The Lymphatic Drainage of the Faucial 
Tonsils. 
BY 
GEORGE BACON WOOD, M.D., 
OF PHILADELPHIA. 
FROM THE 
AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
August, 1905. Extracted from the American Journal of tie.MftfEcal AtfgSst, 1W0.5 
THE LYMPHATIC DRAINAGE OF THE FAUCIAL TONSILS.1 
By George Bacon Wood, M.D., 
OF PHILADELPHIA. 
(From the Wistar Institute of Anatomy, University of Pennsylvania.) 
That various micro-organisms may gain access to the general 
system through the tonsillar tissues of the throat has been so firmly 
established that it is not necessary again to demonstrate the absorbing 
properties of the tonsils and to point out the various infections which 
may enter through this portal. The fate of the micro-organisms 
which have entered the parenchyma of the tonsil is dependent upon 
two factors: first, the pathogenic potency of the germ itself, and, 
second, the vital resistance offered by the tissues to its invasion. If 
a non-pathogenic germ enters a crypt it is destroyed probably by 
the phagocytosis of outwandering polymorphonuclear leukocytes. 
On the other hand, if the vitality of the germ is sufficiently great, it 
lives and may penetrate through the epithelium into the interfollic- 
ular tissue. 
It has been proven by several very thorough and capable investi- 
gators that foreign bodies in the crypts can pass through the epithe- 
lium into the interfollicular tissue. This absorption is probably 
dependent upon two factors: first, the action of the muscles of the 
throat during their various physiological movements, and, second, 
the presence of a lymph current in the tonsil. The palatoglossal 
muscle and the palatopharyngeal muscle during deglutition com- 
press the faucial tonsil and force the centrally lying movable bodies 
toward the periphery. If the foreign body is at the bottom of the 
crypt it is pushed in an outward direction,and, finding no appreciable 
barrier in the differentiated epithelium, passes into the tonsil paren- 
chyma. The second factor in the absorption of foreign bodies from 
the crypts is the constant production of lymphoid cells in the fol- 
licles. The interfollicular tissues of the tonsils consists of a fine 
connective-tissue reticulum interspersed with numerous lymphoid 
cells. These lymphoid cells may be looked upon as being in con- 
stant motion, passing from the follicles in the direction of least 
resistance. If the cellular metamorphosis of the epithelium has 
weakened this barrier so that the crypt is in the direction of least 
resistance, the lymphoid cells break througluand pass into the crypt, 
but more commonly the lymphoid cells pass into the lymph spaces 
1 Candidate's thesis. American Laryngological Association, June, 1905. 2 
wood: lymphatic drainage of the faucial tonsils 
which terminate in the trabeculae of the tonsil and which in their 
turn empty into the efferent lymphatics of the tonsil. Therefore, 
the production of lymphoid cells in the follicles causes what we 
might term a lymphoid current, and this lymphoid current, except 
when there is an accidental rupture of the cryptal epithelium, is 
toward the connective-tissue trabeculae of the tonsil and thence 
through the lymph radicles to the periphery. A foreign body having 
gained access to the interfollicular tissue must be influenced by this 
current. I understand thoroughly that in advancing this idea, I am 
open to criticism for theorizing about a scientific subject. It seems 
to me, however, that the above is a probable explanation of the 
mechanism of tonsillar absorption and helps to substantiate the 
theory that the faucial tonsil is more important as a source of infec- 
tion than is the lymphoid tissue on the lateral folds and posterior 
pharyngeal wall of the pharynx. As regards the absorption of 
living virulent micro-organisms, it must be remembered that bac- 
teria are not inert foreign bodies, but possess certain vital properties 
which influence their entrance into living tissue. When uninfluenced 
by extraneous forces a micro-organism invades living tissue by two 
methods: first, if it belongs to the motile class the individual bac- 
terium by its own locomotion may carry itself to some more or less 
distant spot, and, second, micro-organisms may invade tissue by the 
very act of their growth. This last is the most important method 
by which the pathogenic germs gain entrance into their host. 
It is practically impossible to establish with absolute certainty 
the relative importance of the different lymphatic masses in the 
throat as gates of infection. Circumstantial evidence, however, 
both clinical and experimental, tends to show that the larger the 
lymphatic mass and the deeper its crypts, the more readily do 
pathogenic germs pass through the tonsillar tissues to the tonsillar 
efferents. 
