nodes. 



Lymphatic vessels from the scalp also enter the superficial cervical set of nodes. 



Skin efface and neck = submaxillary, parotid, and superficial cervical nodes. 



External ear = superficial cervical nodes. 



Lower lip = submaxillary and suprahyoid nodes. 



Buccal cavity = submaxillary and upper set of deep cervical nodes. 



Gums of lower jaw = submaxillary nodes. 



Tongue Anterior portion = suprahyoid and submaxillary nodes. Posterior portion = 

 upper set of deep cervical nodes. 



Tonsils and palate = upper set of deep cervical nodes. 



Pharynx. Upper part = parotid and retropharyngeal nodes. Lower part = upper set of 

 deep cervical nodes. 



Larynx, orbit, and roof of mouth = upper set of deep cervical nodes. 



Nafial fossae = retropharyngeal nodes, upper set of deep cervical nodes. Some lymphatic 

 vessels from posterior part of the fossae enter the parotid nodes. 



Treves' table indicates the nodes usually involved, but the seat of primary disease cannot 

 invariably be affirmed from a knowledge of the seat of glandular involvement, because the 

 course of the lymphatic vessels is sometimes varied from that which usually maintains; for 

 instance, in some cases lymphatics from the right side of the tongue pass to nodes in the left 

 side of the neck. 



A retropharyngeal abscess begins laterad of the pharynx. It enlarges toward the centre rather 

 than from it, because the Constrictors of the pharynx limit the outward progress of the pus. 



The nodes within the parotid salivary glands not unusually become tuberculous, and the 

 surgeon may be led to believe that the salivary gland is the seat of primary disease. 



Sometimes, though seldom, after the extensive removal of lymph nodes the region drained 

 by their tributaries becomes the seat of persistent hard edema (lymph edema). It used to be 

 thought that wounds of the thoracic duct were of necessity fatal, but it is now known that, unless 

 close to the vein, they are seldom even very dangerous. It may be possible to suture a partly 

 divided duct. In an unsutured wound of the duct recovery follows if a collateral lymphatic 

 circulation is established. 



