Chapter 22Lymphatic SystemSection1tion of immunity,clearing and repair.It is composedIntroductionof lymphoid organs,lymphoid tissues, lymphaticThe new research shows that Lymphatic system isvessels and fluids (Fig.I-2-1).Lymph organs includethe saving oneself system in human body and its func-lymph nodes, tonsils, thymus and spleen where largeOccipital lymphnodesMastoidlymphnodesSuperficial parotid lymphnodesSuperficial lateralcervical lymphnodesSubmandibularlymphnodesDeep lateral cervical lymphnodesRight brachiocephalic vSuperior vena cavgHemiazygosv.AxillarylymphnodesThoracicductCubital lymph nodesRight lympaticLumbar lymphnodesIntermal jugular y.ductSubclavianv.Extermal iliaclymphnodesDeepinguinallymphnodesThoracicductSuperficial inguinallymphnodesSuperficiallymphaticvesselfferentlymphatic vesselAfferent lymphaticPoplitealvessellymphnodesLymphnodeArteriole-DeeplymphnodesVenuleCapillaries-PostcapillaryTissue fluidFig. I-2-1 The structure and matchoflymphatic system of human body237扫描全能王创建
·238·PARTIIANGIOLOGYnumbers of lymphocytes gather.While the blood ispassing through the blood capillaries, certain fluidelements filter through the wall of capillaries into thetissue spaces and become the tissue fluid. Most ofthe tissue fluids formed by blood capillaries return toblod circulation,and 10%-20% of these fluids passintolymphvessels andbecomelymph.Lymphistransparentand colorlessexceptforlymphfluids fromintestines which aremilky.The composition of lymphiscloselyresemblesbloodplasma,butwithlowerconcentration of proteins.Lymph passes through oneormore lymph nodes before return to blood circulation,Soas an accessory system ofcardiovascular sys-tem.Iymphaticsystemcantransports andfilterstissuefluids,collects proteins fron tissues,clean up refusemajormolecules,forinstance,germs,virus,alloplasmand death cells etc,repair the tissues and cells whichwere injured,alsoparticipates immune responsesofFig. II-2-2 The comparison of lymphatic capillarylymphocytes.andblood capillaryAs weknow that the natural world is not alwaysso kind tothehuman body.Sometimes the changesThe open and overlapping junctions may be seenof theinternal and external environments often causeon the lymphatic capillary.And blood capillary is inthe various damages. The viruses, bacteria and otherthe right inferior corner.microorganisms may attack ourbody.The lymphaticsystem plays the primary roleto struggle withthese2.Lymphatic vesselsmicroorganisms,and interacts with other systems todefend the body against infection and disease.Lymphatic capillaries unite to form lymphaticvesselswhich resemble veins in structure, buthaveI.Lymphatic Vesselsthinner walls and more valves.In the path of thelymphatic vessels there are number of lymph nodesat various intervals. In general, the lymphatic vessels.Lymphatic capillariesof the skin travel in loose subcutaneous tissue fol-lowing the superficial veins,however, the deep lym-Lymphatic capillaries are microscopic vessels inphatic vessels of the trunk and viscera travel with thetissue space, and they are anastomoses each other todeep arteries.There are widespread communicatingform networks.Their structures have been revealedbranches between the superficial lymphatic vesselsthat the endothelial cells making up the capillariesand the deep lymphatic vessels. Speed of lymph cir-wall are not tightly joined:their edges loosely over-culation is slow,only as slow as one tenth ofblood inlap each otherand form the opening junctions.Theseveins. In order to maintain the circulation of lymph,arrangement permits fluid to enter easily into the lym-the quantity of lymphatic vessels and their valves arephatic capillariesbut prevents theflow out of the capmany times of these veins.illary much like a one-way valve would operate.Theyare slightly larger and more permeable than blood3.Lymphatic trunkscapillaries (Fig.II-2-2).So lymphatic capillaries arestructurally adapted to ensure the return of proteins toLymphatic trunks are formed by the union of thethe circulation when they leak out of blood capillar-larger lymphatic collecting vessels and named most-ies. Lymphatic capillaries exist throughout the body,ly for the regions from which they collect lymph.except thesplenic pulp,bonemarrow,epidermis,hairThe nine major trunks are the paired lumbar trunks,nails, cornea, lens, cartilages, and the central nervousbrmediastinaltrunk,ubclaviantrunkjuguarsystem.trunks and the single intestinal trunk (Fig, I-2-3).扫描全能王创建