The research outlined in this paper is a preliminary report of a 
series of investigations concerning the lymphatic anatomy and 
drainage of the tonsils and surrounding portions of the throat. My 
first investigations concern the faucial tonsil, because in the etiology 
of infections it is the most important tonsillar structure, and I have 
not been able to find any reliable published data concerning the 
glands that receive its efferent lymphatics. 
The lymphatic glands of the neck constitute one of the most 
important chains of glands in the whole body and is probably the 
chain which is most frequently diseased. The infection which 
inoculates a lymph gland may possibly come through its efferent 
lymphatics by a retrograde thrombosis, but much more frequently 
it follows the current of the lymph stream and enters through the 
afferent vessels. In the large majority of cases the infection of the 
cervical lymphatics comes from the nose, mouth, or throat. As a 
general rule, the efferent lymphatic vessels from a given structure wood: lymphatic drainage of the faucial tonsils 
3 
drain into that lymphatic gland which is nearest it, and, therefore, 
to understand the importance of the different structures of the nose, 
throat, and mouth as portals of infection it is essential to have clear 
in our minds the topographical relations of the deep and super- 
ficial lymph glands. 
The cervical glands of the neck are divided into two main groups, 
the superficial or collecting glands and the deep or terminal glands. 
The superficial are arranged as a sort of collar around the upper part 
of the neck, with a few irregular extensions. This pericervical 
glandular circle is composed of the following subgroups: 
1. Suboccipital group and aberrant glands of the nape of the 
neck. 
2. The mastoid group. 
3. The parotid and subparotid groups. 
4. The submaxillary group with the facial glands as an offshoot. 
5. The submental glands. 
6. The retropharangeal glands. 
The terminal or deep glands of the neck form a perpendicular 
chain beneath the sternocleidomastoid muscle. This main set of 
glands is flanked by several secondary chains of less importance. 
The superficial glands constituting the pericervical collar receive 
their afferents from those portions of the external and internal head, 
which are in more or less close relation with the individual group. 
The efferents of all these collecting glands empty into the deep chain. 
The deep cervical lymphatics or the substernocleidomastoid glands 
constitute in appearance a continuous chain, but for convenience 
sake they may be divided into an external and internal group. The 
external glands are placed posteriorly and rest indiscriminately on 
the insertions of the splenius, levator anguli scapulae, and scalene 
muscles, and they are usually continuous with the glands occupying 
the supraclavicular triangle. The internal glands of the substerno- 
cleidomastoid group may be termed the internal jugular chain, 
because they rest either directly on the internal jugular vein or are 
immediately adjacent to its external border. The glands of this sub- 
group are larger than the glands of the external, and some of them 
are fairly constant in their position. One or two large glands are 
constantly found beneath the posterior belly of the digastric, just 
above the spot where the thyrolingual facial vein opens into the 
internal jugular. A few glands are sometimes found between the 
internal jugular and the prevertebral muscles. These two main 
groups of deep glands, the external and internal chains, are united 
by a great many anastomoses. The external glands receive their 
afferents from the posterior part of the head and neck, while those 
of the internal group receive their afferents from the anterior por- 
tion of the neck and head, from the mouth, nose, pharynx, larynx, 
and thyroid body. While the majority of the afferents of the deep 
glands of the neck are the efferents from the superficial glands, quite 4 
wood: lymphatic drainage of the faucial tonsils 
a number of lymph vessels pass directly from the lymph radicles 
of the throat and nose to the deeper chain of glands. For instance, 
the majority of the lymph vessels from the vault of the pharynx 
drain into the retropharyngeal glands, but some of them pass 
directly to the upper glands of the deep cervical chain without any 
interruption. 
The method of injection employed in the present research was 
essentially that devised by Gerota. It consisted in rubbing up Berlin 
blue with pure spirits of turpentine until it assumed the consistency 
of a rather thin, syrupy liquid. A small quantity of ether is added 
Fig. 1 
Dissection of the neck of a child, showing an enlarged tonsillar lymph gland and its relation 
to the digastric and stylohyoid muscles: 1, facial nerve ; 2, external carotid artery ; 3, stylo- 
hyoid muscle ; 4, facial artery ; 5, submaxillary lymph gland ; 6, hypoglossal nerve; 7, pos- 
terior belly of the digastric muscle; 8, tonsillar lymph gland. 
and the mixture filtered through chamois skin. The coarser gran- 
ules of the Berlin blue are held back in the filter while a clear, thin, 
blue liquid passes through as the filtrate. Gentle agitation of the 
fluid while it is filtering ensures a better mixing of the turpentine, 
ether, and Berlin blue, consequently a deeper color to the filtrate. 
