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THE TRACHEO-BRONCHIAL LYMPHATIC GLANDS by H

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THE TRACHEO-BRONCHIAL LYMPHATIC GLANDS by H THE TRACHEO-BRONCHIAL LYMPHATIC GLANDS By H. P. NELSON, M.B., F.R.C.S. Anatomical Department, St Bartholomew's Hospital Medical College THE advance of surgery may call for the investigation of anatomical fields that previously appeared to be of little clinical value. The present anatomical study was undertaken as part of an investigation of the possibility of irradiating the tracheo-bronchial lymphatic glands in bronchial carcinomata by the transtracheal and transbronchial implantation of Radon seeds. This paper attempts to describe the shape, position and relations of the tracheo-bronchial lymphatic glands to be found in the mediastinum and hila of the lungs in an adult of over forty years of age. A suitable terminology is suggested by which we may refer to the various members of this group, which should be of particular value to pathologists in giving an accurate description of glandular metastasis in the chest. The material required for this investigation was obtained from the autopsy room in cases where there appeared to be no gross lesions in the lungs. The thoracic viscera were removed en masse by the usual post-mortem method, but special care was taken not to tear the lung tissue; a rubber tube was then tied into the trachea and the lungs distended with about 2000 c.c. of formalin solution. The specimen was next put into a mould (made from the skeleton of a thorax) and surrounded by more formalin; thus the gross anatomical relations were maintained while the tissue was being fixed. In seven cases the viscera were cut into serial macroscopic sections on a macrotome and in five others were dissected. TERMINOLOGY There is considerable variation in the terminology employed for these glands. Most authorities describe those on the sides of the trachea and in the angle between the two main bronchi, but no attempt is made to describe and name the various glands that lie in the angles of division of the larger bronchi. Poirier, Cuneo and Delamere do not devote more than one page to the description of the " peri-tracheo-bronchial glands." They describe a right and left "pre-tracheo-bronchial" group of glands, an "inter-tracheo-bronchial" group and then they say: "The inter-bronchial glands occupy the angles of division of the larger bronchi. According to Cruvellier, glands may be found even in divisions of the fourth order." The Tracheo-Bronchial Lymphatic Glands 229 Dickey describes the " bronchial glands " as follows: (a) Superior tracheo-bronchial glands, a right and a left set, in the angles between the trachea and the right and left bronchus. (b) Inferior tracheo-bronchial glands, between the two bronchi and in front of the oesophagus and aorta, nine or ten in number. (c) Broncho-pulmonary glands lie in the angle which each smaller bronchus makes with the main stem of the bronchial tree. (d) Pulmonary glands, lymphoid masses situated in the lung and the sub- pleural tissue. Since all the tracheo-bronchial glands are in close contact with the bronchial tree and, broadly speaking, with the exception of the tracheal group, are wedged into the angles between the dividing bronchi, it would appear wisest to adhere to a classification that describes them in relation to this tree. Before we can proceed with the terminology of these glands, we must find a satis- factory nomenclature for the bronchi. Let us consider for the moment that the bronchial tree divides in a dicho- tomous manner, and that there are two primary bronchi, four secondary, eight tertiary and so on in geometrical progression until the terminal bronchi are reached. Then those lymph glands between the primary divisions might be called "inter-primary" and for the others, a right and left inter-secondary, right and left upper inter-tertiary, etc. The actual arrangement of the tree is, however, partly dichotomous and partly monopodic, and in addition is asymmetrical, but in spite of this, with a fewmodifications intheexistingterminologyof the bronchi, it is possible to have a classification of lymphatic glands based on this simple dichotomous scheme. Thefirst modification is to recognize that the left upper lobe bronchus divides almost immediately into two bronchi which are equivalent in their area of distribution to the upper (eparterial) and middle lobe bronchi on the right side. According to Narath, the left middle bronchus is phylogenetically the original, and the left upper (1st dorsal of Narath) has developed as a side branch from it. In addition it may be added that the arrangement of the blood vessels for this middle lobe area is the same on the two sides. The second modification is to recognise that the first dorsal bronchus of the lower lobe (2nd dorsal