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A TREATISE
OF HUMAN ANATOMY

KDITKD BY

P. POIRIER and A. CHARPY

Profcssettr ft' Anatomic a Pro/esseur d' Anatomic a

la Faciilte dc Paris, l a Facultf de Mede-

Chirurgicn dcs Hofiitaux cine a Toulouse



THE LYMPHATICS



THE LYMPHATICS

GENERAL ANATOMY OF THE LYMPHATICS BY

G. DELAMERE



SPECIAL STUDY OF THE LYMPHATICS
IN DIFFERENT PARTS OF THE BODY BY

P. POIRIER and B. CUNEO

Professeur d* Anatomic a la Faculte dc Professeur figrege a la Vacultfide

Me'dedne a Paris, Cbtrurgien dcs Hopltaux Medcclne dc Paris

AUTHORISED ENGLISH EDITION

TRANSLATED AND EDITED BY

CECIL H. LEAF

M.A., M.B. (Cantafi.1, F.A'.C.S. (Eng.\ Assistant Sutyeon to

the Cancer Hospital, and to the CorJon Hosf-italfor

Rectal Diseases. Late Demonstrator of

Anatomy, London Hospital



WITH 117 ILLUSTRATIONS AND DIAGRAMS






RnU

\ . ' - n



CHICAGO
W. T. KEENER AND CO

90 WABASH AVENUE
1904



All rights reserved



In compliance with current copyright law,

U.C. Library Bindery produced this replacement volume on

paper that meets the ANSI Standard Z39.48-1984 to replace

the irreparably deteriorated original.



1990



TO THE MEMORY OF
PROFESSOR SAPPEY




Editor's Preface

THIS work, a section of The Treatise of Human Anatomy, edited by
P. Poirier and A. Charpy, is divided into two parts. The first
on the General Anatomy of the Lymphatic System is by G.
Delamere. The second on the Special Study of the Lymphatics
in different regions of the body is by P. Poirier and B. Cuneo.
The names of these authors are sufficient guarantee of the care
and accuracy bestowed on their respective subjects.

From a practical point of view, a thorough knowledge of the
histology and functions of the lymph, and definite ideas as to the
arrangement and distribution of the lymphatic vessels, become
more and more essential every day. In both these subjects it
will be found that the present work considerably extends our
knowledge.

Gerota's method of injection, which was advocated by Poirier
in 1892, has been freely used by the authors, with the result that
our knowledge of the lymphatics of certain regions of the body,
which were not well adapted for injections by mercury, is more
complete to-day than it was in the past.

In the work of translation I have endeavoured as far as possible
to reproduce the French, but where there was any possibility of
ambiguity resulting therefrom, I have not hesitated to give a
free rendering.

I have much pleasure in acknowledging my indebtedness to
my brother, F. Walton Leaf, for kindly overlooking the proof-
sheets, and for many timely and valuable suggestions.

CECIL H. LEAF.

WIMPOLE STREET,

August, 1903.