The injecting apparatus consisted of a fine glass needle drawn out 
of a glass tube and attached by a piece of rubber tubing to the nozzle 
of an easy-working syringe holding about 10 c.c. 
The glass needle was inserted beneath the mucous membrane 
covering the tonsil and held very carefully in its place, while an wood: lymphatic drainage of the faucial tonsils 
5 
assistant made gentle but gradually increasing pressure, according 
to the ease with which the fluid entered the tonsil. The amount 
injected was regulated somewhat by the amount of resistance felt in 
the syringe and also by the distention of the tonsillar tissues. If 
the injection was properly made the tonsil gradually swelled out 
becoming two or three times its normal size and of a deep-blue 
color. The blue fluid in such injections must not be forced in hur- 
riedly, as a certain amount of time is necessary for it to find its way 
into the lymph spaces and thence through the lymph radicles to the 
Fig. 2 
Dissection of the neck of an adult, showing enlarged internal jugular lymph glands : 1, paro- 
tid gland ; 2, masseter muscle ; 3, facial nerve ; 4, facial artery ; 5, submaxillary lymph gland ; 
6, submaxillary salivary gland ; 7, thyrofacial lingual vein ; 8, internal jugular vein ; 9, brachial 
plexus of nerves; 10, superficial cervical plexus ; 11, spinal accessory nerve ; 12, internal jugular 
lymph glands. 
lymph vessels. In injecting the tonsil, it frequently happens that 
the fluid returns through the crypts. In the case of this regurgitation 
being so free that internal pressure cannot be exerted, the point of 
the needle is to be changed until a position is found from which the 
injected material does not so readily gain access to the crypts. 
After the injection has been made the excess of material should be 
washed from the surface by a stream of cold water. Gentle massage 
of the tonsil with the finger tends to force the injected fluid 
farther into the tissue. It is best to leave the fresh material in plain 6 
wood: lymphatic drainage of the faucial tonsils 
water for several hours before fixing it in 10 per cent, formalin. 
After fixing the specimen the dissections may be made and the 
injected gland sought for, special care being exercised to avoid 
wounding any of the injected lymph vessels 
Eight injections were made, some of them resulting in failure, 
but the majority showing distinctly that the tonsillar lymph follows 
a fairly constant route. The direction of this drainage as established 
by these injections is as follows: 
The lymph vessels pass from the external portion of the tonsil 
through the peritonsillar connective tissue, the pharyngeal aponeu- 
FtG. 3 
Superficial dissection of Specimen No. VI., showing enlarged tonsillar lymph gland project- 
ing just beyond the edge of the sternocleidomastoid muscle: 1, external jugular lymph 
glands; 2, great auricular nerve; 3, tonsillar lymph gland; 4, external jugular vein ; 5, 
external glands of the substernomastoid group ; 6, submaxillary salivary gland ; 7, submaxil- 
lary lymph glands ; 8, facial artery. 
rosis, and the superior constrictor of the pharynx, and, as one or 
two or more fine small vessels run obliquely in a downward, pos- 
terior, and outward course, passing below the facial artery. Bend- 
ing more posteriorly the lymph vessels next run between the internal 
jugular vein and the stylohyoid muscle, reaching finally the superior 
surface of an enlarged lymph gland, placed just beneath the ante- 
rior border of the sternocleidomastoid muscle, where it is crossed 
by the posterior belly of the digastric muscle. The efferent vessels 
from this gland are generally two or three in number, and pass into 
the neighboring glands of the internal jugular group. Further wood: lymphatic drainage of the faucial tonsils 
7 
anastomoses which connect the lower glands of the internal jugular 
group with those receiving the tonsillar drainage form a complete 
lymph channel, through which the tonsillar lymph finally empties 
into the jugular lymph trunk. 
In none of the preparations did the injected fluid enter into super- 
ficial glands, except in one case, where there was an aberrant gland 
lying on the facial artery near its origin. This gland seemed to be 
simply an interrupting nodule in the course of the tonsillar efferents. 