Chapter2LymphaticSystem·239Left jugular trunkRight lymphatic ductLeft subclavian trunkLefbronchomediastinaltrunkThoracicductCisterma chyli一Leftlumbartrunk1Right lumbartrunkIntestinal trunkFig. II-2-3 Lymphatic trunks and ductssurface of lymph nodes through afferent lymphatic4.Lymphatic ductsvessels, and leaves by efferent lymphatic vessels athilus.There arefewer efferent lymphatic vessels thanafferent lymphatic vessels, so the rate of lymph flowLymph is finally delivered to one of two largethrough the nodes is slowed and the diameter of ef-ducts in thoracic and cervical region.These two ductsferent lymphatic vessels is wider than that of afferentare named thoracic duct and right lymphatic duct. De-lymphaticvessels.However,theefferentlymphatictails will be considered in section2 (Fig.II-2-3)vesselsof onelymph nodemaybeafferentlymphaticvessels of the another lymph node.Lymph nodes of-II.LymphNodesten get together and are classed by deep fascia intoLymph nodes are small round or bean-shapedsuperficial group and deep group. Superficial groupsstructures located along lymphatic vessels.In gener-can be easily touched, but deep groups often locatedal, they are grayish pink with length rangefrom 5tonear the hilus of viscera or the branch of blood ves-25mm.Lymphnodes contain slight depressionon onesels in abdomen and pelvis. They are often namedsidecalledhilus wherebloodessels,nerveandffby their location or nearby blood vessels (Fig.IⅢI-2-4)entlymphaticvesselspass.Lymphenterstheconvex扫描全能王创建
240·PARTIⅢIANGIOLOGYCapsuleTrabeculeCortexAfferent lymphaticvesselParacortexzoneCortical sinusLymphaticnoduleArteryNerve-Efferent lymphaticvesselVeinFig.II-2-4 Lymph nodediameter (Fig. II-2-3).This duct begins as dilation,Clinic notescisterna chili,which lies in front of the first lumberIn addition,to act as filter of lymph,lymphvertebra, Cisterna chyli receives intestinal trunk andnodes alsoproduct lymphocytes andplasmocytes,a pair of lumbar trunks. Begins from cistern chyli,and play a role in activatingtheimmunesystem.thoracic duct then passes the aortic hiatus of the dia-Lymph of an organ or region will flowto somephragm behind theaorta and enters theposteriorme-lymphnodeswhichiscalledregional nodesofthisdiastinum in whereit liesbetween vertebral columnorganorregion.Knowledgeofregionalnodesmayand oesophagus.At the level of the fifth thoracic ver-be helpful in diagnosing the site of an infection iftebra it crosses to the left of the vertebral column. Atthere are infected lymph nodes.The location ofthe root of the neck, the duct forms arch of thoraciclymphnodes anddirectionof lymph filowarealsoduct, and enters the left venous angle. At the root ofimportant in the diagnosis and prognosis of cancerthe neck, it also receives subclavian trunk,left jugularwithmetastasis.trunks, left bronchomediastinal trunk.Through thesesix lymphatic trunks, thoracic duct receives lymphSection 2 Lymphaticfrom the left side of the head, neck and chest, theleftupper limb, abdomen, pelvis and two lower limbs,Ductsabout 3/4partsof thewholebody.The principal trunks pass their lymph into twoII .Right Lymphatic Ductlarge ducts,thoracic duct and right lymphatic duct.Each duct empties lymph into venous circulation atRight lymphatic duct is a short duct about I to 1.the venous angle (junction of the internal jugular vein5cm long, and 2mm in diameter. It is united by rightand subclavianvein)on its own side.Thus,lymph isjugular trunk,right subclavian trunk,and right bron-drained back intoblood.chomediastinal trunk.Sometimes the three lymphatictrunks may open separately into right internal jugularI.ThoracicDuctor subclavian veins. Right lymphatic duct receiveslymph from the right side of head, neck,chest, andThoracic duct is the largest lymphatic vessel ofthe right upper limb, about 1/4 of the whole body (Fig.human with about 30 to 40cm in length and 3mm inIⅢI-2-3)扫描全能王创建
