Applied Anatomy of the
F. P. Millard, D.O.
THE LYMPHATICS OF THE THORAX
The Lymphatics of The Lungs and Pleura
The most perplexing part of the lymphatic system
to a student is possibly that of the thoracic region. It is easy
to understand the thoracic duct and its cluster of tubes at the lower part,
the cysterni chyli, but the drainage of the intercostals, the lungs, bronchi,
esophagus, heart and diaphragm is difficult to comprehend. There
seems to be a lack of plates in most texts on anatomy to furnish object
lessons. In a general way a few of the channels are shown, but the
student is still at a loss to comprehend just how there may be ducts that
convey lymph from these various organs and tubes as the bronchi, esophagus
and aorta, and still be independent of the great thoracic duct.
Let us open this discussion by saying that the lymph
must eventually reach the subclavian veins, or possibly the innominate
veins. The student is familiar with the fact that the lymph flow
to the subclavian veins empties through two main ducts, the right lymphatic,
and the thoracic duct. There are other points of entry separate from
these two main ducts; sometimes two or three. For instance, the internal
mammary ducts usually empty into the subclavian as distinct ducts.
The mediastinal may join the mammary or empty separately, but they all
enter the veins at some point within a small radius. It may be on
the upper surface, the anterior, or even inferior surface of the vein.
Now let us take up the drainage of the bronchial nodes first. Around
the lower part of the trachea and over the surface of the bronchi the tracheo-bronchial
nodes are scattered. At the angle of the bronchi and also where the
bronchi divide nodes are present. They even extend to the bronchioles
but not into the alveoli.
All of these nodes have efferents and must be drained.
The drainage is upward toward and into the subclavian veins. These
nodes drain the lung tissue as well as the bronchi and trachea. The
lymph from the heart reaches these nodes also in part at least.
The efferents from these nodes join in some instances
those of the internal mammary and pass on to the subslavian veins.
The right may enter the right lymphatic duct, or may enter the subclavian
vein direct. On the left side the thoracic duct may receive the mammary
efferents or the subclavian vein receive the drainage directly. The
lungs have their superficial and deep plexuses of vessels, but they all
drain towad the yilum which receives the lymph flow of the lung tissue.
From these nodes the tracheo-bronchial nodes collect and through their
efferents eventually empty into the internal mammary or mediastinal nodes
to be conveyed to the veins on either side. The superficial and deep
lymph vessels in the lungs anastomose only at the hilum, at the root of
the lung, on either side. The pleura has a more distinct drainage
as the visceral layer drains into the lung afferents on its surface, while
the parietal lymph streams are collected according to the regions they
are located in. In front they are collected by the internal mammary
after passing through the intercostal muscle lymphatics, while the lower
parietal lymph vessels may join with the vessels of the diaphragm.
In the posterior region the mediastinal nodes collect the lymph from the
parietal part of the pleura.
PLATE XVI. The internal
mammary lymph chain collects lymph from the anterior intercostal spaces,
inner areas of breasts, some from the pleura, and from the upper anterior
surface of the liver.
Thus we see how simple the drainage is if we remember
the collecting tubes of the different regions.
Dr. Snyder, in his chapter on the lungs, outlines
very nicely the drainage of these tissues. In this general discussion
we wish only to give an idea of the drainage, so that we may refer to some
features of the applied anatomy of the same.
In the first place, we wish to emphasize the importance
of free lymph drainage in the nodes that collect and send forward the lymph.
We have mentioned in another chapter the fact that lung infection is usually
downward from the throat. It is easy for a catarrhal condition to
work its way downward, also infection and congestion.
The nodes in children are of a pinkish tint, but
in the adult they often become dark or black and enlarged. If these
blocked nodes become infected with tubercular germs, suppuration may take
place, and the discharge may be thrown into the bronchi. This will
infect the lung tissue in time, as only part of the discharge can be coughed
up. The breaking down of the nodes is often the result of dust laden
particles being conveyed to the bronchial tubes.
Now, we come to the osteopathic idea of keeping these
nodes in tone. We cannot keep people away from dust and irritating
inhalations, but we can keep the pulmonary and bronchial vessels and tissues
toned up through our method of adjustment.
The contour of the chest wall may have a lot to do
with the condition of the blood and lymph supply within. A flat-chested
person has not the chance for resistance that a well rounded chest has.