VII



The Lymphatics

FIRST PART

GENERAL ANATOMY OF THE LYMPHATIC SYSTEM

Page
GENERAL CONSIDERATIONS ........ 3

LYMPH ........... 4

LEUCOCYTES . . .... . . . . 9

I. THE WHITE CORPUSCLE IN GENERAL .

II. THE DIFFERENT LEUCOCYTKS . . . 32
THE LYMPHATIC VESSELS .... . . 5(i

THE LYMPHATIC GLANDS .. . . 81



SECOND PART

SPECIAL STUDY OF THE LYMPHATICS OF THE

BODY

CHAPTER I. LYMPHATICS OF THE LOWER LIMB . "."'; 111

I. GLANDULAR GROUPS OF THE LOWER LIMB . . . 112

II. LYMPHATIC VESSELS ,, ,, ... 120

CHAPTER II. LYMPHATICS OF THE PELVIS AND

ABDOMEN . ...... . . . . 129

T. GLANDULAR GROUPS OF THE PELVIS AND ABDOMEN .129

1. Ilco-pel vie Glands . . . . . . .129

2. Abdomino-aortic Glands . . . . .139
II. LYMPHATIC VESSELS OF THE PELVIS AND ABDOMEN . . 148

1. Lymphatics of the Abdominal Wall . . ' . . 148

2. ., External Genital Organs . . 152

3. ,, ,. Internal Genital Organs . . 160

4. ,, ., Urinary Passages . . .175

5. ,, ., Sub-diaphragmatic Portion of the
Digestive Tube . . . . . . . 18G

CHAPTER III. LYMPHATICS OF THE THORAX . . . 208

I. GLAND ULAH GROUPS OF THE THORAX . ... 208

1. Parietal Glands . . . . . . . 208

2. Visceral 212



x TABLE OF CONTENTS

Page
IT. LYMPHATIC VESSELS OF THE THORAX . . . .215

1. Parietal Lymphatic Vessels . . . . .215

2. Visceral 228

CHAPTER IV. LYMPHATICS OF THE UPPER LIMB . . .233

I. LYMPHATIC GLANDS or THE UPPER LIMB . . . .233

II. LYMPHATIC VESSELS ,, ,, ,, . . . . 240

CHAPTER V. LYMPHATICS OF THE HEAD AND NECK . . 247

I. GLANDULAR GROUPS OF THE HEAD AND NECK . . . 247

1. Peri-cervical Glandular Circle ..... 247

2. Descending Cervical Chains . . . . .256

II. LYMPHATIC VESSELS OF THE HEAD AND NECK . . .203

1. Lymphatic Vessels of the Cranial Region . . . 263

2. Face . 205

3. ,, Fncio-Cervical Portion of

the Digestive -Passages 209

4. Lymphatic Vessels of the Facio-Cervical Portion of

the Respiratory Passages ..... 283

CHAPTER VI. TERMINAL COLLECTING TRUNKS OF THE LYMPHA-
TIC SYSTEM . . . . . . 290

I. TERMINAL COLLECTING TRUNKS OF THE SUPRA-DIAPHRAG-

MATIC PORTION OF THE BODY ..... 290

II. THORACIC DUCT 292



Introduction

EVER since the commencement of my works on anatomy (1876) I
have been especially attracted towards the study of the lymphatic
system. Admitted into the private laboratory of my master,
the lamented Professor Sappey, I learnt from him the method of
injecting by mercury. Under the direction and control of this
kind and skilful master, I have studied the lymphatics of numerous
organs, and I have been fortunate enough to be able to fill in the
details of former works and supplement them on many points

" Lymphatic Vessels of the Larynx : the Praelaryngeal Gland."
Societe Anatomique et Progres Medical, 1887.

" Lymphatic Vessels of the Articulations." Traite (T Anatomic
Humaine, vol. i. p. 557.

"Vessels and Lymphatic Glands of the Lower Limb and of the
Inguinal Region " ; specimens placed in the Museum of the Faculty.

" Lymphatics of the Testicle arid of the Spermatic Cord " ; speci-
mens prepared for the meeting of Prosectors, 1883 ; placed in the
Museum of the Faculty.

" Lymphatic Vessels of the Meninges, and of the Encephalon."
Anatomic Medico-Chirurgicale, pp. 164-165, 1892.

" Lymphatics of the Female Generative Organs : Uterus, Vagina,
Fallopian Tube, Ovary." Societe Anatomique et Pr ogres Medical,
1890.

"Lymphatics of the Tongue." Traite d'Anatomiehumaine, t. iv.
p. 105, 1895, and Gazette Hebdomadaire, 1902.

"Lymphatic Glands of the Axilla." Progres Medical, 1888.

Numerous illustrations accompany the various articles, of which
a number have become classical, and have been reproduced in
France and abroad.