The statement in some text-books on anatomy that the tonsil drains 
Fig. 4 
Deep dissection of Specimen No. VI., showing the tonsillar lymph gland and its relation to 
the substernomastoid group: 1, reflected sternocleidomastoid muscle; 2, tonsillar lymph 
gland ; 3, spinal accessory nerve; 4, branch of cervical plexus; 5, internal jugular vein; 6, 
omohyoid muscle. 
into the posterior gland of the submaxillary group would seem to be 
absolutely erroneous and very misleading. 
Clinically, the gland which becomes enlarged during tonsillar 
infection appears to be superficial and possibly it is this appearance 
that has led to the belief that the posterior gland of the submaxil- 
lary group is infected through the tonsils. The tonsillar gland, if I 
may be pardoned for using the term, is placed external and slightly 
anterior to the internal jugular vein and is embedded in loose areolar 
tissue containing more or less fat. Consequently, enlargement of 
this gland means its dislocation outward and forward, and especially 8 
wood: lymphatic drainage of the faucial tonsils 
so if the other glands of the internal jugular group become subse- 
quently enlarged; also the action of the substernocleidomastoid 
muscle would tend to force it anteriorly. If an enlarged gland 
found at the angle of the jaw belongs to the deep substernocleido- 
mastoid group, it may be pushed back under the muscle of the same 
name. In cases of enlargement of the submaxillary glands such as 
result from infection from carious teeth, the glands are found along 
Fig. 5 
Superficial dissection of Specimen No. II., showing portion of tonsillar lymph gland and its 
relation to the sternocleidomastoid muscle and the external jugular vein : 1, lymph glands of 
the internal jugular group; 2, parotid gland ; 3, facial vein; 4, facial artery ; 5, submaxillary 
lymph glands ; 6, submaxillary salivary gland ; 7, tonsillar lymph gland ; 8, omohyoid muscle; 
9, sternocleidomastoid muscle; 10, external jugular vein ; 11, great auricular nerve. 
the edge of the jaw and cannot be displaced backward and only 
slightly downward. In the description of the anatomy of the cervical 
lymphatics previously given it was stated that where the posterior 
belly of the digastric muscle crossed the sternocleidomastoid there 
were constantly found one or two large glands. In a child one week 
old in which I was able to trace the course of the tonsillar efferent 
vessels this gland was very little larger than many more of the exter- 
nal jugular group. In children who have reached six or more months wood: lymphatic drainage of the faucial tonsils 
9 
of age this gland was generally twice or three or four times larger 
than any other, and in every injection of the tonsil it wTas this 
enlarged gland that primarily received the blue injecting fluid. 
Does it not seem possible that this enlargement consequent to 
birth may. be due to the absorption of toxins through the faucial 
tonsils ? 
Fin. 6 
Deep dissection of Specimen No. II., showing position of tonsillar lymph gland and its con- 
nection with other glands of the substernomastoid group: 1, internal substernomastoid lymph 
glands ; 2, external jugular vein ; 3, facial vein ; <*, facial artery ; 5, submaxillary lymph glands ; 
6, submaxillary salivary gland ; 7, superior thyroid artery ; 8, tonsillar lymph gland , 9, com- 
mon carotid artery; 10, internal jugular vein; 11, omohyoid muscle; 12, jugular lymph 
trunk; 13, efferent vessels of tonsillar lymph gland; 14, external substernomastoid lymph 
glands. 
I have chosen to call the lymphatic gland which receives the 
efferents of the tonsil the tonsillar lymph gland. This term is not 
sufficiently comprehensive, because most probably other lymph 
vessels from the throat, besides those from the tonsil, drain into this 
gland, but the most important infections of the cervical lymphatics 
originate through the tonsil, and because of the importance of the 
tonsil in the origin of infections, I feel that the term tonsillar is a most 10 
wood: lymphatic drainage of the faucial tonsils 
appropriate one. Certainly, it is convenient to be able to easily 
designate so important and constant a lymphatic gland. 
Following are the descriptions of the individual injections of the 
tonsils. The technique was practically the same in all of them. 
Specimen I.-Child about six months old. The injection in this 
case failed probably because there was some obstruction in the 
injecting needle. Dissection of the neck showed hypertrophy of the 
tonsillar lymph glands. 