The sagging of the ribs may be due to lack of tone in the muscles, but
we find that more often there is either a curvature or one or more lesioned
To correct posture we must first secure spinal alignment.
We may have to start at the innominates and work from that basic standpoint.
As we secure normality of the spine, we can elevate the ribs and secure
better vasomotor control. Adjustment of the upper thoracic area will
add tone to the lung tissue as the circulation will be more regular.
Where we secure a good arterial supply we also insure a better venous drainage.
We are now reaching the point where we can work to advantage on the lymph
stream. We pointed out the various drainage tubes, and it is to the
end of securing a better lymph flow that we now work. The nodes are
secondary in importance in some respects to the efferent flow of lymph.
Unless we have a free drainage we cannot expect to relieve the over-burdened
lymph nodes. If it were possible to keep the thorax in normal position,
vertebrae, ribs and sternum, we would have little difficulty in regulating
the blood supply. The good blood coursing through the vessels and
tissues would sustain a tone that would prevent germs from gaining a hold
on the nodes. The nodes are usually normal if the blood circulation
is perfect or nearly so. You will recall the generous blood supply
that most nodes have. It is this supply that keeps the nodes capable
of resisting invasion. If we work to the end of regulating blood
supply to nourish and drain, vascularly, the nodes, we will find we have
accomplished much. The sinuses within the nodes are kept normal mainly
through the blood that supplies each node. Here is where we check
the points of invasion. A node breaks down because it has lessened
resistance through faulty circulation of the blood. Thus we have
the proposition of keeping up the tone of the lymph nodes and vessels through
vasomotor control of the blood vessels. This point is seldom if ever
emphasized, but it holds good in any part of the body where nodes exist.
The entrance of dust, irritants, poisons, germs or
foreign substances of any nature into the nodes may be offset to a large
degree by the regulation of the blood supply to and from the nodes.
PLATE XVII. Lymph drainge
of the larynx, trachea, bronchial tubes and bronchioles.
In weak-chested people we must first of all secure
alignment, then good posture, and finally good tone through indirect vasomotor
The efferents from the pleura include the internal
mammary, as we have said. The internal mammary receives part of the
intercostal drainage. If there are one or more costal lesions a proportionate
blockage will result. If the scaleni muscles are tensed through cervical
lesions, and the first and second ribs drawn upward, there is a possibility
of interference with lymph drainage from a portion of the lungs and pleura.
The vessels crossing the first ribs may be interfered
with and the thoracic duct on left side drawn in a position to check drainage
into the vein. The vessels to the bronchial tubes and lungs are controlled
through vasomotor centres that may be influenced in the upper thoracic
sections. The nerves to the lungs may be influenced by cervical lesions
as well as upper thoracic.
Blockage of the lymph stream in the neck or around
the trachea may interfere with the lung efferents. The tracheo-bronchial
nodes and the mediastinal may be checked in their drainage through congested
membranes and tissues. This calls for a better vascular regulation.
These two systems work together to clear any area or region. We must
work to secure good lymph drainage by not only removing any interference
with the effervents from the nodes, but through the reducing of congestion
around the nodes and efferents.
The clavicles have much to do with interference with
lymph drainage at times. We find a clavicle in some instances not
in true alignment, occasionally backward at external end. It is well
to see that they are not drawn out of line. There are so many vessels,
nerves, tubes, etc., passing through the upper thoracic opening that we
need to determine if there is room for these various structures; also,
note the presence of congested or thickened areas. The person with
a goitre may have a weak-chested condition not only through disturbed nerve
impulses, and irregular blood flow, but by lymph blockage as pointed out
in the chapter on the thyroid gland.
The broncho-pulmonary nodes are usually over-burdened
at their best. It is a question whether any one has normal nodes
in this region. Inhalations and catarrhal exudates and infections
by tubercular germs, even though practically latent, all contribute to
keep the nodules in the region of the hilum in an overtaxed state.
The alveoli have no nodes, but the lymph vessels are found in the lung
tissue. The correcting of lesions that will insure better respiration
will do much to clear the lymph vessels.
Any interference with the intercostal muscles or
costovertebral attachments will shorten breathing and correspondingly impair
lymph drainage. Very few people breathe properly, and when they contract
colds or have a cough they almost immediately assume a faulty posture.
This drooping of the chest not only affects the intercostal lymph vessels
but retards the flow of lymph in the thoracic duct and mediastinal nodes.
The erect posture relieves the pressure and the efferents convey their
lymph more readily.