In recent years a method of injection with Prussian blue,



xii INTRODUCTION

called " Gerota's process," having been applied to the study of the
lymphatic vessels and glands, I asked my pupil, colleague and
friend Cuneo, who introduced this method into France, to teach
me the technique, the use of which I had advocated since 1892
(Anatomie-medico-chirurgicale, pp. 164-165), and which he has
applied with known success to the study of the lymphatics of the
stomach, the bladder, the rectum, and genital organs. Together we
have again undertaken the study of the lymphatics of the entire
body, as much with the object of perfecting our knowledge on the
subject as for adding to well-ascertained facts.

As I felt incompetent to adequately deal with the histology of
the lymphatic vessels and glands and of the lymph, which is so
important a matter, I entrusted this part of the work to my
devoted pupil Delamere, who has personally undertaken these
researches in the laboratory and under the guidance of Professor
Mathias Duval.

It follows therefore that this portion of the treatise of Human
Anatomy (the last but one) is, like the preceding ones, not simply
a general review, a work of compilation, but is a record of opinions
which have been formed as a result of personal researches. It
shows the state of the science of to-day and indicates the lines on
which the work must be conducted in the future.



General Anatomy of the Lymphatic System



BY

G. DELAMERE.



FIRST PART.

General Anatomy of the Lymphatic System

BY

GABRIEL DELAMERE.

THE Lymphatic System is made up of vessels which, after travers-
ing the glands, bring the lymph into the venous system. The
capillaries of origin have closed extremities which never penetrate
beyond the epithelial linings ; by
their anastomoses they form primary
networks, from which commence the
first collecting trunks, which divide
again into capillaries on traversing
the gland. Passing out of the gland
the efferent vessels join, and form the
large terminal collecting trunks, tri-
butaries of the vena cava superior.

In man, the terminal collecting
trunks are usually two in number :
the thoracic duct and the right lym-
phatic duct.

The interposition of glands daring
the passage of the lymph gives the
lymphatic system an entirely pecu-
liar character ; in fact, it appears as
though formed of a series of portal
systems superposed.

The study of the lymph and the leucocytes, being necessary to
the thorough comprehension of this system and that of the glands,
we will study

1. The lymph.

2. The leucocytes.

3. The lymphatic vessels.

4. The glands.

B*




FIG. 1. General scheme of tho
lymphatic system 1. Origin of
capillaries close under the epithe-
lium ; 2. Networks which give origin
to the collecting trunks, which
divide into capillaries in the gland ;
3. Larger but less numerous efferent
trunks which divert the lymph into
the venous blood (portal lymphatic
system of the gland).



4 THE LYMPHATICS

The lymph is generally considered a tissue, of which the cells
the leucocytes are placed in a fundamental liquid, the plasma.
We consider, however, that the essential part of the lymph is the
plasma ; and the typical elements which it contains, and of which
the most essential are the leucocytes, are only casual guests.
Contrary to custom, we shall devote a separate chapter to their
consideration.

The plasma, moreover, or, if one prefers to call it so, the lymph
for these are in our opinion two synonymous terms ought not to
be considered as a simple product of filtration, but rather as a
secretion, the genuine result of cellular activity.

Claude Bernard, having shown that soluble salts such as iodide of potas-
sium or prussiate of potash, injected into the blood, pass immediately into
the lymph, and Noll and Ludwig having demonstrated the influence of blood
pressure on the lymphatic flow, it has become customary to speak of the
lymphatic plasma as being the result of capillary filtration from the serum
of the blood.