Chapter2LymphaticSystem·241Section 3 Lymphnodes,submandibular lymph nodes,submental lymphnodes from posterior to anterior.These lymph nodesNodes and Lymphreceivethe lymph from thehead and face, and thenempty to lateral cervical lymphnodes (Fig.II-2-5)Drainage of Whole Body(1)Occipital lymph nodesI.Lymph Nodes and LymphTheylocate on the surfaceof the insertion of traDrainage of Head and Neckpezius, and receive lymph from occipital portion andnape.1.Lymph nodes and lymph(2) Mastoid lymph nodesdrainage of headThey liebehind ear and on surface of the attachmentofsternocleidomastoid,andreceivelymph fromMost of the lymph nodes of the head are locatedthe parietal, temporal region and retroauricular rein the junction ofhead and neck.They are the occipigion.tal lymph nodes,mastoid lymph nodes,parotid lymphidlymphnodeMastoid lymph.nodeOccipital lymphnodeubmentallvmphnodesSuperficiallaterSubmandibularcervical lymph nodeslymph.nodesFig. II-2-5 The lymph nodes of head and neck(4)Submandibularlymphnodes(3) Parotid lymph nodesThey locate in submandibular triangle near sub-They can beclassed intothe superificial anddeepmandibulargland,receivelymphfrom face,orbitgroups, whichlocate onthe surfaceofparotidglandnasal part, and oral cavity.and intesustanceothegland respectively,andreceive lymphfrom forehead, temple,auricle,extemal(5)Submental lymph nodesybThey lie in submental triangle,receive lymphid gland.扫描全能王创建
·242.PARTIANGIOLOGYThey arange along the superficial jugular vein andfrom chin,lowerlip,and tip oftongue.receivelymphfromsuperficiallayerofanteriorneck2) Deep anterior cervical lymph nodesTheylieinfront ofthelarynx and receivelymphfrom lar.2. Lymph nodes and lymphynx, thyroid gland, and trachea.Eferent vessels drainage of neckthesetwogroupsoflymphnodesemptyintolateralcervical lymph nodes.Lymph nodes of neck can be divided into anteri-or cervical lymphnodes and lateral cervical lymph(2)Lateral cervical lymphnodesnodes.They are dividedintothe superficiallateralcervi(1)Anterior cervical lymph nodescal lymph nodes and the deep lateral cervical lymphnodes (Fig. II-2-6).They liein front of larynx,thyroid gland,and trachea, under the hyoid bone.1) Superficial anterior cervical lymph nodesGenioglossusJugulodigastric lymphSubmental lymphnodesSubmandibular lymphnodesSuperiordeep lateralcervical lymph nodesInfrahyoid lymphnodesJuguloomohyoid lymph nodePrelaryngeallymphnodesSupraclavicular lymph nodesPretracheal lymph nodes福Fig. II-2-6 The deep cervical lymph nodes1) Superficial lateral cervical lymph nodesinferior groups bounded by the omohyoid(Fig. II-2-5)They arrange along the superficial jugThe superior deep lateral cervical lymph nodesular vein and receive the lymph from superficial layerlieon theupper partofthe internal jugular vein, theyofneck and the efferent vessels of mastoid lymphreceive the efferent lymph vessels ofthe lymph nodesnodes,occipital lymph nodes,and submandibularof the head and the superficial lateral cervical lymphlymph nodes.Their efferent vessels empty into deepnodes, also receive the lymph from the nose,tongue,cervical lymph nodes.pharynxlarynx,thyroidgland,trachea and theeph2) Deep lateral cervical lymph nodes Thereagus.are as many as 10-15 lymph nodes in number, andThe inferior deep lateral cervical lymph nodesthey locate along internal jugular veinfrom base ofsurround the lower part of the internal jugular vein,skull to root of neck. Some of them lie along thesomeof them liealong the transverse cervical bloodaccessory nerve and the transverse cervical bloodvessels which are called the supraclavicular lymphvessels. They may be divided into the superior andnodes.Somelymph nodes arelocated just infront扫描全能王创建