We have not given the lymph flow sufficient thought
in the past. We have never realized the full significance of free
lymph drainage. The lymphatic system peripherally being a blind end
or closed system, we have felt that it simply cleared itself according
to the physiological activities found in various conditions.
The lymphatics start their collecting system in the
capillaries and it is only through indirect tone furnished by the tissues
and vasomotors that control the vessels that we can expect a normal flow
of lymph. Only the numerous valves prevent the lymphatics from becoming
thoroughly blocked. At all times work to secure good lymph drainage.
By so doing you invariably at the same time secure better vascular regulation.
The lymph stream is the weak member in the circulatory
system and we must study out every method of securing better drainage of
lymph in order that the nodes will not become blocked and indurated.
We depend upon the lungs to purify the blood but
we must not forget that there is a separate set of blood vessels that supply
the lung tissues, and that these tissues must be drained also by not only
the veins but the lymphatics.
Unless we can keep the broncho-pulmonary lymph nodes
clear the aeration of the blood in the alveoli and lung tissues, will not
be sufficient to prevent breaking down of the general system through a
checking and final infection in the nodes around the bronchi. The aeration
of the blood in the lungs is no more important than the preventing of induration
in the nodes that drain the lung tissue.
To have good general circulation and tone throughout
the body we must have cleared afferents and efferents in the broncho-pulmonary
Lymphatics of the Axillary Region
The physician is more familiar with this region,
lymphatically considered, than any other except the cervical. It
is so common to find enlargement of the axillary nodes in infectious diseases
and after vaccination that his attention is called to this area frequently.
The possibility of lymph blockage at this point makes
one think of the efferents that lead to the subclavian nodes. These
nodes empty by vessels on the right side into the subclavian vein or directly
into the right lymphatic duct. Between the subclavian nodes and the
terminal drainage point the subclavian trunk passes between the vein and
the subclavius muscle, and then behind the clavicle. On the left
side the trunk may enter the thoracic duct or empty directly into the subclavian
vein at the junction with the jugular. The subclavian muscle may
be in a state of tension from a subluxated clavicle or through disturbed
innervation of the muscle. These lesions will retard the flow of
lymph in the vessels.
When we consider the deep lymph drainage of the axillary
region, its drainage of bone, periosteum, ligaments, muscles and other
tissues, we get an idea of the relative importance of keeping all muscular
contractures at a minimum. If there are costal lesions they will
affect lymph drainage, and if the pectoral muscles are tense, we must expect
a similar retardation of lymph flow. The free anastomosis found in
the lymph vessels of the arm, as elsewhere, makes the lymph drainage of
the axillary region a common one. The central group of nodes in this
region collect from a vast area and the point of interest lies in the direction
of the terminal drainage point. The supraclavicular and the subclavian
nodes are often blocked. Even the lower cervical nodes are involved
when the axillary are enlarged. Snow refers to regurgitation in malignant
case leading to retrosternal involvement and secondary infection of the
head of the humerus. We find regurgitation possible elsewhere as
in the lymph vessels in gastric cancer. This simply proves that although
lymph vessels have numerous valves there may be regurgitations under certain
conditions. Going back to the lymph drainage of the muscles we may
reach and influence the flow of lymph through a better vasomotor control
of the blood vessels that supply the tissues and nodes. We may also
reach the lymph drainage through correction of lesions that remove muscle
tension over and around the lymph vessels and nodes. This will call
for adjustment of the cervical region to insure normal tone in the brachial
plexus. Correction of upper thoracic and rib lesions will stimulate
vasomotor and trophic centres. Costal correction will regulate the
upper thorax so that the lymph drainage into the subclavian veins will
not be checked. The scaleni may be overtensed through cervical lesions.
Correct posture will help to insure good lymph drainage
from the axillary region. The lymph vessels and nodes often are attached
to the sheath of the veins. They follow the vessels closely in many
instances. This is another reason why we should keep muscle tension
at a minimum, as a tensed muscle will interfere with the blood flow and
a thickening of the adjacent tissues may block the lymph flow and cause
an undue toxic effect that will result in a blocking of certain lymph nodes
and vessels. The axillary region is an active one in that the use
of the arms cause the muscles of the shoulder and pectoral region to be
actively engaged. Normally muscular activity aids lymph flow as well
as venous flow. It is when there is axillary adenitis or lymph blockage
in the afferents that motion is sometimes disadvantageous to the lymph
stream. The mammary area, if blocked, will check the flow in many
of the vessels. If there is an additional axillary blockage the regarded
mammary lymph flow will cause a pectoral disturbance that will not clear
until the axillary and subclavian nodes are reduced. The subclavian
may receive mammary lymphatics, also the internal mammary nodes will take
up part of the mammary drainage, but it is through the axillary nodes collecting
the pectoral lymph that we must look for drainage when we find tumors forming
in the breast. We are called upon almost constantly to reduce these
“lumps.” If there is no malignant condition we are reasonably sure
of reducing them by axillary drainage unless they are unduly indurated.