Fig. 7 
Deep dissection of Specimen No. IV., showing the efferent lymph vessels of the faucial tonsil 
entering the tonsillar lymph gland. The posterior belly of the digastric muscle and the whole 
of the stylohyoid muscle have been reflected downward : 1, parotid gland; 2, stump of the 
stylohyoid muscle; 3, stump of the posterior belly of the digastric muscle ; 4, tonsillar lymph 
gland; 5, reflected sternocleidomastoid muscle; 6, brachial plexus of nerves; 7, substerno- 
mastoid lymph glands ; 8, internal jugular vein ; 9. omohyoid muscle ; 10, stylohyoid muscle; 
11, posterior belly of the digastric muscle; 12, hypoglossal nerve ; 13, efferent lymph vessel of 
the faucial muscle ; 14, facial artery ; 15, position of faucial tonsil. 
Specimen II.-Child about six months old. The injection in this 
case was very successful. The tonsil itself became enlarged and 
there was a slight overflow of the fluid toward the faucial pillars, the 
blue color, however, was limited to the fauces. A few injected 
lymph vessels were seen running posteriorly into the sinus pyriformis 
and anteriorly toward the base of the tongue. The dissection of the wood: lymphatic drainage of the faucial tonsils 
11 
neck showed that the blue fluid had entered a slightly enlarged 
lymph gland situated just below the point where the anterior border 
of the sternocleidomastoid muscle is crossed by the posterior belly 
of the digastric. The gland was superficial to the digastric muscle 
just above the facial vein, where it joins the external jugular. A 
deeper dissection demonstrated that the injected gland belonged to 
the anterior group of the upper deep cervical lymph glands and had 
three efferent vessels, which also contained the blue injecting fluid. 
The connecting lymph vessels between this gland and the jugular 
trunk were dissected out. The most direct route showed that the 
lymph current from the tonsil, in order to enter the jugular trunk, 
had to pass through two or more glands after leaving the tonsillar 
lymph glands. In this specimen, however, I was unable to find the 
efferents running from the tonsil to the tonsillar lymph gland. Figs. 
5 and 6 were made from this specimen. 
Specimen III.-Child one week old. Only a small quantity of 
fluid was injected into the tonsil. The dissection showed a slight 
injection of the glands situated just below the posterior belly of the 
digastric. 
Specimen IV.-Child one week old. A rather full injection of the 
tonsils was made and there was some infiltration of the surrounding 
mucosa. This injection was very instructive, as by careful dissection 
lymphatic vessels could be traced running from the infiltrated tonsil 
directly to the gland situated just below the posterior belly of the 
digastric beneath the anterior border of the sternocleidomastoid 
muscle. This lymph gland was considerably injected, but the 
importance of the specimen was in the demonstration of the efferent 
lymphatics of the tonsil. The course which the lymphatic vessels 
took was as follows: Leaving the tonsillar mass and running pos- 
teriorly and inferiorly, they pass slightly outward beneath the facial 
artery, running along the upper border of the lingual vein, then 
turning directly posterior, they pass between the stylohyoid muscle 
and the internal jugular vein, reaching the upper surface of the ton- 
sillar lymph gland. Fig. 7 was made from this specimen. 
Specimen V.-Child about three months old. Too much fluid 
was injected in this specimen, and, although the tonsillar lym- 
phatic gland and its efferents contained the blue solution, the 
extravasation through the connective tissue of the neck was so great 
as to make it impossible to recognize the topography. 
Specimen VI.-Child about three months old. This injection was 
a most successful one. Quite a large amount of fluid was injected in 
this case without any extravasation. In the throat the fluid was 
limited to the confines of the tonsil and the dissection showed that it 
had followed the lymph vessels through six or more of the upper deep 
cervical glands. The efferents from the tonsil could be traced passing 
in a direction very similar to that described under Specimen IV. 
There were two or three lymph vessels which ran closely together in 12 
wood: lymphatic drainage of the faucial tonsils 
a more or less parallel course. At first they passed obliquely down- 
ward, posteriorly, and outward until they reached the facial artery. 
Running beneath this and internal to the stylohyoid muscle and the 
posterior belly of the digastric muscle, they entered the internal 
side of the tonsillar lymph gland. 
In closing, I desire to express my thanks to Dr. James M. Stotsen- 
burg and especially to Dr. Harold D. Senior for their skilful aid 
in making the injections. LEA'S PERIODICALS 
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