In spite of this, it is onh' possible for us to regard it as a selective filtration
process, seeing that Cheauveau found much less glucose in the lymph plasma
than in the bloocl plasma. It should be added that for some time other authors
have suspected that the lymph was not a simple product of filtration ; thus,
according to Ch. Robin, it is formed not only from substances derived from
the blood plasma, but very probably also from the breaking up of anatomical
elements. Longet holds that it is a sort of chyle which is formed at the
expense of the actual substance of the animal. But of late years one is
compelled to strenuously oppose the idea, always a classical one, of the lymph
being a mechanical product of filtration from the blood. It was Heidenhain
originally, who seeing the lymph form and circulate one or two hours after
a subdiaphragmatic ligature of the aorta, concluded that the lymph was
not a product of filtration but a product of enclothelial secretion. The
same physiologist also remarks that certain substances act as lymphagogues
as long as the blood pressure remains normal or a little under. The action
of these bodies can only be explained on the supposition that they call upon
the fixed elementary tissues for a supply of lymph. Starling contests these
deductions : he thinks that in Heidcnhain's experiment the lymph comes
from the liver and that the subdiaphragmatic ligature of the aorta does not
alter the pressure in the hepatic capillaries. According to him, the lympha-
gogues paralyze the muscular walls of the vascular system, and especially,
by altering the endothelium, increase its permeability.

In order to verify Heidenhain's views, and to rebut the objections raised
by Starling, Hamburger studied the behaviour of lymph in the neck of
a horse whose head was rendered immobile, but whose body and limbs were
allowed to move. Under these conditions, he has seen the quantity of lymph
become tripled and quadrupled in spite of the diminution of pressure in the
carotids and jugulars. Finalty, by the haemolytic method he has found that
the lymph possessed greater osmotic powers than the serum in the jugular.
In the same way, by means of the cryoscope, Leathes, Fano and Bottazi,
have shown that the coagulation point (A) of lymph is always higher (further
removed from 0) than that of the blood.



GENERAL ANATOMY OF THE LYMPHATIC SYSTEM 5

A (lymph) A (serum) (Leathes).

- 620 - 610.

- 630 - 625.

- 625 - 617 (Fano and Bottazi).

According to Fano and Bottazi, injections of phosphorus, which destroy
the endothelial wall, produce no effect upon the concentration of the blood,
but diminish the concentration of lymph in the thoracic duct (before in-
jection, A-063; after injection, A-058).

Tscherewkow positively states that, though venaesection diminishes the
amount of solid elements in the blood serum to a marked degree, the lymph
is unaffected.

Aslier and Barbera find that lymph increases in the same proportions as
the nitrogen in the urine ; its toxicity is greater than that of blood. It is
the result neither of a filtration (the classical theory), nor of an endothelial
secretion (theory of Heidenhain) : it owes its origin to the vital functions
of cells.

Moussu does not regard the lymph as being secreted by the endothelium
of the blood capillaries. Its production is aided by the blood pressure :
above all it results from the functional activity of the tissues. In fact, both
chemistry and the cryoscope, demonstrate the fact that lymph is different
from blood ; physiology makes us regard it not so much as a product of
filtration as of a vital elaboration from cells. Containing the residual pro-
ducts of cellular life, we regard it as a kind of fluid excretion.

It would seem at first sight peculiar that such a fluid, instead of being
eliminated externally, should be poured into the venous blood, and that it
should afterwards pass again into the organs with the arterial blood. But
i* not this fluid at first modified in the lymphatic glands, and again perhaps
in the pulmonary endothelium ? Certain experiments of Brown-Sequard
tend to prove the pathogenic properties of expired air, and it may be that
their expiration is the result of the excretion of certain toxic matters from
the lungs. Moreover, though the physiologists (Starling, Asher, Moussu), do
not admit the existence of an endothelial secretion of blood capillaries, which
is Heidenhain's view, Ranvier has shown the histological existence of an en-
dothelial lymphatic secretion : the lymph is not only a liquid excretion, it
is even more, a product of secretion. Therefore it is not surprising that, like
the internal secretions of the thyroid gland and the suprarenals, it is poured
into the blood.