The lessening of pectoral muscle tension and correction
of costal lesions, as well as cervical and upper thoracic lesions, to insure
normal nerve tone, will be the more important. Direct manipulation
of the axillary nodes is contraindicated. It is far better to reduce
node enlargement through adjustment of lesions as outlined above.
Sometimes a lymph vessel from the mammary gland passes
through the substance of the pectoralis major leading to the subclavian
nodes. If there is faulty innervation to this muscle the undue contraction
may check the lymph flow.
The region of the scapula is drained by efferents
into the axillary nodes. We now see what a large area these nodes
in the axilla collect from. In cases of scoliosis, where there are
group costal lesions, we may find a sufficient blockage to over-burden
the nodes of the axilla. If there is a goitre, and the lower cervical
nodes are enlarged, we may find an additional pectoral blockage, especially
if the lymph vessels of the upper extremity empty into the two large terminal
trunks, the right lymphatic and the thoracic. It takes but very little
supraclavicular edema to interfere with terminal drainage. The entire
arm may be affected. Slight puffiness around the fingers may lead
us to suspect lymph blockage either in the axillary or clavicular regions.
The small nodes in the cubital fossa, or the epitrochlear nodes may become
enlarged if there is interference above.
The establishing of better circulation in the arms
by vasomotor tone will assist in clearing up a lymph sluggishness.
The cervical area must be cleared first. The
first dorsal nerve must not be overlooked as a branch of that nerve enters
in the nerve plexus. The first rib is sometimes slipped sufficiently
to cause a lymph disturbance.
Test out the arm movement to be sure that the tendon
of the biceps is absolutely in the groove, and that there is a good free
Neuritis is so common that we find many mild cases
in every day practice. Well-marked cases are fairly common also.
The lymph flow, if checked, will poison or irritate the nerves as there
is a certain amount of lymph fluid within the sheath of the nerve.
In fact, I am inclined to believe that neuritis and tic are lymphatic disorders.
In experimenting with both of these maladies we have found that there is
always a lymphatic involvement, and that, upon freeing the lymph flow,
the symptoms disappear. This statement may be new. I have not
seen it discussed elsewhere, but if you will work on lymphatic drainage
technique in these two troubles, you will soon find that the lymph flow
that has been checked for a period of time has much to do with the unpleasant
symptoms that are associated with it.
Secure good venous drainage and then work to the
end of reducing the nodes by treatment around the base of the neck.
We will take up intercostal lymph drainage in the
next section. The pectoral lymph vessels anastomose with the intercostals
at some points, but axillary drainage does not include intercostal drainage
to any great extent.
The intercostal area is extensive. The combined
length of the intercostal arteries and veins would measure possibly 72
feet. The lymphatic vessels have nodes principally at the sternal
and vertebral ends. A few nodes may be found in the intercostal spaces.
The posterior nodes of the intercostal lymphatic chain lie near the heads
of the ribs and receive the afferents from the intercostal spaces and muscles.
The upper five or six nodes have efferents leading to the subclavian veins
in the two main ducts. The lower six nodes have efferents leading
to the beginning of the thoracic duct near the receptaculum chyli.
Thus the drainage of the posterior and lateral sections of the intercostals
is partly upward and partly downward, and then upward. The right
lymphatic duct receives only the efferents of the upper six intercostals
in the posterior region on that side, and the thoracic duct the upper six
left at its terminal into the subclavian vein and the lower six, right
and left into the beginning of the thoracic duct.
About eighteen intercostal efferents of the posterior
thoracic region enter the thoracic duct at some point and only six the
right lymphatic duct.
The anterior intercostal drainage lymph vessels are
in relation to the internal mammary blood vessels. The internal mammary
nodes collect and carry lymph by efferents to the subclavian veins.