Chapter2LymphaticSystem·243.fossa.ofscalenus anterior,theleftonesofthem arecalledVirchow's lymph node, which may be involved in theCubital lymph nodescancer of the stomach and esophagus.They are one or two lymph nodes in number,II.Lymph Nodes andand are located near elbow and medial epicondyle ofLymph Drainage of Upperhumerus.They receive lymph of lymphatic vesselsLimbalong basilic vein and ulnar blood vessel, and thenempty into axillarylymph nodes.Lymphatic system of upper limb is composed ofsuperficiallymphaticessels,deeplymphatic v-Axillary lymph nodessels, and lymph nodes. Superficial lymphatic vesselsdrain lymph of skin and subcutaneous fascia; deepThere are about 15-20 lymph nodes in axillarylymphatic vessels drain lymph of muscles, tendons,fossa around axillary blood vessels, and are dividedbones, and joints. These lymphatic vessels emptyinto five groups (Fig. II-2-7).mainly into regional lymph nodes. Lymph nodes ofupperlimb concentrated mainly atelbow and axillaryApical lymph nodesCentral lymph nodesLateral lymph nodesParastermal lymphnodesSubscapular lymph nodesPoctoral lymph nodesFig. II-2-7 Axillary lymph nodes and lymph drainage of breastmammary gland.(1) Lateral lymph nodes(3)SubscapularlymphnodesThey are located along axillary vein, receiveThey are located along subscapular artery,receivelymphfrom superficial anddeeplymphaticvesselsoflymphfromposteriorpartof neckandthoracicwall.upperlimb.(4)Central lymphnodes(2) Pectoral lymphnodesThey lie along inferior border of the pectoralisThey are embedded in fat near the base of axil-minormuscle,receivelymphfromanteriorand laterallary,receive lymph from lateral lymph nodes, pecto-thoraciwallsandcentralandlateralportionsfromral lymph nodes, and subscapular lymph nodes.扫描全能王创建
·244·PARTIANGIOLOGYlymphnodes(5)Apical lymphnodesParietal lymph nodesThey are located along the proximal parts ofThe superficial lymphatic vessels of thoracic wallaxillary artery and vein, the apical lymph nodes re-empty mainly into axillary lymph nodes.Howeverceive lymph from central lymph nodes and superiorthe deeplymphatic vessels ofit drain into the parietalportions of mammary gland.The efferent lymphaticlymph nodes,which include parasternal lymph nodes,vessels of these lymph nodes empty into subclavianintercostal lymph nodes,and superior phrenic lymphtrunk.nodes (Fig.II-2-8).1) Parasternal lymph nodes They are locatedIII .Lymph Nodes andalong internal thoracic artery and vein, receive lymphLymphDrainage of Thoraxfrom anterior wall of thorax and abdomen above um-bilicus, medial part of mammary gland, superior sur-Lymph nodes of the thorax are divided into twoface of diaphragm and liver.The efferent lympha-groups named parietal lymph nodes and visceralrastemalPalymphnodeseriorphreniclymphnodesFig. II-2-8 Parietal lymph nodes of thoraxtic vessels of these lymph nodes empty intobroncho-2.Visceral lymph nodesmediastinal trunk or empty directly into thoracic ductand right lymphatic duct.2) Intercostal lymph nodes They are locatedVisceral lymph nodes can be divided into threein theposterior partof theintercostal spaces,receivegroups as anterior mediastinal lymph nodes, posteriorlymph from deeper layerof theposterior aspect ofmediastinal lymph nodes and lymph nodes of the tra-the chest and parietal pleura.Their efferent lymphaticchea, bronchi and lungs (Fig. II-2-9).vessels empty into thoracic duct.1) Anterior mediastinal lymph nodes They3)Superior phrenic lymph nodesThey areare located in the front of pericardium and the bloodlocated on the superior surface of diaphragmand canvessels arise from aortic arch, receive lymph frombedivided into three group named as anterior,middlethymus, heart, pericardium, diaphragm, and superiorand posterior, and receive lymph from diaphragm,surface of liver.Their efferent lymphatic vessels emp-pericardium, pleura and superior surface of liver.ty into right and left bronchomediastinal trunks.Their efferent lymphatic vessels empty into para-2) Posterior mediastinal lymph nodes Theysternal lymph nodes and anterior mediastinal lymphlie around oesophagus and thoracic aorta, and receivenodes.lymph from oesophagus and tissues around thoracic扫描全能王创建