The lymph contains leucocytes also, which are, so to speak, its casual guests.
It is supplied with little or no oxygen in the trunks, and therefore affords
a most unsuitable medium for their development. Later on we will speak
of the morphological varieties which are met with ; for the present, however,
we will confine ourselves to the study of their number. The number is much
greater at the centre than at the periphery of the system. Formerly, Frey
had remarked that the commencing chyliferous vessels contained few or m>
cells at all. Recently Renaut has noted the absence of leucocytes in the
capillaries of origin of the loose connective tissue of the marmot. All authors
find that the number of leucocytes are considerably increased after their pas-
sage through the gland. Judging from the somewhat numerous ideas ex-
pressed in the older writings, the number of leucocytes in the lymph is very
variable, not only in different animals, but also in different animals of the
same species : thus Malassez counts only 180 in a cubic millimetre of frog's
lymph, Ranvier counts 11,300 in the same quantity of rabbit's lymph, 4,800-
and 7,500 in the lymph of the dog, and 8,200 in that of man.



6 THE LYMPHATICS

Again one finds some red blood corpuscles in the lymph, but always in
small quantities. They are, however, sometimes so numerous as to impart
a rosy tint : this rose colouration was specially observed in the lymph
coming from the spleen, or from lymphatic glands (Hewson, Gulliver, Lane
and Ancel, Simon, Reuss and Emmert). It increases in the lymphatic
A r essels which have been blocked by a ligature (Eisner, Retterer), and when
the blood pressure rises (Strieker, Hering, Laulanie). Finally, it would
appear as though the lymph becomes reddest in starving animals (Collard
de Martigny, Nasse). In contradistinction to these last-mentioned authors,
I have noted the perfect whiteness of both chyle and lymph in a rabbit
and a dog which have died from starvation. Similarly, I have bled some
animals without being able to observe the slightest red colour in their
lymph an observation already made by Hayem.

The presence of red blood cells is not perhaps absolutely constant, since
Kolliker has not found them in human chyle, but unquestionably they
are frequently present. One cannot agree with Krause, who asserts that
lymph collected without accidental mixing with blood, is always destitute
of red blood corpuscles. It seems that the presence of some of them may
be explained by the reflux of venous blood into the thoracic duct (Colin).
In the case of hyperdis tension, others come from blood vessels, either owing
to rupture, or by diapedesis. However, it is not probable that such is
their sole origin, and without affirming as the old authors have done, that
the red blood corpuscles are always derived from the white corpuscles,
we may ask if some of them do not come from lymphatic glands. We will
study this question when dealing with the functions of these organs.

Before undertaking the chemical study of the plasma of the lymph, it
is advisable to recall its histological characters. On the one hand, Renaut
considers that this plasma contains no albuminoid matter in the capillaries
of origin. On the other hand, Ranvier has observed in the trunks, granules
of a hyaline substance, myeloid in nature, which are stained yellow by
picrocarmin ; these granules are manufactured by the endothelium.
Retterer also found granules in the lymphatic plasma. I have observed
the same thing in the contents of the lymphatic capillaries of the glands,
and of that of the thoracic duct. These granules are more rare in the blood
vessels, with the exception of those in the liver.

The origin of these granular coagula seems complex : the granules are
apparently derived as much from the endothelium as from the protoplasm
of the white blood corpuscles. Admitting that secretion takes place to a con-
siderable extent within the intraglandular passages, it is possible that the
formation of these granules is also one of the products of the secretion of the
lymphatic gland.

All that we know of the lymph, its origin, and the alterations it most
probably undergoes after traversing the gland, lead us to think that it pos-
sesses a very variable chemical composition, which depends not only upon
the condition of the animal, but also upon the particular vessel from which
the lymph is drawn. This explains the discrepancies which have been ob-
served in the different analyses published up to the present time, notably
by Schmidt, Gubler and Quevenne, Hensen and Dahnhardt ; it also explains
the difference which, it is now recognized, exists between the peripheral
lymph and the mesenteric lymph or chyle. In reality, the difference simply
amounts to this : that the chyle is loaded with fat derived from the lacteals
of the intestine.