They collect from the thorax, mammary bland, upper surface of the liver,
the diaphragm, internal intercostal muscles, and subpleural tissue.
So we have two systems of drainage of lymph in the
intercostal region, and two chains of nodes, one on front of ribs near
costovertebral union, and one behind sternal end of ribs in relation to
internal mammary blood vessels. The two chains on either side of
the sternum in the anterior region have efferents from their nodes to the
subclavian veins. Each side draining into the vein on each side as
compared with the posterior lymph drainage of three fourths into thoracic
duct and one fourth in right lymphatic duct.
The nodes found behind the sternum at the lowest
point collect from the diaphragm and the upper surface of the liver and
pleural surface in that area. It is through the anastomoses of these
two anterior chains and their collection from the outer mammary region
that infection may cross from one side to the other in malignant breast
cases. It is also through the lower collection of lymph back of the
ribs in the sternal end that diseases of the lungs and liver may be conveyed
from one organ to another. The lymph vessels from the parietal pleura
enter these nodes. The many lesions that may interfere with intercostal
lymph drainage hinge principally on the lack of normality of the spine.
Single or group lesions of the ribs will interfere with lymph drainage.
The first rib may cause more disturbance than any other, as it is in relation
to the subclavian vessels and these veins receive the terminal drainage
of all the lymph.
So, we will start at the top; first, we will detect
any subluxation through scaleni tension or through costovertebral tension.
Next the upper thoracic vertebrae to determine existing lesions, three
vertebrae usually, at least. A single vertebra is seldom in lesion
without disturbing the one above and the one below. The intercostal
nodes near heads of ribs may be enlarged through the state of the tissues
supplied by the intercostal blood vessels, through lesioned ribs, or vertebrae.
These nodes are usually independent of communication with the mediastinal
nodes and vessels. They simply drain the lymph from the intercostal
spaces and convey it to the subclavian veins. The internal mammary
nodes receive the lymph vessels of the pleura in that region and connect
with lymph vessels of the diaphragm and the upper surface of the liver.
These last nodes and efferents may eventually join the tracheobronchial
and anterior mediastinal to form the brochomediastinal that empty into
the subclavian vein directly, or into the large ducts on either side.
The second rib may also be lesioned, by contraction
of the attached scalenus muscle, or by a vertebral lesion. This rib,
with the first, forms the uppermost intercostal space.
The lymph flow will be interfered with if there is
undue intercostal tension, as by separation of the two ribs through stress
or lesion, and lymph blockage may occur if the ribs are approximated through
vertebral lesions or costal subluxations. The postero-lateral intercostal
lymph vessels follow the blood vessels, as is the rule elsewhere, and the
lymph drainage may be interfered with, secondarily, by the blood supply
being checked, or through venous stasis by lack of vascular drainage.
So we might go on, rib by rib, and discuss each intercostal
space, but suffice it to say that single rib lesions may cause a greater
proportionate disturbance than group lesions where there is an extended
scoliosis of gradual development.
In any instance, however, we are interested in the
lymph flow, and especially the efferents that convey the terminal drainage.
The thoracic nerves are nourished by a regulated blood supply. The
lymph enters into the drainage of the tissues and the channels must be
kept clear if we wish tone in tissues supplied with blood.
Faulty posture and a drooped chest will not only
affect the intercostal venous and lymph drainage but may block the veins
and lymphatics of the organs both in the chest and below the diaphragm.
We cannot have a blockage at any point between the terminal lymph ducts
and a more remote area without a checking of the lymph flow beyond the
point of blockage. The proposition is similar to that of the blood
stream. Impaired intercostal drainage will prevent hepatic, pleural
and diaphragmatic lymph flow.
In fairly normal conditions the interference with
lymph flow at any point may not mean systemic disturbance, but if there
exists inflammation as is found in certain organs and coverings when certain
diseases are present, we find the collateral anastomotic lymph vessels
conveying and spreading the toxic products, and in malignant cases regurgitation
in some instances, as referred to in another section.
In certain dissections we have observed nodes more
numerous than found in bodies where no malignant conditions exist.
In the epigastric region especially the blockage in the venous tissues
and the resultant thickened tissue, through congestion and toxic deposit,
there are numerous small nodes and disturbed lymph afferent and efferent
vessels, which allow a more widely spread toxic condition.
