1392 SUKFACE AND SUKGICAL ANATOMY. 



the level of the hyoid bone it receives the large common facial vein, while at an 

 inferior level it receives the superior and middle thyreoid veins which are often 

 greatly enlarged in goitres. 



By the term deep cervical glands is included a broad chain of lymph glands 

 which is closely related to the internal jugular vein, and which stretches from the 

 transverse process of the atlas to the root of the neck. The chain is in reality 

 made up of subsidiary glandular groups, each of which receives its lymph vessels 

 from fairly well-defined areas. In the first place, the chain may be divided into 

 an upper and a lower portion, the former situated above the bifurcation of the 

 common carotid artery, the latter below it. Each of these divisions is again 

 subdivided into a medial and a lateral chain. 



Of the four groups, the superior medial is the most important, as it is there 

 that disease first manifests itself in the vast majority of cases. The reason for this 

 predilection is the fact that this group of glands, in addition to receiving efferent 

 lymph vessels from the glands of the circular chain, receives also lymph vessels 

 directly from the nasal part of the pharynx, including the palatine and pharyngeal 

 tonsils. These latter structures are now known to provide the chief portals 

 of entrance through which the tubercle bacilli reach the efferent lymph vessels. 

 Wood, of Philadelphia, has succeeded in tracing the lymph vessels from the palatine 

 tonsils directly into one of the glands of this group, namely, that situated a little 

 below the angle of the mandible, under cover of the anterior border of the sterno- 

 mastoid immediately below the posterior belly of the digastric. The relations of the 

 deep surface of this gland are important. It lies upon the anterior surface of the 

 internal jugular, in the angle between it and the common facial vein. It plays 

 such an important role in tuberculous adenitis that it is now termed by surgeons 

 the tonsillar lymph gland. In the great majority of cases it is the first gland in 

 the neck to show signs of tuberculous enlargement. When the superior medial 

 deep cervical glands become enlarged they form a swelling which projects from 

 beneath the sterno-mastoid forwards into the carotid division of the anterior 

 triangle. The mass soon becomes adherent to the general envelope of deep 

 cervical fascia, and, if the disease is allowed to run its course, the latter becomes 

 perforated, with the result that a subcutaneous tuberculous abscess soon develops. 

 The glands are also liable to become adherent to the digastric- muscle, and to the 

 stylo-mandibular ligament, which separates them from the submaxillary lymph 

 glands. The most important adhesions, however, from the surgeon's point of view, 

 are to the common facial and internal jugular veins. 



The superior lateral group of deep cervical glands lies postero-lateral to the 

 internal jugular upon the origins of the splenius and the levator scapulae muscles. 

 They Tire smaller in size than the medial group, but when enlarged they may 

 form a swelling which projects across the posterior triangle as far as the trapezius. 

 They are embedded in a quantity of fibro-fatty tissue which supports the accessory 

 nerve and the cervical plexus. Wood has shown that the lymph vessels from the 

 pharyngeal tonsil, after piercing the posterior wall of the pharynx, pass downwards 

 and laterally behind the sheath of the great vessels to enter the glands situated 

 deeply, just below the tip of the mastoid process. 



The inferior medial group forms a somewhat narrow chain, which is continued 

 down the anterior aspect of the internal jugular as far as its junction with the 

 subclavian. Above the bifurcation of the common carotid artery this chain is 

 continuous with the superior medial jugular group, while, below, it comes into 

 relation with the superior mediastinal glands. 



The inferior lateral group of deep cervical glands is continuous above with 

 the superior lateral group. Like the superior lateral group, they lie altogether 

 behind the internal jugular vein, upon the levator scapulae, the scalenus medius, 

 and the brachial plexus. The most inferior glands of the group, viz., the supra- 

 clavicular, are subdivided into a superficial and a deep cluster by the omo-hyoid 

 muscle and the middle layer of deep cervical fascia. They receive their afferent 

 vessels from the subclavicular group of axillary glands. 



The hype-glossal nerve is deeply placed in the carotid triangle, being overlapped 

 by the internal jugular vein and the inferior border of the posterior belly of the 