The lymph is a slightly viscous liquid, with no colour, or with a colour



GENERAL ANATOMY OF THE LYMPHATIC SYSTEM 7

varying from a slight lemon or hardly recognizable opal, to a yellow tint
that is, before its passage through the gland. The moment digestion com-
mences it becomes milky. In the thoracic duct and in the efferent vessels
of the spleen, we have seen that sometimes it is of a faint rosy tint.

It is as a rule inodorous : but some observers detect a faint odour, which
varies in different kinds of animal. Others maintain that when cold, the
chyle smells like spermatic fluid, and when heated, like fat. It is faintly
alkaline to the taste. Its specific gravity varies between 1,015 and 1,045 ;
that of chyle between 1,012 and 1,022. It is less alkaline than blood-lymph,
requiring 0'35 gr. lactic acid to neutralize 100 grs., whereas blood, requires
0'50 gr. to neutralize the same quantity.

According to Krause, the total quantity of lymph equals one-third the
weight of the body ; according to Ludwig and Majendie, one fourth ; Bidder
says that in the cat and dog it is equivalent (approximately) to from \ to of
the weight. In the case of the horse, Schmidt has obtained in twenty-four
hours a quantity of lymph equal to the total quantity of blood. More
recently Moussu has obtained in ten minutes, from different horses in a state
of rest, quantities varying between 0'60 gr. and 6'50 gr. on an average a
little more than two grammes. 'In the ox he has also obtained in the same
time quantities varying from 2-26 gr. In an ox of average weight the
amount is a little more than 10 gr.

By making a fistula in the thoracic duct, Colin has obtained 95 kgs. 286
grammes in twenty-four hours. In the dog, Lesser has obtained 300 cubic
centimetres in four hours ; in man, 5 litres and a half have been collected in
the same time. The quantity depends, we know, not only upon mechanical
influences such as pressure, etc., but especially upon cellular activity in all
its conditions ; thus, Moussu has collected 5, 10, and even 20 times more
lymph from an animal in a state of activity, than from the same animal in a
state of rest.

Lymph increases fairly quickly under the influence of pilocarpine, less
quickly under that of ergotine ; it increases also after the injection of certain
toxins (Charrin, Moussu) ; after a hypotensive dose of toxin, viz. diphtheria
toxin, and also after a hypertensive dose of toxin, such as tuberculin. Though
Beard and Wilcox, and Retterer, firmly believe they have seen the lymph
increase after bleeding, Moussu, on the other hand, has stated that in the horse,
bleeding to the extent of 4 litres has led to a marked diminution of this fluid.
Ranvier has seen the lymph diminish considerably in frogs which have been
placed in a vacuum, or kept in a dry place. In the case of the curarized
frog, the lymph accumulates in the retrolingual space (Ranvier, Tarchanoff).

Regarding the numerous lymphagogues we ought, as Heidenhain suggests,
to classify them, and place in the first class such as are of an albuminoid
nature, or of animal origin, such as the muscle extract of the crayfish, head
and body of leeches, bodies of aiiodons, the intestine and liver of the dog, and
the peptones. In the second class, crystalloids : the sugar, salts, and urea, should
be included. Outside the vessels lymph coagulates more slowly than blood,
taking from five to twenty minutes. 1,000 parts of lymph yield 44*8 parts
of clot (Schmidt) ; the same quantity of chyle produces only 32' 6 of clot.
The clot is soft, somewhat white, slightly retractile. The serum is colourless
and transparent.

Coagulation yields considerably less fibrin than that given by the same
quantity of blood. In 1,000 parts of lymph taken from the inguinal glands
of the bull and cow, Schmidt finds 1*2 gr., 2 gr., and 2'2 gr. of fibrin.
In the same quantity of human lymph, Hensen and Dahnhardt find 1'07 gr.



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