The lack of rib movement in certain cases where the
spinal and costal muscles are almost rigid through colds or lesions or
even organic reflex irritation, all point to a checking up of the lymph
flow in the intercostal vessels and nodes; also in the trunks leading to
the subclavian vessels. There must be freedom of chest movement,
as mentioned by Dr. Bush in her chapter on exercises, if we may expect
free lymph flow in the afferents. There must also be motion in every
thoracic articulation to insure intercostal lymph and blood flow.
The vasomotors that control the intercostal arteries
have an indirect influence on the lymph flow. The better the blood
circulation in both arteries and veins, the more normal will be the lymph
flow. A subluxated rib may affect the lymph flow sufficiently to
cause poisoning of the tissues around a nerve. Thus we see in herpes
a breaking out on the skin due to a lesion affecting the nerve and its
In almost every instance an osseous lesion will cause
a lymph disorder as well as vascular irregularities and nerve instability.
The lymph spaces are almost everywhere and they must be reckoned with if
we wish healthy tissues. Wherever there is muscle rigidity or tension
we will find the lymph spaces and vessels more or less blocked by undue
tension and altered vascularization.
The lymph flow must move onward just the same as
the venous blood, or there will be pathological changes as a result of
the inactivity. The lymph passes through nodes continuously in a
normal tissue condition. The checking of this flow through any of
the causes that interfere with the nodes’ activities, or of the lymph vessels’
conveying properties, will mean a changed lymph substance. If the
nodes collect and retain lymph laden with toxic products, suppuration will
result. Should this occur in the bronchial nodes, there is danger
of tubercular infection in the lung tissue from the broken down nodes that
lie along the branches of the bronchial tubes.
If the nodes in the mammary gland become enlarged
and indurated and then malignant, through adjacent tissue and duct poisoning,
there is danger of spreading of this substance through the lymph vessels.
The lymph must be conveyed to the subclavian veins without nodular retardation
to be good lymph. The moment there is a checking of the lymph flow
in the vessels or nodes, that moment the lymph is altered in its consistency.
The influence on the immediate tissues surrounding a blocked lymph node
may be observed in palpable areas, and if there is continued blockage and
nodular enlargement, the other nodes and vessels may cause the disorder
to become a systemic one instead of local.
The whole system of lymphatics may become altered
eventually, through a primary pathological area in which there has been
retained toxins followed by suppuration.
Lymphatics of the Heart and Pericardium
The relation of the heart to the trachea allows lymph
drainage of both to readily enter the tracheobronchial nodes. The
plexus of lymph vessels in the endocardium communicate freely with the
plexus found inside the visceral pericardium. The efferents follow
the coronary vessels in the grooves on the surface of the heart and the
right and left vessels pass backward in relation to the pulmonary artery
to reach the trachea and bronchi.
The lymphatic drainage of the heart is worthy of
special consideration. Here we have an organ in a class by itself;
a moving organ, pulsating and pumping blood all over the body after receiving
it, with valves opening and then closing. The lymph vessels are moving
also with the heart in motion, and they are also influenced by the constant
contraction and relaxation of the cardiac muscle. Possibly nowhere
in the body do we find a better lymph flow than in the heart, and its covering,
the pericardium. The absence of nodes is explained by the active
drainage through the efferents. Nodes are practically unnecessary,
and if present might, in certain cardiac disorders, cause undue pressure
and disturbance to an organ that is sensitive to pressure or stress.
The lymph spaces between the bundles of cardiac muscles in the connective
tissue communicate with the vessels in the endocardium and epicardium.
Thus we have normally a perfect drainage of lymph from the heart to the
nodes on the trachea and its divisions. It is through a blockage
of the tracheobronchial nodes that we find interference with the lymph
flow in and around the heart. In tubercular conditions of the lungs,
when there are enlarged tracheobronchial nodes and suppuration, a secondary
effect upon the heart is noticed. The cardiac efferents no longer
drain the lymph freely into the nodes and terminal efferents. There
is a tendency toward coronary vessel thickening and hardening. In
angina we find the lymph drainage has been checked and a deposit formed
that is due to continued lymph blockage. Again we find the cardiac
nerves affected by lymph blockage and node enlargement in the areas where
the nodes are adjacent to the cardiac nerve trunks. The cervical
cardiac sympathetics as well as those coming from the pneumogastric may
be compressed by poor lymph drainage in the cervical nodes and vessels.