of Narath) is of the order of a secondary bronchus rather than a tertiary branch of the lower secondary bronchus. This bronchus arises from the dorsal surface of the " main stem " at a point exactly opposite the origin of the middle lobe bronchus on the right and just below the origin of the upper lobe bronchus on the left. Its external diameter is only 1 mm. less than that of the middle bronchus (Dickey). Its arterial supply arises from the descending branch of the pulmonary artery opposite the artery to the middle lobe, and its venous drainage is a large independent vessel that joins the inferior pulmonary vein just before it pierces the peri- cardium. Deve, who has devoted special attention to this lobe and calls it the "lobus posterior," points out that it is frequently separated off by a fissure 230 H. P. Nelson from the rest of the lower lobe, especially in children, where he states that it occurs in 50 per cent. of cases (counting bilateral cases as two), and in common with all accessory lobes is more frequent on the right. The dividing fissure of this dorsal lobe occurs as a continuation of the horizontal fissure, so that the lung is divided by a +-shaped cleft (see fig. 1). The third modification is to substitute the word "ventral" for "middle" lobe or bronchus. It will be seen that this classification is based on the inner structural relations of the bronchi rather than on the morphology of the lungs. To summarise our terminology for the bronchi: The trachea divides into two primary bronchi and on the right side the primary bronchus gives off from its right lateral wall a branch to the upper lobe, the upper secondary bronchus, and then continues as a main secondary bronchus which terminates by dividing into three secondary bronchi; a ventral branch to the ventral (middle) lobe, the ventral secondary bronchus; a dorsal branch to the apical portion of the lower lobe, the dorsal secondary bronchus; and the continuation of the main stem to the rest of the lower lobe, the lower secondary bronchus. On the left side the primary bronchus is twice as long as on the right. It divides iito two main secondary bronchi, upper and lower, which almost immediately break up into two more; thus the four secondary bronchi on the left side arise within a few millimetres of each other. The upper main bronchus divides into an upper secondary and a ventral secondary bronchus. The lower main bronchus gives off a dorsal secondary bronchus to the apical portion of the lower lobe and then continues to the rest of the lower lobe as the lower secondary bronchus. These secondary bronchi divide into tertiary, quaternary, etc. THE TRACHEO-BRONCHIAL GLANDS These glands form the "packing" that occupies the cracks and corners between the complex system of vascular and tracheo-bronchial tubes to be found in the mediastinum and hila of the two lungs. They may be classified as follows: I. Those in the mediastinum 1. Right tracheal: (a) Transverse. (b) Vertical. 2. Left tracheal: (a) Ascending. (b) Central. (c) Descending. (d) Anterior. 3. Inter-primary: (a) Superficial. (b) Deep. The Tracheo-Bronchial Lymphatic Glands 231 II. Those in the hila of the lungs 1. Right upper inter-secondary. 2. Left upper inter-secondary. 3. Right ventral inter-secondary. 4. Left ventral inter-secondary. 5. Right dorsal inter-secondary. 6. Left dorsal inter-secondary. 7. Right upper inter-tertiary. 8. Left upper inter-tertiary. III. Those in the lung fields 1. Ventral inter-tertiary. 2. Dorsal inter-tertiary. 3. Lower inter-tertiary. 4. Inter-quaternary, etc. The description that follows represents the average state found in the study of twelve cases (two-thirds of which were females) with an average height of sixty-five inches and age of sixty-five years. 1. The right tracheal group (R.T.) lies along the right antero-lateral surface of the trachea in the thorax. The group has a J-shape, having an expanded lower end that lies transversely and a vertical portion that runs up the trachea. The transverse part (T.R.T.) consists of one large gland lying medially and two to three smaller ones lying laterally. They extend from the mid-line of the trachea onto the superior border of the right upper bronchus. The right pul- monary artery forms their lower boundary, which level also corresponds approximately to the internal bifurcation ofthe trachea (carina). The ascending branch of the right pulmonary artery separates the lateral glands of this group from the right upper inter-tertiary and in those cases where the glands are large, the transverse group are grooved by this artery and extend across in front of it to meet the inter-tertiary, so that the artery passes under an arcade of gland tissue as it crosses in front of the upper bronchus. In front of these glands is the ascending aorta and the superior vena cava.
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