Chapter22LymphaticSystem·245Right lymphatic ductThoracic ductParatracheal lymphnodesAnterior mediastinallymph nodesSuperior tracheo bronchiallymphnodesInferior tracheobronelymph nodesEsophagusPosteriormediastinal-lymphnodesBronchopulmonarylymphnodesFig.II-2-9The visceral and lymph nodes of the thoraxaorta.Efferentlymphatic vessels empty into thoraciclymphatic vessels empty intotrachobronchial lymphduct.nodes.The trachobrochial lymph nodes can be divid-3) Lymph nodes of the trachea, bronchi anded into superior and inferior two groups and locatelungsPulmonary lymph nodes are located in lungnear the bifurcation of trachea, Their efferent lymphsubstance and receive lymph from lung.Their effer-nodes empty intoparatracheal lymphnodesand thenentlymphatic vessels empty into bronchopulmonaryempty into right and left bronchomediastinal trunkshilar lymph nodes,which locate in the hilus of eachand finally drain to thoracic duct and right lymphaticlung and receive lymph from lung. Their efferentduct(Fig.II-2-10)Paratracheal lymphnodesIntermal pulmonarylymphnodesSuperiortracheobronchial lymph nodesInferiortracheobronchial lymphnodeBronchopulmonarylymph nodesPosterior mediastinallymph nodesFig. II-2-10 Lymph nodes fthe trachea, bronchi and lungs扫描全能王创建
·246PARTIANGIOLOGYofabdomen andthe abdominal paired viscera.IV. Lymph Nodes and2.Visceral lymph nodesLymphDrainage of AbdomenLymphatic vessels of paired abdominal visceradrain into lumbar lymph nodes, these of unpairedLymph nodes of abdomen aredivided intoparietalvisceradrainintoceliaclymphnodes,superiormeslymph nodesand visceral lymphnodes.enteric lymph nodes, and inferior mesenteric lymphnodes.1)Celiac lymph nodes are located nearthe origin1.Parietal lymph nodesof celiac trunk which receive lymph from stomach,liver,duodenum,gallbladder,pancreas and spleen,The superficial lymphatic vessels of the anteriortheir efferent lymphatic vessels empty into intestinalwall ofabdomen aboveand below umbilicus emptiestrunk.This group of lymph nodes including right andinto the axillary lymph nodes and the superficial in-leftgastric lymph nodes,right and left gastroepiploicguinal lymphnodes,and the deep lymphatic vesselslymph nodes,pyloric lymph nodes,hepatic lymphdrain upwards to the parasternal lymph nodes andnodes, and pancreaticosplenic lymph nodes.Thesedownwards to the deep inguinal lymph nodes respec-lymph nodes are located along arteries with sametively.Thelymph from posterior wall ofabdomenname and receive lymph of similar area supplied byis emptied into lumbarlymph nodes.Lumbar lymphthe arteries with the same name (Fig.III-2-11)nodes are located around inferior vena cava and ab-dominal aorta,and receive lymph from posterior wallCeliaclvmphnocCystic lymph nodeeaticlymphnodesHepatic lymph nSuprapyloric lymphnodeSpleniclymphnodesSubpyloriclymphnodLeftgastroepiploiclymphnodesPancreaticoduodenal lymph ngRightgastroepiploic lymphnodesFig. II-2-11 The celiac lymph nodes2)Superiormesenteric lymphnodes arelocatedmesenteric lymph nodes unite into intestinal trunk,around the origin of superior mesenteric artery,andand then empty into cisterna chyli (Fig. II-2-12)receivelymphfromlymphnodesofmesentery,ileoV. Lymph Nodes andcolic,right colic and middle colic lymph nodes.Theselymph nodes locate along the corresponding vessels.Lymph Drainage of Pelvis3)Inferiormesenteric lymph nodes are locatedaround the origin of inferior mesenteric artery,andLymph nodes of pelvis are composed of the inter-receive lymph from left colic,sigmoid colic,and su-naliliaclymph nodes,sacrallymph nodes,xernalilperior rectal lymph nodes.iac lymph nodes, and common iliac lymph nodes(Fig.The Efferent lymphatic vessels of celiac lymphⅢI-2-13, 14).nodes, superior mesenteric lymph nodes,and inferior扫描全能王创建