There may be an edematous condition of the tissues in the neck and throat
due to lymph blockage that will reflect itself upon the base of the heart
and the superficial and deep cardiac plexuses. The lesions that cause
vasomotor instability of the coronary arteries and blood vessels leaving
the heart, pulmonic and systemic, may influence the lymphatics in the walls
and around the heart. The blood supply to the various cardiac nerves
and plexuses may cause a change in the lymph spaces which, in time, will
produce a slight cardiac variation of rhythm. This has not been accounted
for in the various treatises on heart diseases, but we have found that
the lymphatic system plays a goodly part in the rhythmic action of the
heart. In one case treated some months ago, when an accelerated cardiac
action existed, we noted a lymph blockage and nodular enlargement in the
cervical region accompanied by edema in the supraclavicular area.
Desirous of regulating the heart’s action by a better lymphatic drainage,
we worked to that end. Reduction of cervical nodes and a better drainage
of the efferents from the tracheobronchial nodes brought about a more normal
heart action in a very short time. We assumed that the lymph spaces
were more or less blocked in the cardiac muscle tissue and poisoning or
irritation had existed through lack of free drainage of the lymph in the
right and left trunks that go to the tracheobronchial nodes. The
lymph had been retained too long, and the effect upon the cardiac muscle
was observed. The cervical area also had its influence on the cardiac
nerves through lymph inactivity, and the edematous area above the clavicles
aided the blocking of the lymph flow from the lower nodes and efferents.
In cases of goitre we also have noted that a part
of the cardiac variation from normal was due to lymph blockage in the region
of the thyroid vessels. Pressure of the gland also affected the nerves.
Interference with the blood supply of the heart and pericardium affects
the lymph stream in the grooves containing the blood and lymph vessels.
Too little attention has been paid to the lymphatic
consideration in relation to heart action. Hardening of the coronary arteries
is a lymph proposition to a great extent, and the primary lymph blockage
may be at a distant point. The effect of costal and vertebral lesions on
the flow of lymph has been discussed in another section, but we wish to
emphasize again the importance of free lymph drainage through the correction
of lesions that will block the lymph flow from the tracheal region and
cardiac efferents. Very little lymph flow interference in the auricles
and ventricles will in time cause a cardiac fluctuation from normal. We
may look for this in cases where there is bronchitis and nodular enlargement
above the clavicles.
Lymphatics of the Esophagus
This tube is of sufficient length to have at least
two collecting systems of lymph vessels. We find the network of lymphatics
in the muscular coat collected by the submucous. They collect from
the lymph spaces in the mucous tissues and in the lower part of the esophagus
the drainage is toward the nodes in the coeliac region. In the upper
part of the esophagus the posterior mediastinal nodes receive the afferents
and convey the lymph by efferents to the subclavian veins. The esophagus
is drained then by nodes that lie adjacent to the tube. The flow
of lymph depends chiefly upon the normal activity of these adjacent nodes.
The lower drainage will depend upon the patency of the thoracic duct that
indirectly receives the lymph vessels from the esophagus. It is the
upper drainage that is the more important as all of the lymph must eventually
reach the thoracic duct and subclavian vein in some way.
Should there be bronchial affection and enlarged
nodules in the posterior mediastinal area, the lymph checking will be reflected
upon the drainage of the esophagus. The vasomotor control of the
blood vessels to the esophagus will indirectly act upon the lymph vessels.
Lesions that cause a vascular irregularity in the
esophageal tissues will block the lymph spaces and cause retarding of lymph
that will produce a change in not only the mucous tissues but in the lymph
fluid. Retardation of lymph in the lymph spaces for any period will
cause changes that in time will interfere with the normal action of this
The nodes that collect the lymph from the esophagus
also collect the lymph from the diaphragm, upper surface of the liver,
and sometimes a part of the pericardium.
The extent of lymph interference then may be reflected
upon several membranes as well as the esophagus. It is impossible
to check the lymph flow in certain nodes without affecting in some regions
several different organs or membranous coverings.
The esophagus may be constricted through lesions,
and when this condition is present we also find a lymph space obstruction
which reacts and makes the altered change more marked.
The esophagus passes through the diaphragm and we
may find there at times, through costal lesions, an altered flow.
In gastroptosis the esophagus is extended sufficiently at
time to affect the lymph in the spaces of its mucous and muscular tissues.
The absence of nodes within the esophageal tissues throws the burden on the
collecting nodes in adjacent areas. The terminal drainage points must
receive the most consideration.